A prospective study of epidemiological risk factors for ingestion of fish bones in Singapore

Pediatric Esophageal Foreign Bodies: The Role of Socioeconomic Status in Ingestion Patterns

OBJECTIVE

Pediatric esophageal foreign bodies (EFBs) are common and can result in serious complications. Little is known about the influence of socioeconomic status (SES) on EFB ingestion in children. The goal was to study SES as a risk factor for dangerous foreign body ingestion and in-hospital complications in children.

METHODS

This was a retrospective cohort study of children presenting to a tertiary care pediatric hospital with an esophageal foreign body from 2010 to 2021. SES was assessed for each patient by linking their postal code to the Ontario Marginalization Index to determine a quintile score across four dimensions of deprivation: residential instability, material deprivation, dependency, and ethnic concentration. Dangerous EFBs were defined as magnets, batteries, sharp objects, or bones. In-hospital complications included: intensive care unit admission, prolonged length of stay, and postoperative sequelae.

RESULTS

A total of 680 patients were included. Dangerous EFB ingestion was higher for children with increased residential instability (odds ratio [OR], 2.1; 95% confidence interval [CI], 1.2-3.6) and increased material deprivation (OR, 2.2; CI, 1.9-2.8), which was similarly true for odds of complications. Odds of dangerous EFB ingestion were higher in older children (OR, 1.1; CI, 1.0-1.1) and odds of complications were higher in children with comorbidities (OR, 1.1; CI, 1.0-1.3).

CONCLUSION

Higher levels of housing instability and material deprivation are associated with dangerous EFB ingestion and complications related to EFB ingestion. These findings emphasize the role that SES plays on child health outcomes and the need for initiatives to mitigate these disparities.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:2945-2953, 2024.

Consideration of Hyoid Variability in the Diagnostic Workup of Fishbone Foreign Body Aspiration

Fishbone foreign body (FFB) can lodge in the upper respiratory or gastrointestinal tracts and frequently cause discomfort. While FFBs are common, variations in the hyoid may present radiographically similarly. The authors present a case in which a 32-year-old woman presented with pain in the right neck with a globus sensation after eating fish. Examination, including flexible fiberoptic laryngoscopy, did not reveal a foreign body. Given the patients' persistent symptoms, a noncontrast computed tomography was performed, demonstrating a radiopaque body superior to the right lateral hyoid bone, consistent with FFB. Direct examination under anesthesia was performed, and no FFB was noted. A reassessment of the imaging suggested a likely aberrant hyoid bone. The authors report this case to remind clinicians that while rare, aberrant hyoid variants may mimic FFB. The authors also review the imaging findings of aberrant hyoid variants in this report, as recognition of hyoid variability can mitigate unnecessary intervention.

Pulmonary artery penetration due to fish bone ingestion: A rare case report

Accidental fish bone ingestion is a common manifestation at emergency departments. In most cases, ingested foreign bodies usually pass uneventfully through the gastrointestinal tract and complications only present in less than 5% of all patients. In this report, we present the first documented case of pulmonary artery injury due to a fish bone in a 63-year-old male patient hospitalized with hemoptysis after accidentally swallowing a fish bone 30 days ago. This patient subsequently had surgery and endoscopy to safely remove the foreign body and then recovered well on a follow-up examination. For cases of fish bone ingestion, contrast-enhanced chest computed tomography is one of the most essential tools to assess vascular problems and associated mediastinal infections-risk factors for life-threatening and long-term recurrent inflammation. Reconstructing planes along the foreign body axis and changing windows when analyzing CT scans is necessary to avoid missing lesions and dilemmas.

Risk Factors of Difficult Pharyngeal Accidental Fishbones Ingestion

OBJECTIVE

Accidental pharyngeal fishbone ingestion is a common complaint in ear, nose, and throat clinics. Approximately two-thirds of the accidentally ingested fishbones can be removed using tongue depressors and indirect laryngoscopy. However, the remaining third is challenging to identify and remove using these methods. These difficult fishbones require identification and removal via more advanced approaches. Video-guided laryngoscope is used to deal with difficult fishbones in our center. This study aimed to explore the risk factors for difficult fishbones.

METHODS

A prospective study was performed at a teaching hospital on 2080 patients. Univariate and multivariate analyses were performed to identify the risk factors.

