I Think I Have a Fish Bone Near My Wish Bone!

LEARNing Rounds:  Learn, Evaluate, Adopt Right Now…

I Think I Have a Fish Bone Near My Wish Bone!

By Colin Kaide MD, OSU EM Assoicate Professor // Edited by Michael Barrie MD, OSU EM Assistant Professor

Chief Complaint:  Foreign Body in throat

HPI 

This patient is a 57 y.o. female with no related past medical history who presents with foreign body sensation in her throat. Patient states this started approximately one hour ago. She was eating fish, and says that she has a fish bone stuck in her throat. She has not had anything to eat or drink since that time. She denies chest pain, shortness of breath. She states that the foreign body sensation has not moved since that time and is located in the left side of her anterior lateral neck, above the sternal notch. Denies fevers. Denies history of similar. No issues with swallowing prior to the sensation.

Focused Physical Exam

Blood pressure 143/81, pulse 86, temperature 98.2 degrees F (36.8 degrees C), temperature, source Oral, resp. rate 16, SpO2 99 %.
Physical Exam
Constitutional: She is oriented to person, place, and time. She appears well-developed and well-nourished. No distress.
HENT:  No FB visualized on oral exam.
Head: Normocephalic and atraumatic.
Eyes: Conjunctivae and EOM are normal. Pupils are equal, round, and reactive to light.
Neck: Normal range of motion. Neck supple. No tracheal deviation present.

ED COURSE & MEDICAL DECISION MAKING

DDX includes:

  • Foreign body in the pharynx
  • foreign body in the esophagus
  • minor pharyngeal injury such as a small abrasion without residual foreign body
  • no signs of mediastinitis
  • no signs of perforated esophagus

XRAY showed no radiopaque foreign body.

Despite negative xrays, the patient insisted that there was still a foreign body present.

The patient received the following interventions:

  • 120 mg of lidocaine nebulized (3cc of 4% lidocaine by nebulizer),
  • followed by HurriCaine® spray topically (20% benzocaine)
  • After topical anesthetization was attained, a GlideScope® blade was carefully inserted to look for a foreign body.
  • The FB was visualized in the inferior tonsillar pillar and removed using a Magill® Forceps.
  • The foreign body is consistent with approximately a 2 cm long fishbone.

On reassessment, the patient had complete resolution of foreign body sensation and pain.

Disposition:  Patient’s symptoms were completely resolved. The patient was discharged home.

Learning Points:

