A 45-year-old patient with a 4-5 day history of a sensation of something stuck in the right side of their throat, accompanied by odynophagia (painful swallowing), and no dyspnea (trouble breathing), what is the differential diagnosis and initial management?

Differential Diagnosis and Initial Management

This patient most likely has either a foreign body impaction, pharyngitis with referred pain, or less commonly a displaced thyroid cartilage cornu, and should undergo direct laryngoscopy with flexible fiberoptic examination of the hypopharynx as the initial diagnostic step, followed by lateral neck X-ray if no obvious cause is identified. 1, 2

Immediate Assessment

Key Historical Features to Elicit

• Determine if this is true dysphagia versus globus sensation: True dysphagia involves actual difficulty with food passage, while globus is a sensation of a lump that typically does not interfere with swallowing and may be relieved by eating 3
• Assess for foreign body ingestion: Adults often can identify and localize foreign body ingestion to a specific area of discomfort, with typical presentation being acute onset of odynophagia, neck tenderness, retrosternal pain, or foreign body sensation 1
• Lateralization is significant: Unilateral throat pain with swallowing suggests a structural lesion (foreign body, abscess, displaced cartilage) rather than a functional disorder 2

Physical Examination Priorities

• Examine for fever, cervical subcutaneous emphysema, or neck erythema/tenderness as these indicate complications requiring urgent intervention 1
• Perform flexible fiberoptic rhinolaryngoscopy to directly visualize the hypopharynx, as this is the most helpful diagnostic procedure for foreign body sensation at the hyoid level 2
• Palpate the neck carefully to assess for displaced thyroid cartilage cornu, which can cause persistent foreign body sensation and is surgically correctable 2

Differential Diagnosis (In Order of Likelihood)

1. Foreign Body Impaction

• Most common in the hypopharynx or upper thoracic esophagus at anatomical narrowing points (cricopharyngeus, aortic arch) 1
• Fish or chicken bones have false-negative rates up to 85% on plain X-ray, making clinical examination critical 1
• Obtain lateral neck X-ray and chest X-ray to assess for radiopaque objects, though biplanar radiography reduces false-negative rates 1

2. Pharyngitis or Peritonsillar Process

• Unilateral odynophagia with 4-5 day duration fits infectious etiology timeline 4
• Examine for tonsillar asymmetry, erythema, or exudate on direct visualization 2

3. Displaced Superior Cornu of Thyroid Cartilage

• Uncommon but surgically correctable cause of persistent foreign body sensation at the hyoid level 2
• Diagnosed by careful neck examination and flexible fiberoptic rhinolaryngoscopy 2
• Consider if symptoms persist despite negative workup for other causes 2

4. Gastroesophageal Reflux Disease (GERD)

• Common cause of globus sensation, but less likely given acute 4-5 day onset and unilateral localization 3
• GERD typically causes bilateral symptoms and may be relieved by food intake 3

Initial Diagnostic Approach

First-Line Testing

Order lateral neck and chest X-rays immediately to screen for radiopaque foreign bodies or signs of perforation (subcutaneous emphysema, pneumomediastinum), though sensitivity is only 32% for fish bones 1

If X-rays Are Negative

Proceed to CT scan of the neck with contrast as it has 90-100% sensitivity and 93.7-100% specificity for fish bone impaction, compared to 32% sensitivity for plain X-ray 1

Critical Pitfall to Avoid

Do NOT order contrast swallow studies as they are not recommended and should not delay other investigations or interventions 1

When to Escalate Care

Indications for Urgent Endoscopy

• Inability to swallow saliva (drooling) 1
• Fever, cervical subcutaneous emphysema, or signs of perforation 1
• Choking, stridor, or dyspnea suggesting airway obstruction 1

Biochemical Investigations if Complications Suspected

• Complete blood count (CBC), C-reactive protein (CRP), blood gas analysis for base excess and lactate 1

Management Based on Findings

If Foreign Body Identified

• Urgent ENT or gastroenterology consultation for endoscopic removal 1
• CT scan should be performed if perforation or other complications are suspected 1

If No Foreign Body but Symptoms Persist

• Consider trial of proton pump inhibitor therapy for GERD-related globus 4, 3
• Re-examine for displaced thyroid cartilage cornu, which may require surgical trimming 2
• Ensure complete visualization of the entire esophagus, as distal lesions can cause referred sensation to the throat 1, 4

Red Flag: Alarm Features Requiring Expedited Workup

• Progressive dysphagia, weight loss, or age >55 years indicate increased malignancy risk and warrant esophagogastroduodenoscopy 5
• However, this patient's acute 4-5 day presentation makes malignancy unlikely 4