RESULTS

The common fishbone locations were the tonsils (39.8%; defined as STEP-I), tongue base (37.1%), vallecula (13.3%; STEP-II), and hypopharynx (9.8%; STEP-III). With increasing STEP level, the ratio of difficult fishbones correspondingly increased (Z = 13.919, P < .001), and the proportions were 21.1%, 41.9%, and 70% in STEP-I, II, and III, respectively. In particular, fishbones in STEP-III (vs STEP-I) had a higher risk of difficult fishbones (odds ratio [OR]: 11.573, 95% CI: 7.987-16.769). Complaints of neck pain (yes vs no), foreign body sensation (yes vs no), and shorter length of fishbones always had a lower risk of difficult fishbones (OR: 0.455, 95% CI: 0.367-0.564; OR: 0.284, 95% CI: 0.191-0.422; OR: 0.727, 95% CI: 0.622-0.85). Missing teeth (yes vs no), swallowing behavior after fishbone ingestion (yes vs no), and male patients (vs female) had a higher risk of difficult fishbones (OR: 1.9, 95% CI: 1.47-2.456; OR: 1.631, 95% CI: 1.293-2.059; OR: 1.278, 95% CI: 1.047-1.56).

CONCLUSIONS

Neck pain, foreign body sensation, fishbone length, patient age and sex, tooth status, and swallowing behavior after fishbone ingestion are independent risk factors for difficult fishbones.

Pesky Pesce: A Forgettable Fish Dinner with a Late Surprise, a Perianal Abscess

Clinical presentation after ingestion of foreign body is a common finding in surgical practice. Perianal sepsis due to a foreign body is, usually, secondary to introduction via the trans-anal route. The case here reported is extremely rare since an ingested fishbone passed asymptomatically through most of the gastrointestinal tract, with resultant late-onset ischiorectal abscess. Moreover, clinical evidence of the perianal abscess manifested one month after the fishbone had been ingested. The final localization of the fishbone-lying anterior to the sacrum-complicated the preoperative and intraoperative detection of the ingested foreign body.

Migratory pharyngeal foreign bodies and related complications: Analysis of 20 cases

PURPOSE

To explore the diagnostic approach and therapeutic method of migratory pharyngeal foreign bodies and related complications, to improve the understanding of such disease and to reduce misdiagnosis and missed diagnosis.

MATERIAL AND METHODS

A retrospective study was performed by collecting patients who were treated because of the related complications caused by migratory pharyngeal foreign bodies from 2012 to 2020.

RESULTS

A total of 20 patients were admitted to hospital due to the related complications. 14 cases showed cervical mass; 3 cases showed abscess of the mouth floor; 1 cases showed retropharyngeal abscess; 1 cases showed laryngeal granuloma; 1 cases showed mass of tongue. All patients received imaging examination of B-ultrasonography or computed tomography (CT). 19 patients were treated by surgery, and 1 patient was taken conservative treatment. All foreign bodies was successfully removed. As for the type of foreign bodies, there have 15 cases of fishbone, 2 cases of crabshell, 2 cases of shrimp shell, 1 cases of duck bone.

CONCLUSIONS

Migrating foreign bodies and related complications are rare in clinic, much attention should be paid to avoid missed diagnosis or misdiagnosis.

Abdominal CT manifestations in fish bone foreign body injuries: What the radiologist needs to know

Fish bone is one of the most common foreign body ingestions encountered in the emergency department. Fish bone perforations occur most commonly in segments with acute angulation like the ileocecal region and rectosigmoid junction and can present acutely with obstruction and free air or with chronic complications like abscess and sepsis. Radiologists should be familiar with the high-risk clinical scenarios, the CT appearance of radiopaque fishbones, and the spectrum of imaging findings related to gastrointestinal (GI) tract so as to direct management and timely referral to GI endoscopists and surgeons.

Clinical presentation, diagnosis and management of aerodigestive tract foreign bodies in the adult population: Part 1

In the adult population, foreign bodies may be accidentally or intentionally ingested or even inserted into a body cavity. The majority of accidentally ingested foreign bodies pass through the alimentary tract without any complications and rarely require intervention. Accidentally ingested foreign bodies are usually fish bones, bones of other animals, and dentures. Oesophageal food impaction is the commonest cause of oesophageal foreign bodies in the Western hemisphere. Intentionally ingested foreign bodies may be organic or inorganic, and often require intervention; these patients have either underlying psychological or mental disease or are involved in illegal activities such as body packing, which involves trafficking narcotics. Imaging plays a crucial role in not only identifying the type, number and location of the foreign body but also in excluding any complications. In this comprehensive pictorial review, we provide an overview of the spectrum of foreign bodies ingested in adults, emphasising the role of various imaging modalities, their limitations and common foreign body mimickers on imaging.