  1. Not all fish bones are radiopaque on xray!  They do however show up on CT very well!
    • THE RADIO-OPACITY OF FISHBONES:   Ell, S.R., et al, Clin Otolaryngol 17(6):514, December 1992
      1. Bones from cod and haddock were the most radio-opaque, and could be easily seen in all locations.
      2. Bones from lemon sole, grey mullet, cole fish, gurnard, monkfish, plaice, and red snapper were also readily apparent in all locations.
      3. Trout, salmon and pike bones were barely visible.
      4. Mackerel and herring bones had the lowest density scores and were not considered to be identifiable.”
    • Diagnosing Fish Bone and Chicken Bone Impactions in the Emergency Department Setting: Measuring the System Utility of the Plain Film Screen.  Devarajan K, et al. The Annals Of Otology, Rhinology, And Laryngology, 2015 Aug; Vol. 124 (8), pp. 614-21. Date of Electronic Publication: 2015 Feb 26.
      1. X-rays are poor screening tools in determining fish or chicken bone impactions with poor diagnostic and system utility. Further studies should be performed to evaluate the role of a low-radiation CT screen.
    • Proposal for methods of diagnosis of fish bone foreign body in the Esophagus. Woo SH, et al.  The Laryngoscope [Laryngoscope] 2015 Nov; Vol. 125 (11), pp. 2472-5. Date of Electronic Publication: 2015 May 11.
      1. Methods: A prospective study was performed on 286 patients with a history of fish bone foreign body impaction. Sixty-six patients showed positive findings in the esophagus, and an attempt was made to remove the obstruction using transnasal esophagoscopy.
      2. Results: In 66 patients, a fish bone foreign body was detected in the esophagus by CT. In contrast, plain radiography detected a foreign body in only 30 patients. The fish bone foreign bodies were most commonly located in the upper esophagus (n = 65, 98.5%), followed by the lower esophagus (n = 1, 1.5%).
      3. Conclusion: CT is a useful method for identification of esophageal fish bone foreign bodies. Therefore, CT should be considered as the first-choice technique for the diagnosis of esophageal fish bone foreign body.
    • The management of possible fishbone ingestion. Akazawa Y, et al. Auris Nasus Larynx. 2004 Dec;31(4):413-6.
      1. METHODS:  X-ray and CT imaging were performed in 76 patients in whom esophageal impaction of fish bones was suspected.
      2. Conclusion:  In the present study, sensitivity and specificity of plain X-ray was 54.8% (17 of 31) and 100% (45 of 45), respectively. However, for CT, both sensitivity and specificity were 100%. CT was determined to be very useful in the diagnosis of impacted fish bones in the esophagus.
  2. In my experience, when someone says they have a fish bone FB, I have almost always found one…some by direct visualization and some on CT and a few on plain xrays.
  3. Direct visualization with a GlideScope®:  This technique is very easy and usually successful with a cooperative patient and obviates the need to have ENT scope the patient.
    1. Nebulize 3-4 cc of 4% lidocaine (ordered as 120-160 mg of lidocaine).  Have the RT or RN put the medication into a standard nebulizer and deliver it just like you would do for albuterol.
    2. Use HurriCaine® (benzocaine 20%) spray to augment local anesthesia on the tongue, uvula and other posterior pharyngeal structures.
    3. Gently slide the GlideScope® blade along the tongue and pan laterally to both sides and look as you advance.  One trick to help increase tolerance of the scope is to have the patient put his or her hand on the scope with you…it seems to decrease gagging.
    4. Use the Magill® forceps to remove the FB.fish bone
  4. Do remember that the use of topical benzocaine can (very rarely) induce methemoglobinemia.  Your patient will turn blue with chocolate colored blood and show an O2 sat that oddly reads a steady 85%, regardless of the actual oxygen saturation.  It either will spontaneously resolve or require methylene blue administration.  I have only seen one case from benzocaine and this happened with the use of Oragel® in a teething toddler.  I have never seen when using benzocaine for a procedure.
  5. A small amount of benzodiazepine may be useful if the patient is very anxious or is having trouble tolerating the GlideScope® blade.
  6. Recognize that although this is usually a benign condition, there are case reports of pharyngeal perforation and subsequent abscesses from fish bone foreign bodies.
  7. By the way, the wishbone, or “furcula” (“little fork” in Latin) is a forked bone found in the neck of birds and some other animals, and is formed by the fusion of the two clavicles. In birds, its primary function is in the strengthening of the thoracic skeleton to withstand the rigors of flight.

fish bone

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4 thoughts on “I Think I Have a Fish Bone Near My Wish Bone!

  1. The same method of extraction can be used to find and remove another type of less well-known foreign body, the metal grill brush wire. These can be harder to get a history on, as the patient will simply remember eating some hamburger or steak cooked on the gas grill. The culprit is a broken piece of silver wire from the brush used to clean the grill surface, which was not seen and became embedded in the cooking meat. This now accounts for thousands of cases annually nationwide.

    There are now available grill brushes using bright red stiff plastic wire-like brushes, which are thicker and much easier to see and avoid.

  2. Curious to see thoughts from others but have usually consulted ENT first when fishbones are perceived (that we cannot extract) while GE for meat impactions.

    Also interesting that in this case the patient re-presented a few days later with mild epiglotitis diagnosed by CT and ENT laryngoscopy but now is improving (as of my phone call today) on antibiotics and steroids.

    Despite the subsequent infection, I would try this technique in the future.

    1. If a patient cannot tolerate liquids with an esophageal meat impaction, I always consult GI. To help dispo I generally place these patients in Obs as most times it is safe to wait until normal business hours to do endoscopy. It’s tempting to use an Ed technique such as a bougie to push a meat bolus into the stomach, however everything I’ve read says that this comes with too high of a risk for perforation.

      I like Colin’s technique to evaluate for pharyngeal foreign bodies because it can avoid radiation and a consult. I would like to also hone my techniques with an NP scope but the downside is no way to remove the FB once visualized via NP route.

  3. I’ve removed fishbones using indirect laryngoscopy and bayonette forceps. Usually the bone is just sticking out of the tissue and fairly easy to see and grasp. Pain relief is immediate as in this case. Not sure if anyone uses indirect laryngoscopy any more, but I think it’s a useful skill, especially to rule out conditions like epiglotitis and lingual tonsilitis. I’ve also impressed a few ENT consultants by diagnosing supraglottic tumors this way.

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