What is the diagnosis and treatment for a fishbone stuck in the throat?

Fishbone Stuck in Throat: Diagnosis and Management

For a suspected fishbone in the throat, proceed immediately to flexible fiberoptic nasendoscopy (FNE) as the first-line diagnostic and therapeutic approach, avoiding lateral soft tissue X-rays which have poor sensitivity (only 10% positive predictive value) and should not delay definitive endoscopic evaluation. 1, 2

Diagnostic Approach

Initial Assessment

• Fiberoptic nasendoscopy is the gold standard first-line diagnostic tool and should be performed immediately by a gastroenterologist or ENT specialist 1, 2
• Lateral soft tissue X-rays are not beneficial when FNE is available—only 10% of X-rays positive for fishbone actually correlate with true foreign bodies, and 13 of 23 positive X-ray cases had negative FNE findings 2
• Plain radiographs have up to 85% false-negative rate for non-radiopaque foreign bodies 1

Key Clinical Red Flags

• Drooling indicates complete or near-complete esophageal obstruction with high risk of aspiration and perforation, requiring emergent intervention within 2-6 hours 1, 3
• Persistent symptoms (foreign body sensation, sharp pain with swallowing, odynophagia) require endoscopic evaluation even when radiographic examination is negative 4, 1
• Neck swelling, hoarseness, or delayed presentation (>3 days) suggest extraluminal migration with potential for abscess formation, vascular injury, or thyroid gland penetration 5, 6, 7, 8

Advanced Imaging Indications

• CT scan with contrast is indicated when:
  • FNE is negative but symptoms persist 1
  • Suspected perforation or extraluminal migration 4
  • Complications such as neck abscess, mediastinitis, or thyroid involvement are suspected 5, 6, 7
• CT is the key exam for suspected perforation or foreign body-related complications 4

Treatment Algorithm

Immediate Management (Symptomatic Patients)

1. Emergent flexible endoscopy (<2-6 hours) for:

   • Drooling or signs of complete obstruction 1, 3
   • Sharp-pointed objects like fishbones 4
   • Any esophageal foreign body causing symptoms 1

2. Perform endoscopy under general anesthesia with endotracheal intubation to protect the airway, especially in patients with drooling or aspiration risk 1, 3

3. Remove the fishbone using appropriate retrieval techniques (grasping forceps, baskets, or snares) 1

4. Obtain at least 6 biopsies from different esophageal sites to evaluate for underlying pathology such as eosinophilic esophagitis, found in up to 25% of foreign body impaction cases 1

Specialist Consultation Pathway

• Gastroenterologist (first-line): Flexible endoscopy has up to 90% success rate and should be the primary approach 1
• ENT/Otorhinolaryngologist: Consult for rigid endoscopy if flexible endoscopy fails or for upper esophageal foreign bodies 1
• Thoracic or General Surgeon: Required if endoscopic removal fails, perforation occurs, or the foreign body is irretrievable 4, 1

Surgical Intervention for Complications

Indications for surgery include: 4

• Confirmed or suspected esophageal perforation
• Foreign body irretrievable by endoscopy or close to vital structures
• Extraluminal migration (e.g., thyroid gland, neck soft tissue) 5, 6, 7
• Mediastinitis, neck abscess, or vascular injury 4, 8

Surgical approach: 4, 9

• Esophagotomy with foreign body extraction and primary closure is preferred
• Direct repair with adequate drainage for perforations
• Buttressing repair with vascularized tissue (muscle flap) decreases leakage risk 9

Critical Pitfalls to Avoid

Do NOT Delay Intervention

• Avoid 24-hour observation while fasting—this increases aspiration risk and delays necessary removal 1
• Delaying intervention beyond 24 hours significantly increases morbidity and mortality (3.92-50% mortality without appropriate management) 4, 9

Do NOT Rely on X-rays Alone

• Lateral soft tissue X-rays are unreliable, especially for the suprahyoid area where fishbones commonly lodge 2
• Not all fish have radio-opaque bones, making X-rays even less reliable 2

Patient Education is Critical

• Instruct patients NOT to force swallowing or induce vomiting, as these maneuvers can cause the fishbone to migrate extraluminally, leading to serious complications including thyroid penetration, abscess formation, or vascular injury 6
• Patients who self-extrude fishbones should still seek urgent medical attention due to risk of delayed complications (perforation, abscess, vocal cord paresis) 8

Beware of Extraluminal Migration

• Fishbones can migrate from the pharynx/esophagus to the thyroid gland, neck soft tissue, or mediastinum within days to weeks 5, 6, 7
• Maintain high suspicion if FNE is negative but symptoms persist—proceed to CT imaging 1, 5, 6
• Extraluminal fishbones require surgical removal via cervicotomy, potentially with thyroid lobectomy if thyroid involvement is confirmed 6, 7