Perianal abscess due to a long fish bone: a case report

Few articles have reported cases of perianal abscess due to ingested foreign bodies. Herein, we report a case of perianal abscess due to a long fish bone.

A 72-year-old man who was toothless and wore a denture had a chief complaint of anal pain. His left-side buttock had swelling and redness. Computed tomography revealed a perianal abscess on his left-side buttock and high-intensity linear structure in the abscess cavity. We made a diagnosis of perianal abscess due to a fish bone and performed an emergency operation. We opened the abscess cavity and removed the 5 cm fish bone from the cavity. After drainage of the abscess cavity and antibiotic administration, he was discharged from our hospital on day 8.

A long fish bone could cause perianal abscesses. Rapid diagnosis and ensuring fish bone removal are important to prevent sepsis.

Investigative strategies for fish bone foreign bodies during the coronavirus disease 2019 pandemic: an analysis of ENT UK guidelines

Background

By nature of their specialty, otolaryngologists are disproportionately exposed to coronavirus disease 2019 through aerosol-generating procedures and close proximity to the oropharynx during examination.

Methods

Our single-centre, retrospective study analysed the pertinence of guidelines produced by ENT UK to improve the investigation and management of suspected upper aerodigestive fish bone foreign bodies during the coronavirus disease 2019 pandemic.

Results

Our results demonstrated 43.3 per cent (n = 13) low-risk cases and 56.7 per cent (n = 17) moderate-risk cases. Nine fish bones (two low risk, seven moderate risk) were found; none of these were confirmed with X-ray and three (moderate risk) required nasoendoscopy for diagnosis. One patient required rigid pharyngoscopy.

Conclusion

This study confirms that soft tissue neck X-ray and flexible nasoendoscopy are unnecessary in low-risk cases; however, early nasoendoscopy in higher suspicion cases is appropriate. Recommendations are made about the long-term sustainability of these guidelines, and additional measures are encouraged that relate to repeat attendances and varying prevalence of coronavirus disease 2019 in the hospital catchment area.

Fish bone induced bronchial artery pseudoaneurysm in a patient with underlying bronchiectasis—a case report

Background

Fish bones are the most common cause of accidental foreign body ingestion, especially in Asian and Mediterranean nations. In most cases, the fish bones pass through the alimentary tract without any complications and rarely require any intervention. Less than 5% of the patients with accidentally ingested fish bones develop complications. In this report, we present the first documented case of a fish bone induced bronchial artery pseudoaneurysm in an elderly male with underlying bronchiectasis; the latter recognized as a risk factor for developing bronchial artery hypertrophy.

Case presentation

We report a case of a fish bone induced bronchial artery pseudoaneurysm in a patient with underlying bronchiectasis. The vascular complication induced by the fish bone was identified only on intravenous contrast CT and would not have been identified on plain CT alone. The patient underwent bronchial artery embolization, following which the fish bone was dis-impacted endoscopically.

Conclusions

Intravenous post contrast chest CT may have an important role in the evaluation of accidental fish bone ingestion, especially in patients with underlying lung diseases, as vascular complications are most often overt on a non-contrast CT study.

Appendicitis-mimicking presentation in fishbone induced microperforation of the distal duodenum: A case report

BACKGROUND

Upper gastrointestinal fishbone microperforations are rare and not commonly reported in medical literature. Despite the increasing use of computer tomography (CT) imaging and the employment of the Alvardo criteria, misdiagnosis of acute appendicitis can still occur. We report the rare case of an elderly Chinese gentleman who had a fish-bone induced microperforation of the duodenum that closely mimicked the symptoms of acute appendicitis.

CASE SUMMARY

This 79-year-old man presented with migratory lower abdominal pain that localized at his periumbilical region and right lower quadrant. He had associated pyrexia, general malaise and was noted to have an elevated white cell count. CT investigations initially revealed a distended appendix which was resected laparoscopically but showed no obvious signs of gross inflammation. The patient then deteriorated clinically and had increased oxygen requirements immediately after the surgery. This prompted further investigations. A further review of his CT scan revealed a fine fishbone microperforation in the distal duodenum associated with retroperitoneal abscess formation and seepage extending into the right lower quadrant. He was then started on broad spectrum intravenous antibiotics and subsequently underwent a laparotomy 12 h later to manage the obscure aetiology and to drain the abscess. The post-operative course was uneventful and he was discharged 11 d later including a 2-d stay in the intensive care unit.

