An Elusive Fishbone: The Role for Repeat Imaging and Rigid Endoscopy

Abstract

Accidental ingestion of fish bones with fear of oropharyngeal or esophageal impaction is a common emergency room presentation. Only 20-30% of patients, however, will have a confirmed retained fish bone. Sharp objects in the esophagus are a medical emergency given the risks of potentially fatal complications to include esophageal perforation, bacteremia, abscess and esophageal-aortic or tracheoesophageal fistula formation. Radiographic studies are recommended to localize foreign bodies as well as to evaluate for signs of perforation. We present a 50-year-old female with CT images confirming a fish bone impacted in the cervical esophagus despite normal flexible endoscopy. Our aim is to highlight the elusive nature of impacted fish bones and their appropriate management. A 50-year-old female with history of anxiety and dysphagia, presents with a suspected retained fishbone and odynophagia. She had a normal EGD one year prior to presentation. The patient was uncomfortable and drooling with a persistent foreign body sensation. An oral exam did not reveal any foreign bodies. A CT scan confirmed a 2.7cm linear density with a punctate focus of air. Otolaryngology performed a flexible laryngoscopy but did not identify the bone or any signs of trauma. Gastroenterology was then consulted for an EGD which was unremarkable. A repeat CT scan confirmed the bone had not passed and was still in the proximal esophagus. Rigid endoscopy was subsequently performed with successful removal of a 2.7 cm fish bone buried in the right posterolateral cervical esophageal wall. The patient was admitted, started on prophylactic antibiotics, and was discharged home the next day without complications. The majority of fish bones will become lodged in the oropharynx, posterior tongue, pyriform sinuses or cervical esophagus. Traditionally, impactions in the cervical esophagus and oropharynx can be removed with flexible endoscopy. Our case demonstrates the value of repeat imaging and potentially rigid endoscopy when flexible endoscopy fails to localize or remove a foreign body. Given the elusive nature of fish bones and the significant potential complications of this condition, providers should maintain a high index of suspicion even with negative flexible endoscopy.Figure 1Figure 2Figure 3