3.13 Foreign Body in Throat
Presentation
The patient thinks he recently swallowed a fish or a chicken bone, pop
top from an old-style can, or something of the sort, and still can feel a
foreign body sensation in his throat, especially (perhaps painfully) when
swallowing. He may be convinced that there is a bone or other object
stuck in the throat. He may be able to localize the foreign body
sensation precisely above the thyroid cartilage (implying a foreign body
in the hypopharynx you may be able to see), or he may only vaguely
localize the foreign body sensation to the suprasternal notch (which
could imply an foreign body anywhere in the esophagus). A foreign
body in the tracheobronchial tree usually stimulates coughing and
wheezing. Obstruction of the esophagus produces drooling and spitting
up of whatever fluid is swallowed.
What to do:
- Establish exactly what was swallowed, when, and the progression of
symptoms since then. Patients can accurately tell if a foreign body is
on the left or right side.
- If symptoms are mild, test the patient's ability to swallow, first using
a small cup of water and then small piece of bread. See what
symptoms are reproduced, or if the bread eliminates the foreign body
sensation.
- Percuss and auscultate the patient's chest. A foreign body sensation
in the throat can be produced by a pneumothorax, pneumomediastinum,
or esophageal disease, all of which may show up on a chest x ray.
- With the patient sitting in a chair, inspect the oropharynx with a
tongue depressor, looking for foreign bodies or abrasions
- Inspect the hypopharynx with a good light or headlamp mirror, paying
special attention to the base of the tongue, tonsils and vallecula, where
foreign bodies are likely to lodge. Maximize your visibility and
minimize gagging by holding the patient's tongue out (use a washcloth
or 4x4" gauze for traction and take care not to lacerate the frenulum of
the tongue on the lower incisors) and have the patient raise his soft
palate by panting "like a dog." This may be accomplished without
topical anesthesia, but if the patient is skeptical or tends to gag, you
may anesthetize the soft palate and posterior pharynx with a spray
(Cetacaine, Hurricaine or 10% lidocaine) or by having the patient gargle
with viscous Xylocaine diluted 1:1 with tap water. Some patients may
continue to gag even with the entire pharynx anesthetized.
- If you find an foreign body to pluck out or an abrasion of the mucosa,
you may have diagnosed the problem. A small fish bone is frequently
difficult to see. It may be overlooked entirely except for the tip, or it
may look like a strand of mucus. If the object can been seen directly,
carefully grasp and remove it with bayonet forceps or hemostat.
Objects in the base of the tongue or the hypopharynx require a mirror
or indirect laryngoscope for visualization. Fiberoptic nasopharyngo-
scopy is preferred when available. Further treatment is probably not
required, but you should instruct the patient to seek followup if pain
worsens, fever develops, breathing or swallowing is difficult, or if the
foreign body sensation has not totally resolved in 2 days.
- If you and your patient are not satisfied, you may proceed to a soft
tissue lateral x ray of the neck. This will probably not show radiolucent
or small foreign bodies, such as fish bones, or aluminum pop tops, but
may point out other pathology, such as a retropharyngeal abscess,
Zenker's diverticulum, or severe cervical spondylosis, which might
account for symptoms (and also allows some time for the patient's gag
reflex to settle down, in case you were not able to inspect the
hypopharynx on the first try). Lateral soft-tissue x rays can be very
misleading because ligaments and cartilage in the neck calcify at
various rates and patterns. The foreign body you see on a plain x ray
may simply be normal calcification of thyroid cartilage.
- You may also want to proceed to a barium swallow, if available, to
demonstrate with fluoroscopy any problems with swallowing motility, or
perhaps coat and thus visualize a radiolucent foreign body. Remember
that endoscopy is technically difficult after barium has coated the
mucosa and possibly obscured a foreign body. It may be preferable to
use a water-soluble contrast (e.g., Gastrographin) but even under the
best of circumstances, contrast studies are of limited value.
- Reserve rigid laryngoscopy, esophagoscopy, and bronchoscopy under
general anesthesia for the few cases where your suspicion of a
perforating foreign body remains high (e.g., when the patient has
moderate to severe pain, is febrile or toxic, cannot swallow, is spitting
blood, or has respiratory involvement.
- If x rays are negative and careful inspection does not reveal a foreign
body, and the patient is afebrile with only mild discomfort, the patient
may be sent home and observed. Reassure him that a scratch on the
mucose can produce a sensation that the foreign body is still there, but
that if the symptoms worsen the next day or fail to resolve within two
days he may need further endoscopic studies. If there are any continued
symptoms, the patient should have an otolaryngology referral and
consultation within two to three days.
What not to do:
- Do not assume that a foreign body is absent just because the pain
disappears after swallowing local anesthetic.
- Do not reassure the patient that you have ruled out an foreign body if
you have not. Explain what is likely and why invasive evaluation is
more dangerous than careful follow up.
- Do not miss preexisting pathology incidentally discovered during
swallowing.
- Do not attempt to remove a foreign body blindly from the throat with
a finger or instrument, as you may push it farther down into the airway
and obstruct it or cause damage to surrounding structures.
Discussion
During swallowing, as the base of the tongue pushes a bolus of
food posteriorly, any sharp object hidden in that bolus may become
embedded in the tonsil, the tonsillar pillar, the pharyngeal wall, or the
tongue base itself. In one study, the majority of patients presenting
with symptoms of an impacted fish bone had no demonstrated
pathology, and their symptoms resolved in 48 hours. Twenty per cent
did have an impacted fish bone, and the majority of these were easily
identified and removed on initial visit.
All patients who complain of a foreign body of the throat should
be taken seriously. Even relatively smooth or rounded objects that
remain impacted in the esophagus have the potential for serious
problems, and a fish bone can perforate the esophagus in only a few
days. Impacted button batteries represent a true emergency and require
rapid intervention and removal because leaking alkali produces
liquefactive necrosis. A pill, composed of irritating medicine (e.g.,
tetracycline) swallowed without adequate liquid, may stick to the
mucosa of the pharynx or esophagus and cause an irritating ulcer. Bay
leaves, invisible on x rays and laryngoscopy, have lodged in the
esophagus at the cricopharyngeus and produced severe symptoms until
removed via rigid endoscope.
The sensation of a lump in the throat, unrelated to swallowing
food or drink, may be globus hystericus, which is related to crico-
pharyngeal spasm and anxiety. The initial workup is the same as with
any foreign body sensation in the throat.
Table of Contents
from Buttaravoli & Stair: COMMON SIMPLE EMERGENCIES ©
Longwood Information LLC 4822 Quebec St NW Washington DC 20016-3229
1.202.237.0971 fax 1.202.244.8393 electra@clark.net
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Craig Feied, MD
Mark Smith, MD
Jon Handler, MD
Michael Gillam, MD
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