Characteristics of fish-bone foreign bodies in the upper aero-digestive tract: The importance of identifying the species of fish

Fish bone migration: complications, diagnostic challenges, and treatment strategies

BACKGROUND

Fish bone impaction in the pharynx is a common otolaryngological emergency. However, if the fish bone perforates the pharyngeal wall or the gastrointestinal wall and migrates to the neck tissues or organs, entering the lungs, mediastinum, heart, liver, biliary tract, spleen, pancreas, or other structures, or damages major blood vessels in the thoracic or abdominal cavities, it can lead to severe complications. This condition is rare and dangerous, potentially resulting in a series of serious complications, including neck abscess, thyroid abscess, thrombosis or air embolism of the cervical vessels, esophageal perforation, rupture of major mediastinal vessels, mediastinitis, aorto-esophageal fistula, lung abscess, spinal injury, sepsis, splenic abscess, hepatic abscess, anal fistula, and it may even be misdiagnosed as a tumor.

OBJECTIVE

This narrative review synthesizes evidence on fish bone translocation complications to (1) identify high-risk clinical presentations, (2) guide site-specific imaging selection, and (3) inform multidisciplinary management strategies.

METHODS

Use the keyword "fishbone" to systematically search articles from PubMed、CNKI and Embase databases from 1972 to 2024. Review all original articles and include them in this review where appropriate. This narrative review synthesizes evidence from case reports and observational studies to explore complications and management of fish bone translocation in uncommon sites. Given the predominance of heterogeneous case reports, a formal systematic review with meta-analysis was not feasible; however, we employed systematic search strategies to minimize selection bias.

CONCLUSION

To avoid severe complications, it is crucial to provide comprehensive information on the management of fish bone impaction. When fish bone removal cannot be achieved using laryngoscopy, prompt and decisive surgical intervention is required to extract the foreign body.

Embedded Ileal Fish Bone Removed via Deep Enteroscopy in a Patient with Abdominal Pain and Hematochezia: A Case Report

Ingestion of foreign bodies is a prevalent issue in clinical practice, with fish bones being the predominant cause. While the upper gastrointestinal tract is commonly affected, small intestine impactions pose significant diagnostic challenges due to nonspecific symptoms and lack of awareness of foreign body ingestion. Herein, we describe a case presenting with recurrent, unexplained abdominal pain and hematochezia. Multiple diagnostic investigations, including esophagogastroduodenoscopy and colonoscopy, conducted over several months failed to identify the underlying cause until a retrograde single-balloon enteroscopy for obscure gastrointestinal bleeding revealed a 2.3 cm fish bone embedded in the distal ileum. The successful removal of the fish bone led to the resolution of the patient's symptoms. This case highlights that foreign bodies in the small intestine can be a cause of hematochezia and emphasizes the growing importance of deep enteroscopy techniques in detecting and retrieving these foreign objects, thereby reducing the need for surgery.

Traumatic Vocal Fold Paralysis from Fishbone Foreign Body: Diagnosis and Management

Fish bone foreign bodies (FFBs) are relatively common but can present diagnostic challenges. Herein, we report a case of a 43-year-old female who initially presented to the Emergency Department with fever and throat discomfort after a choking incident, which led to a misdiagnosis of a viral infection after negative chest X-ray findings. Persistent symptoms, including new-onset vocal cord paralysis, prompted further investigation and an otolaryngology - head and neck surgery referral one month later. During the otolaryngology visit eight months after the initial incident, laryngoscopy revealed left true vocal cord paralysis and a subsequent CT scan revealed a 2.3 cm fishbone in the esophagus. Surgical removal involved flexible esophagoscopy and open neck exploration with careful dissection to avoid vascular injury. This case highlights the limitations of initial diagnostic methods, such as X-rays, and the necessity for heightened clinical vigilance and advanced imaging modalities like CT scans for persistent or evolving symptoms, particularly vocal cord paralysis. This case also supports multidisciplinary surgical management in cases of suspected esophageal FFBs involving the internal jugular vein and common carotid artery to prevent serious complications. Laryngoscope, 134:5062-5065, 2024.

