What is the treatment for a patient with a chicken bone lodged in their throat?

Treatment of Chicken Bone Lodged in Throat

For a patient with a chicken bone lodged in the throat, obtain a CT scan immediately if the patient is symptomatic or has high clinical suspicion, as plain X-rays miss up to 85% of chicken bone impactions, then proceed with urgent flexible endoscopy within 24 hours for esophageal foreign bodies or emergent endoscopy within 2-6 hours if there is complete obstruction or severe symptoms. 1, 2

Initial Assessment and Imaging

Clinical Evaluation

• Never ignore a patient who complains of difficulty breathing or persistent foreign body sensation, even if objective signs are absent. 3
• Assess for complete esophageal obstruction (inability to swallow saliva), respiratory distress, fever, or chest pain—these indicate emergent intervention. 2
• Look specifically for: odynophagia (painful swallowing), persistent throat pain, choking sensation, and duration of symptoms. 4

Diagnostic Imaging Strategy

• Plain X-rays are inadequate screening tools with only 15% sensitivity for chicken bone detection—do not rely on negative X-rays to rule out impaction. 1, 5
• CT scan has 90-100% sensitivity and 93.7-100% specificity for detecting chicken bones and should be performed in all symptomatic patients. 1
• CT is essential for: locating the exact position of non-radiopaque bones, evaluating for perforation, and assessing surrounding tissue injury. 1
• Avoid contrast swallow studies as they increase aspiration risk and impair subsequent endoscopic visualization. 2

Important Pitfall

• Be aware that calcified stylohyoid ligaments (Eagle syndrome) can mimic chicken bones on X-ray—physical examination showing tonsillar fossa tenderness and nasopharyngoscopy showing no foreign body suggests this diagnosis. 6

Management Algorithm Based on Clinical Presentation

Emergent Endoscopy (Within 2-6 Hours)

Indicated for: 1, 2

• Complete esophageal obstruction (inability to swallow saliva)
• Sharp-pointed bone fragments
• Severe respiratory symptoms or stridor
• Signs of perforation (fever, severe chest pain, subcutaneous emphysema)

Urgent Endoscopy (Within 24 Hours)

Indicated for: 1, 2

• Partial esophageal obstruction with persistent symptoms
• Esophageal foreign bodies without complete obstruction
• Persistent symptoms for >3 days despite negative initial imaging

Endoscopic Technique

• First attempt gentle pushing of the bone into the stomach using air insufflation and instrumental pushing. 2
• If pushing fails, use retrieval techniques with baskets, snares, or grasping forceps. 2
• Consider rigid endoscopy as second-line if flexible endoscopy fails, particularly for upper esophageal impactions. 2
• Obtain diagnostic biopsies during the procedure to assess for underlying esophageal pathology (present in up to 25% of cases). 2

Non-Operative Management Criteria

Non-operative management can be offered only to hemodynamically stable patients with early presentation, contained esophageal disruption, and minimal contamination of surrounding spaces. 3

Patients must meet ALL of the following: 3

• Hemodynamically stable
• No signs of perforation on CT
• Minimal or no extravasation of contrast
• No systemic signs of severe sepsis
• Close clinical and biological monitoring available

Surgical Intervention

Indications for Surgery

Emergency surgery is required for: 3, 2

• Hemodynamic instability
• Obvious non-contained extravasation of contrast material
• Systemic signs of severe sepsis
• Foreign body irretrievable by endoscopy or close to vital structures
• Confirmed perforation

Surgical Approach

• Esophagotomy with foreign body extraction and primary closure is the preferred approach. 3
• If primary repair is not feasible (large disruption, delayed presentation, pre-existing esophageal disease): consider external drainage, esophageal exclusion, or resection. 3
• Adequate drainage of surrounding spaces is essential. 3

Post-Procedure Care and Monitoring

Immediate Post-Intervention

• Nurse patients upright and administer high-flow humidified oxygen. 3, 2
• Keep patient nil by mouth if concerns about laryngeal competence exist. 3, 2
• Continue standard monitoring with capnography available. 3

Warning Signs Requiring Immediate Re-evaluation

Monitor for: 2

• Stridor or obstructed breathing pattern
• Agitation
• Fever
• Deep cervical or chest pain
• Subcutaneous emphysema (suggests perforation)

Medications

• Obtain CBC, CRP, blood gas analysis if perforation suspected. 1
• Consider steroids (equivalent to 100 mg hydrocortisone every 6 hours) if inflammatory airway edema is present, started as soon as possible and continued for at least 12 hours. 3
• Nebulized adrenaline (1 mg) may reduce airway edema if stridor develops. 3

Special Considerations

Laryngopharyngeal Impaction

• Large chicken bones can impact in the pyriform fossa and may be removed under local anesthesia with guided telescopic laryngeal examination. 4
• This location requires otolaryngology consultation for safe removal. 4

Aspiration Risk

• Hollow chicken bones can lodge in the bronchus, particularly in infants and young children, causing severe respiratory distress even with normal chest X-rays—bronchoscopy is required for diagnosis and removal. 7

Differential Diagnosis

• Acute epiglottitis can present identically to foreign body sensation—maintain high suspicion if no foreign body is found on initial examination, as this is a life-threatening condition requiring immediate antibiotic therapy. 8