CONCLUSION

This case offers an insight into a potential mimic of acute appendicitis and the diagnostic difficulties experienced in such presentations.

Management of Sharp-Pointed Esophageal Foreign-Body Impaction With Rigid Endoscopy: A Retrospective Study of 130 Adult Patients

OBJECTIVES

To propose a management algorithm for adult patients with sharp-pointed esophageal foreign-body impaction (EFBI) who have rigid endoscopy (RE) indications and to conduct a retrospective analysis of their data.

METHODS

All adult patients who received RE at the Department of Otorhinolaryngology in Beijing Shijitan Hospital between January 2017 and May 2019 were enrolled. The demographics, clinical characteristics, and management data were collected and analyzed.

RESULTS

A total of 130 patients were identified, 56.9% were female with median age 60 years. More than half (56.9%) of patients had foreign-body (FB) ingestion on holidays. The most frequent FBs were jujube pits (66.9%) and bones (23.8%). There is a significant female predominance in ingestion of jujube pits (65.5%, P = .005). The most common symptoms were odynophagia (49.2%) and sore throat (47.7%). The majority (96.8%) of FB founded were lodged at upper esophagus. In all, 74 patients were categorized as having mild complications and 54 having significant complications. Time interval from ingestion to presentation longer than 15 hours was an independent risk factor for significant complications, while esophagogram with barium as a protective factor.

CONCLUSIONS

Long-time interval from ingestion to presentation will lead to high risk of significant complications. Computed tomography should be a prioritized imaging method for all patients suspected with EFBI, and multidisciplinary collaboration is recommended. Besides, mass education on eating habits is necessary.

Radio-opacity of the Bones of Commonly Consumed Fish from the Red Sea

Introduction

Foreign body (FB) ingestion is one of the most common complaints presenting at an emergency department (ED), with fish bone impaction being a frequent cause of presentation. Fish bones might be challenging to identify on routine radiography and ED physicians are often left in a state of uneasiness owing to the fear of complications occurring if the fish bone is not removed.

Objective

This study aimed to establish the factors affecting the radio-opacity of fish bones on X-ray.

Materials and methods

The study involved the top three fish species consumed on Saudi Arabia’s western coast. Fish bones from three specimens of each species were radiographically examined by hand-picking bones from different parts of the fish, with particular attention paid to bones that are difficult to spot. Bones were then arranged beside each other, and radiographs were taken for comparison. Inter-species and intra-species radio-opacity variation was tested. Further, the weight of each fish and method of cooking (baked vs. fried) were tested for their effect on radio-opacity.

Results

No significant difference in radio-opacity was found among and between different species, and the method of cooking did not alter the radio-opacity of fish bones. Significant differences in radio-opacity were noted with the difference in the diameter and size of the fish bones, which tended to be less radio-opaque in smaller-sized fish, regardless of the species.

Conclusion

The exact fish species and method of cooking did not alter the fish bone density on an X-ray. The size of the fish and the size of the fish bone are better predictors of higher fish bone density.

Fish Bone Foreign Body: The Role of Imaging

Introduction  Fish bone foreign body (FFB) impaction in the upper aerodigestive tract is a common cause for emergency department referral. Its management varies in both diagnosis and treatment paradigms. Fish bone foreign bodies are more commonly found in the oropharynx in cases of patients < 40 years old, and in the esophagus in cases of patients > 40 years old. Symptoms are typically non-indicative for the location of the FFB, with the exception of foreign body sensation at/superior to the cervical esophagus. A lack of findings during the physical examination is routinely followed by imaging, with computed tomography (CT) being the preferred modality. In practice, many patients undergo unnecessary imaging studies, including CT scans.

Objectives  To identify patients with suspected fish bone impaction who do not require CT imaging and can be safely discharged.

Data Synthesis  We have searched the PubMed database for the following medical subject headings (MeSH) terms: fish bone , fish foreign body AND oropharynx , hypopharynx , esophagus , flexibleesophagoscopy , and rigidesophagoscopy . Our search in the English language yielded 32 papers. Case reports were included, since they highlighted rare and serious complications.

Conclusion  In patients > 40 years old suspected of fish bone impaction, non-contrast CT is recommended and should be urgently performed, even in the presence of ambiguous symptoms. However, in patients < 40 years old presenting within 24 hours from ingestion, imaging has little diagnostic value due to the low probability of esophageal fish bones. For this specific subgroup, in the absence of clinical findings, discharge without imaging studies may be considered safe.