ACEP ID:

Pediatric Emergency Medicine

Pediatric EM Section - Case Study #1

By Larry B. Mellick, MS, MD, FAAP, FACEP

Fish Bone
 

Case:

A 14 year old female presents to the emergency department complaining that a fish bone is stuck in her throat.  She was eating mullet when the foreign body became lodged in her tonsil.  Since the fish bone was easily visualized, no imaging studies were required.  Using hemostats the emergency medicine resident easily removed the wayward fish bone.

Fish Bone Removal 

Discussion:

This fish bone was easily visualized and removed.  However, this case raises several important discussion questions. 

  1. What are potential complications when impaled fish bones are missed? 
  2. How good are radiographs at demonstrating less obvious fish bones? 
  3. How are fish bones commonly removed?

There are a number of case reports describing the potential complications. These complications include intraglossal impaction, migration from the pharynx to the subcutaneous tissue of the neck, recurrent deep space infections, facial artery penetration, migration to prevertebral soft tissues, migration into the thyroid gland, perforation of the aorta and epidural abscesses.1-8 

While there are many studies that prove that fish bones can be seen on x-ray,9-14 the sensitivity is relatively poor. The conclusion of several large studies and a Best Bets review of these studies is that the sensitivity of lateral neck radiographs is so poor that it should be abandoned.15,16,17 When direct visualization with an endoscope or mirror fails to detect a suspected fish bone, computerized tomography (CT) scans successfully recognize these foreign bodies.3,4,5,8,18,19,20 

Most fish bones are beyond the level of direct visualization and indirect laryngoscopy or fiberoptic nasopharyngoscopy are required.  A smaller percentage can be removed by direct visualization using Magill forceps or a hemostat as occurred with our patient.16 If attempts at removal are unsuccessful by the emergency provider, an ENT consultation should be accomplished.

Learning Points

  1. Missed fish bones can have serious associated morbidity.
  2. While radiographs should be considered when the fish bone is not visualized directly, with a mirror or by a fiberoptic nasopharyngoscope; they are not consistently helpful in detecting fish bones and other imaging modalities such as computed tomography or ultrasound may be required.
  3. The removal of fish bones may require ENT consultation.

References

  1. Johari S, Chong KY. Intraglossal impaction of ingested fish bones: a case series. Ear Nose Throat J. 2010 Aug;89(8):364-8.
  2. Chung SM, Kim HS, Park EH. Migrating pharyngeal foreign bodies: a series of four cases of saw-toothed fish bones. Eur Arch Otorhinolaryngol. 2008 Sep;265(9):1125-9. Epub 2008 Jan 4.
  3. Yang SW, Chen TM, Chen TA. Migrating fish bone complicating a deep neck abscess. Chang Gung Med J. 2005 Dec;28(12):872-5.
  4. Chawla A, Eng SP, Peh WC. Clinics in diagnostic imaging (100). Migrated pharyngeal fish bone.Singapore Med J. 2004 Aug;45(8):397-402; quiz 403. 
  5. Hohman MH, Harsha WJ, Peterson KL.Migration of ingested foreign bodies into the thyroid gland: literature review and case report. Ann Otol Rhinol Laryngol. 2010 Feb;119(2):93-8.
  6. Al-Sebeih K, Abu-Shara KA, Sobeih A. Extraluminal perforation complicating foreign bodies in the upper aerodigestive tract. Ann Otol Rhinol Laryngol. 2010 May;119(5):284-8.
  7. Jeon SH, Han DC, Lee SG, Park HM, Shin DJ, Lee YB. Eikenella corrodens cervical spinal epidural abscess induced by a fish bone. J Korean Med Sci. 2007 Apr;22(2):380-2.
  8. Alam AM, Shuaib IL, Hock LC, Bah EJ. Perforation of oesophagus and aorta by an unusual migratory fish bone: case report. Nepal Med Coll J. 2005 Dec;7(2):150-1.
  9. Davies WR, Bate PJ. Relative radio-opacity of commonly consumed fish species in South East Queensland on lateral neck x-ray: an ovine model. Med J Aust. 2009 Dec 7-21;191(11-12):677-80.
  10. Ell SR, Sprigg A, Parker AJ. A multi-observer study examining the radiographic visibility of fishbone foreign bodies. J R Soc Med. 1996 Jan;89(1):31-4.
  11. Ell SR, Parker AJ. The radio-opacity of fishbones. Clin Otolaryngol Allied Sci. 1992 Dec;17(6):514-6. 
  12. Ell SR, Sprigg A. The radio-opacity of fishbones--species variation. Clin Radiol. 1991 Aug;44(2):104-7.
  13. Hone SW, Fenton J, Clarke E, Hamilton S, McShane D. The radio-opacity of fishbones: a cadaveric study. Clin Otolaryngol Allied Sci. 1995 Jun;20(3):234-5.
  14. Wu IS, Ho TL, Chang CC, Lee HS, Chen MK.Value of lateral neck radiography for ingested foreign bodies using the likelihood ratio. J Otolaryngol Head Neck Surg. 2008 Apr;37(2):292-6.
  15. Evans RM, Ahuja A, Rhys Williams S, Van Hasselt CA. The lateral neck radiograph in suspected impacted fish bones--does it have a role? Clin Radiol. 1992 Aug;46(2):121-3. 
  16. Ngan JH, Fok PJ, Lai EC, Branicki FJ, Wong J.A prospective study on fish bone ingestion. Experience of 358 patients. Ann Surg. 1990 Apr;211(4):459-62.
  17. Bethune L. Towards evidence based emergency medicine: best BETS from the Manchester Royal Infirmary. Radiography for fish bones in the throat. J Accid Emerg Med. 1999 Sep;16(5):362-3.
  18. Shaariyah M, Salina H, Dipak B, Majid MA. Migration of foreign body from postcricoid region to the subcutaneous tissue of the neck. Ann Saudi Med 2010;30:475-7.
  19. Masuda M, Honda T, Hayashida M, Samejima Y, Yumoto E.A case of migratory fish bone in the thyroid gland. Auris Nasus Larynx. 2006 Mar;33(1):113-6. Epub 2005 Dec 7.  
  20. Kikuchi K, Tsurumaru D, Hiraka K, Komori M, Fujita N, Honda H. Unusual presentation of an esophageal foreign body granuloma caused by a fish bone: usefulness of multidetector computed tomography. Jpn J Radiol. 2011 Jan;29(1):63-6. Epub 2011 Jan 26.

 

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