The submucosal fish bone.

A 44-year-old man came to our emergency department complaining of odynophagia and a foreign-body sensation in his throat. He said he had eaten fish 2 days previously and had swallowed a bone: his symptoms had been present since. Findings on clinical examination and fiberoptic nasendoscopy were unremarkable. A lateral soft-tissue neck x-ray detected a thin radiopaque object at the level of the vallecula; the object was consistent with an impacted bone (figure, A). On the basis of this finding, we proceeded to direct laryngoscopy and esophagoscopy, but no bone was seen, nor was one palpated. Fluoroscopy was used to locate the bone in the lingual tonsil (tongue base), but it was still impalpable and the procedure was therefore terminated. The patient's symptoms persisted, and computed tomography (CT) was performed the following day in preparation for taking the patient to the operating theater. CT also detected the foreign body in a submucosal plane in the lingual tonsil (figure, B). However, the patient declined further intervention. He remained under review, and no complications had occurred at the 6-month follow-up.

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Lateral neck x-rays have a low sensitivity (28%) and a high specificity (91%) for identifying ingested foreign bodies. (1) Under normal circumstances, direct inspection of the oropharynx, larynx, and esophagus under anesthesia allows for identification and removal of a foreign body. In this case, the suspected fish bone was lodged below the mucosa of the tongue base. Although the bone was visible on a plain radiograph and CT, it was not visualized or palpated in the operating theater. The use of fluoroscopy to locate pharyngeal foreign bodies may be valuable. (2) The sequelae of leaving a foreign body embedded in pharyngeal mucosa are varied: retropharyngeal abscess formation is common, (3) and migration into the soft tissue of the neck has been reported)Dissolution of a fish bone that had migrated into the neck has also been reported. (5)

We have a low threshold for taking patients to the operating theater for inspection of the upper aerodigestive tract in cases of suspected foreign-body impaction. This case highlights the management difficulties associated with foreign bodies that migrate and become lodged in a submucosal plane.

References

(1.) Lai AT, Chow TL, Lee DT, Kwok SP. Risk factors predicting the development of complications after foreign body ingestion. Br J Surg 2003:90:1531-5.

(2.) Bhatt C, Reddy NV, Reddy TN. Removal of sub-mucosal foreign body (metal wire) from the pharynx using image intensifier. J Laryngol Otol 2003:117:902-4.

(3.) Singh B, Kantu M, Har-El G, Lucente FE. Complications associated with 327 foreign bodies of the pharynx, larynx, and esophagus. Ann Otol Rhinol Laryngol 1997;106:301-4.

(4.) Lehman DA, Astor FC. Roy S. Impacted pharyngeal fish bone migrating to the retropharynx. Ear Nose Throat J 2005:84:692-3.

(5.) Canbay E, Prinsley P. The case of the disappearing fish bone. J Otolaryngol 1995;24:375-6.

Patrick M. Spielmann, MBChB, MRCS (Edin); Conroy Howson, FCS (SA) ORL

From the Department of Otolaryngology, Cairns Base Hospital, Cairns, Queensland, Australia.