Can a food foreign body lodged in the neck or airway be visualized on a routine chest X‑ray?

Can Food Foreign Bodies in the Neck/Airway Be Seen on Chest X-ray?

Routine chest X-rays have limited utility for detecting food foreign bodies in the neck or airway, with false-negative rates reaching 47% for esophageal foreign bodies and up to 85% for food impaction, fish bones, chicken bones, and other non-radiopaque objects. 1

Understanding the Limitations of Plain Radiography

Plain radiographs (including neck, chest, and abdominal X-rays) are useful initial screening tools but have significant diagnostic limitations:

• Overall sensitivity is poor: Plain radiography detects only radiopaque objects reliably, missing most food items which are typically non-radiopaque 1
• False-negative rates are unacceptably high: Up to 47% for esophageal foreign bodies generally, and 85% specifically for food bolus impaction, fish bones, chicken bones, wood, plastic, thin metal objects, and glass fragments 1
• Biplanar imaging improves detection slightly: Lateral projections help differentiate between tracheobronchial (windpipe) and esophageal locations, but sensitivity remains limited 1

When to Suspect Airway vs. Esophageal Location

The clinical presentation guides whether the foreign body is in the airway (trachea/bronchi) versus the esophagus:

Airway foreign bodies present with respiratory symptoms:

• Choking, stridor, dyspnea, and signs of airway obstruction 1
• These require immediate bronchoscopy, not reliance on imaging 1

Esophageal foreign bodies present with swallowing symptoms:

• Acute dysphagia, inability to swallow saliva, odynophagia, retrosternal pain, drooling 1
• Most food impactions (84%) lodge in the upper esophagus at anatomical narrowing points 2

The Superior Diagnostic Approach: CT Scanning

When clinical suspicion exists despite negative X-rays, CT scan is mandatory and should not be delayed:

• CT sensitivity is 90-100% compared to only 32% for plain X-rays 1, 3
• CT specificity reaches 93.7-100% 3
• CT accurately localizes non-radiopaque objects, evaluates for complications (perforation, abscess), and guides management decisions 1, 3
• For suspected airway foreign bodies with negative X-rays, CT of the neck and chest is essential 3

Immediate Management Algorithm

For symptomatic patients with suspected food foreign body:

1. Obtain plain neck and chest X-rays as initial screening (recognizing their limitations) 1
2. If X-rays are negative but symptoms persist, proceed immediately to CT scan 1, 3
3. Obtain laboratory studies: CBC, CRP, blood gas analysis, lactate 1, 4
4. Determine urgency of endoscopy based on clinical presentation:
   • Emergent endoscopy (within 2-6 hours): Complete esophageal obstruction, inability to swallow saliva, sharp-pointed objects, respiratory distress 1, 4, 3
   • Urgent endoscopy (within 24 hours): Partial obstruction, persistent symptoms without complete blockage 1, 4

Critical Pitfalls to Avoid

• Never rely solely on negative X-rays to exclude foreign body ingestion in symptomatic patients – the false-negative rate is too high 1
• Do not delay CT scanning in patients with persistent symptoms – this is the definitive imaging modality 1, 3
• Avoid contrast swallow studies – they increase aspiration risk and impair subsequent endoscopic visualization 4
• Do not delay endoscopy for ineffective pharmacologic interventions (fizzy drinks, medications lack evidence) 4
• Recognize that airway foreign bodies require bronchoscopy, not upper endoscopy – differentiate based on respiratory vs. swallowing symptoms 1

Special Considerations for Common Food Items

Fish bones and chicken bones are particularly problematic:

• These account for 94% of dietary foreign bodies in emergency departments (48% fish bones, 46% chicken bones) 2
• Plain X-rays miss up to 85% of these objects 1, 3
• Sharp-pointed fish bones visible on imaging carry up to 35% perforation risk and require emergent removal 3
• CT scan is mandatory for accurate localization 3