What is the appropriate diagnosis and treatment for an elderly male with a sensation of something stuck in the right side of his throat?

Evaluation and Management of Unilateral Throat Foreign Body Sensation in an Elderly Male

This elderly male with a unilateral sensation of something stuck in his throat requires urgent flexible endoscopy within 24 hours to rule out esophageal foreign body, food bolus impaction, or underlying esophageal pathology including malignancy.

Immediate Diagnostic Approach

Primary Concern: Esophageal Foreign Body or Food Bolus

• Urgent flexible endoscopy (within 24 hours) is indicated for esophageal foreign bodies without complete obstruction, which this presentation suggests 1
• The unilateral nature and persistent sensation strongly suggest an actual physical obstruction rather than functional globus sensation 1
• Even without dysphagia to liquids (suggesting incomplete obstruction), the persistent foreign body sensation warrants endoscopic evaluation 1

Critical Red Flags to Assess Immediately

• Assess for complete esophageal obstruction: inability to swallow saliva, drooling, or inability to tolerate liquids requires emergent endoscopy within 2-6 hours 1
• Evaluate for sharp objects or button batteries: these require emergent intervention due to perforation risk up to 35% 1
• Screen for severe complications: neck pain/swelling, fever, or respiratory symptoms could indicate Lemierre syndrome or esophageal perforation 1, 2

Differential Diagnosis Considerations

Esophageal Pathology (Most Likely)

• Food bolus impaction is the most common cause of foreign body sensation, with up to 90% success rate with endoscopic management 1
• Underlying esophageal disorders are found in up to 25% of patients presenting with foreign body sensation, including strictures, Schatzki rings, eosinophilic esophagitis, and malignancy 1
• Malignancy must be excluded in elderly patients with persistent unilateral symptoms, as this is a concerning presentation requiring tissue diagnosis 3

Referred Sensation from Distal Pathology

• Abnormalities of the mid or distal esophagus or gastric cardia can cause referred sensation to the throat, making complete esophageal evaluation essential 1
• A biphasic esophagram combined with pharyngeal evaluation has higher diagnostic value than either alone 1

Less Likely but Important Considerations

• Lemierre syndrome: while typically presents with severe pharyngitis, fever, and sepsis, elderly patients may not mount a febrile response 2
• GERD-related chronic irritation: can present as persistent throat symptoms without classic heartburn 3

Recommended Diagnostic Algorithm

Step 1: Immediate Clinical Assessment

• Determine obstruction severity: Can the patient swallow liquids? Any drooling or inability to handle secretions? 1
• Assess for danger signs: fever, neck swelling/tenderness, difficulty breathing, severe pain, or signs of sepsis 1, 2
• Obtain focused history: duration of symptoms, recent meals (especially meat or bones), prior esophageal problems, weight loss, progressive dysphagia 1, 3

Step 2: Imaging if Indicated

• Plain radiographs may identify radiopaque foreign bodies but have limited sensitivity 1
• CT neck/chest with contrast if perforation suspected (subcutaneous emphysema, severe pain, fever) 1
• Imaging should not delay endoscopy in stable patients 1

Step 3: Endoscopic Evaluation and Treatment

• Flexible endoscopy within 24 hours is both diagnostic and therapeutic 1
• During endoscopy, the "push technique" with gentle air insufflation successfully manages food bolus impaction in up to 90% of cases 1
• Obtain biopsies of any visualized lesions or abnormal mucosa to evaluate for malignancy, eosinophilic esophagitis, or other pathology 1
• Complete esophageal and gastric cardia examination is mandatory even if a proximal cause is identified 1

Management Pending Endoscopy

Symptomatic Relief

• Avoid empiric medications that could mask serious pathology 3
• NSAIDs should be used cautiously in elderly patients due to cardiovascular, renal, and gastrointestinal risks 3
• Keep patient NPO if endoscopy is planned within hours 1

What NOT to Do

• Do not attempt blind passage of nasogastric tube - risk of perforation if sharp object present 1
• Do not give meat tenderizer, proteolytic enzymes, or carbonated beverages - these are ineffective and potentially harmful 1
• Do not dismiss as "globus sensation" without objective evaluation in an elderly patient with unilateral symptoms 3

Common Pitfalls to Avoid

• Assuming viral pharyngitis: the unilateral nature and foreign body sensation make infectious pharyngitis extremely unlikely 1
• Delaying endoscopy: waiting beyond 24 hours increases risk of complications including perforation and aspiration 1
• Missing underlying malignancy: persistent unilateral throat symptoms in elderly patients warrant tissue diagnosis 3
• Overlooking distal pathology: always evaluate the entire esophagus and gastric cardia, as referred sensation is common 1
• Dismissing absence of fever: elderly and immunocompromised patients may not mount febrile responses to serious infections like Lemierre syndrome 2

Surgical Consultation Criteria

• Irretrievable foreign body at endoscopy 1
• Evidence of perforation: free air, mediastinal emphysema, pleural effusion 1
• Failed endoscopic management of impacted foreign body 1
• Foreign body near vital structures (aortic arch) 1