Survey of pharyngeal foreign bodies in Japan: An ecological study using the nationwide claims data

OBJECTIVE

Pharyngeal foreign bodies (PFBs) are a prevalent disease affected by food culture and dietary habits, with fish bones as the leading cause. Most studies were limited to specific regions, and a nationwide survey was not conducted in Japan. In this ecological study, we aimed to conduct a nationwide analysis of outpatient PFB cases in Japan over three years, focusing on seasonal trends, sex- and age-stratified cases, and regional differences.

METHODS

We used the National Database of Health Insurance Claims and Specific Health Checkups of Japan open data from April 2019 to March 2022. The case data were analyzed by month, age, sex, and prefecture. Additionally, we calculated the standardized claim ratios (SCRs) for each prefecture and investigated the association between dietary habits, food culture, and SCR of PFBs using a two-level linear regression model.

RESULTS

We analyzed a total of 164,337 outpatient PFB cases in Japan, revealing an average incidence rate of 45.6 per 100,000 persons. The seasonal trend revealed a peak in July each year from 2019 to 2021, confirming seasonality in PFB incidents. Children reported a higher incidence rate. Living west of Japan and expenditure on fish and shellfish had a strongly positive association with the SCR of PFBs.

CONCLUSION

Our nationwide survey reveals that, even within Japan, there were regional variations influenced by food culture and dietary habits. The data showed that PFB incidence was higher among children, highlighting the need for preventive education.

LEVEL OF EVIDENCE

Level 3.

Penetrating hypopharyngeal foreign body impalement of the thyroid gland: A case report of rare complication of ingested fish bone

INTRODUCTION AND IMPORTANCE

Foreign body ingestion complicated by hypopharyngeal perforation is an uncommon but potentially life-threatening condition. Early recognition and appropriate management are crucial to prevent serious complications. We present an extremely rare case highlighting the importance of this clinical entity.

CASE PRESENTATION

A 60-year-old female presented with odynophagia 10 days after ingesting fish and chicken. Imaging revealed a linear foreign body penetrating through the left lateral hypopharyngeal wall into the left thyroid lobe, with surrounding inflammatory changes. The patient underwent neck exploration, which identified a sharp fishbone lodged in the postero-medial aspect of the left thyroid lobe, necessitating a left hemithyroidectomy for removal.

CLINICAL DISCUSSION

To our knowledge, this is the first reported case of hypopharyngeal perforation by an ingested foreign body penetrating the thyroid gland itself. Despite its rarity, early recognition is crucial to prevent complications like abscess, mediastinitis, and mortality. A high index of suspicion is needed in patients with odynophagia or neck pain after ingesting fish. Advanced imaging and surgical intervention may be required for the management of larger perforations or those involving surrounding structures.

CONCLUSION

This unique case highlights an extremely rare presentation of hypopharyngeal perforation with extension into the thyroid gland caused by an ingested fish bone. Prompt diagnosis through appropriate imaging and treatment with surgical exploration and foreign body removal was key to ensuring a positive outcome. Increased awareness of this potential complication is essential among clinicians.

Ensuring that ingested fishbones that migrate to the neck are located, diagnosed, and removed early

OBJECTIVES

The aim of this retrospective study was to explore the clinical characteristics of and diagnostic and therapeutic strategies for the removal of fish bones that migrate to the neck.

METHODS

We reviewed the clinical data of 30 patients over the past 12 years who underwent neck surgery in our otorhinolaryngology department for the migration of fish bones from the throat. The location of fish bones and the positivity rate of different examination methods (neck CT and B-ultrasound) were evaluated statistically. The diagnosis and treatment strategy for fish bone migration to the neck was also summarized.

RESULTS

A total of 24 patients had a history of foreign body ingestion. The duration from foreign body ingestion to the appearance of symptoms in the neck ranged from 26 to 151 days, with a median of 50 days (interquartile range, 32-86 days). Among the 24 patients with fish bones located in the front or side of the neck, 50% (12/24) and 100% (24/24) of whom had positive neck CT and B-ultrasound results, respectively. Additionally, for 6 patients with fish bones in the retropharyngeal space, the positive rate for neck CT was 100%, whereas neck B-ultrasound showed negative results due to the air and depth in the trachea and esophagus. A strong correlation was observed between the length of fish bones detected by B-ultrasound and CT and the actual length. Indeed, no significant difference was observed between the length of fish bone determined by B-ultrasound and the actual length. In patients with fish bones located in the anterior and lateral neck regions, the foreign bodies were successfully removed by a lateral cervical approach operation (23/24). For the 6 cases with fish bones located in the retropharyngeal space, all (6/6) were removed by incising the posterior pharyngeal wall with assistance from transoral endoscopy.

