What to do if a fish bone is stuck in the throat?

Management of Fish Bone Stuck in Throat

If a fish bone is stuck in the throat, proceed directly to emergent flexible endoscopy within 2-6 hours for removal, as sharp-pointed objects like fish bones carry up to 35% risk of full-thickness perforation. 1

Immediate Actions

Do Not Attempt Home Remedies

• Never try to force the fish bone down by swallowing rice, bread, or inducing vomiting—these methods can cause the bone to migrate outside the esophagus into surrounding tissues, leading to serious complications including thyroid abscess, neck abscess, or vertebral body migration. 2
• Do not wait for spontaneous passage if symptoms persist, as delayed presentation (even after self-extrusion) can result in neck abscess, vocal cord paresis, and other significant morbidity. 3

Seek Emergency Care Immediately

• Activate emergency medical services or go directly to the emergency department for evaluation. 1
• Fish bones commonly lodge in the palatine tonsil, base of tongue, valleculae, pyriform sinus, or esophagus. 4

Diagnostic Approach

Initial Imaging

• Plain radiographs (neck, chest, abdomen) should be obtained first, but understand they have severe limitations with false-negative rates up to 47% for esophageal foreign bodies and up to 85% for small fish bone fragments. 5, 6
• Most fish bones are not reliably visible on X-ray despite being partially radiopaque. 7

Advanced Imaging When Needed

• CT scan is essential if X-ray is negative but clinical suspicion remains high, with 90-100% sensitivity compared to only 32% for plain films. 5, 6
• CT should be performed in all symptomatic patients with suspected fish bone ingestion despite negative X-ray, as it can detect the bone and identify complications like perforation, abscess formation, or migration to extraluminal organs. 5, 7, 4
• Contrast swallow studies are NOT recommended as they increase aspiration risk and impair subsequent endoscopic visualization. 6

Definitive Treatment

Endoscopic Removal

• Emergent flexible endoscopy (within 2-6 hours) is mandatory for sharp-pointed objects like fish bones due to high perforation risk. 1, 6
• If the fish bone causes complete esophageal obstruction, endoscopy must be performed even more urgently due to additional aspiration risk. 1, 6
• Endoscopic evaluation should be performed even if radiographic examination is negative in patients with persistent symptoms. 1, 5

Retrieval Techniques

• Use retrieval techniques with baskets, snares, and grasping forceps for sharp-pointed objects. 1, 6
• For fish bones in the upper esophagus, rigid endoscopy may be needed as a second-line approach if flexible endoscopy fails. 1, 6
• A combined approach using flexible endoscope through a Weerda diverticuloscope or laparoscopic grasping forceps may be necessary for difficult cases. 1

Surgical Intervention

• Surgery is required if the fish bone is irretrievable endoscopically, has already perforated with extensive contamination, or has migrated to extraluminal structures (thyroid gland, vertebral body, prevertebral fascia). 1, 4, 8
• Exploratory cervicotomy with possible thyroid lobectomy may be necessary if the bone has migrated into the thyroid gland. 4, 2

Critical Complications to Monitor

Early Complications (Hours to Days)

• Full-thickness esophageal perforation occurs in up to 35% of sharp-pointed foreign bodies. 1
• Aspiration risk is significant with complete obstruction. 1, 6

Delayed Complications (Days to Weeks)

• Fish bones can migrate from the esophagus to the thyroid gland, cervical vertebrae, or prevertebral fascia even after initial self-extrusion. 4, 8, 3
• Neck abscess, vocal cord paresis, pharyngeal fistula, mediastinal abscess, and thyroid abscess can develop 10-20 days after initial ingestion. 3, 2
• Patients must be warned that even if the bone feels like it passed, delayed complications can occur and require urgent medical attention if new symptoms develop. 3

Common Pitfalls to Avoid

• Do not rely on negative X-rays to rule out fish bone—proceed to CT or endoscopy based on clinical symptoms. 5, 7
• Do not delay endoscopy beyond 6 hours for sharp objects, as perforation risk increases significantly. 1
• Do not discharge patients without clear instructions to return immediately if symptoms recur, as migration can occur days to weeks later. 3, 2
• Elderly patients with dentures are at higher risk and require particularly careful evaluation. 2