CONCLUSIONS

The techniques of B-ultrasound and CT have advantages for the diagnosis of migratory foreign bodies in the neck. Although B-ultrasound is more accurate for estimating the length of migratory fish bones in the neck, a combination of both methods can improve the preoperative positive rate of diagnosis. Therefore, a variety of surgical approaches should be employed to manage the different locations of cervical foreign bodies.

Clinical manifestations, endoscopic findings and outcomes of tonsillar fossa foreign bodies in dogs: seven cases (2020-2023)

OBJECTIVES

Clinical presentation and outcomes of dogs with tonsillar foreign bodies are not described in the literature. The objective of this case series is to describe the presence, clinical manifestations, endoscopic findings and outcomes of foreign bodies in the palatine tonsillar fossa of dogs.

MATERIALS AND METHODS

Medical records of dogs in which tonsillar fossa foreign bodies were removed by endoscopy between 2020 and 2023 at a referral centre were reviewed. Dogs were included if complete medical records were available.

RESULTS

Seven dogs were included. Among all clinical signs reported, acute onset of throat clearing occurred in all dogs. Palatine tonsil enlargement and protrusion from the tonsillar fossa were observed in four of seven dogs. Foreign bodies were removed under endoscopic guidance in all dogs; a vegetal foreign body was found in all but one dog (6/7). Complete resolution of clinical signs was reported in the five dogs for which follow-up information was available.

CLINICAL SIGNIFICANCE

The tonsillar fossa is a rare but possible location for foreign bodies in dogs and should be explored even in the absence of macroscopic lesions of the tonsils, since some dogs could have a normal palatine tonsil appearance. Acute throat clearing should raise the suspicion of tonsillar fossa foreign bodies. The prognosis appears good after removal.

Fishing Out a Bone From the Neck

Foreign body ingestion is a common medical issue in Asian populations. Fish bones are the most commonly ingested foreign bodies due to the practice of cooking fish whole with bones intact, unlike in Western countries where fish are typically prepared as fillets or patties. Patients who have swallowed fish bones usually present with foreign body sensations, odynophagia, and pricking sensations during deglutination. Fish bones can generally be removed in an outpatient setting, but in some cases, patients must be placed under general anesthesia, where rigid esophagoscopy is performed. In some cases, neck exploration is required to extricate the bone. Here, we report the case of a 71-year-old man who underwent neck exploration for a 2.1 cm fish bone lateral to his thyroid cartilage, penetrating the left thyroid lobe.

Translocation of a fish spike from the pharynx to the thyroid gland: A case report

BACKGROUND

A fish spike stuck in the throat is a common ear, nose, and throat (ENT) emergency. However, it is very rare for a fish spike to reach the thyroid tissue through the throat, which is very dangerous and can lead to pharyngeal fistula, cervical abscess, mediastinal abscess, and thyroid abscess. Proper and timely management can help reduce complications, especially in elderly patients.

CASE SUMMARY

In the case presented here, the causative factor was dentures, but improper management aggravated the condition. In the case presented here, an elderly woman with a history of accidentally swallowing fish bones for 20 d had a sensation of foreign bodies in her throat. Eventually, computed tomography (CT) of the neck showed that the left side of the thyroid gland had a dense shadow in the form of a stripe.

CONCLUSION

If a fishbone foreign body is not visible during endoscopic examination but the patient has significant symptoms, the surgeon should be aware that the fishbone may be lodged in the thyroid. To avoid a misdiagnosis, ultrasound, CT, and other tests can be used to clarify the diagnosis. T The first step in treating a fish bone in the thyroid gland is to determine the position of the foreign body and the extent of the infection, and to develop a personalized surgical plan for its removal. At the same time, scientific information should be made available to the general public so that people know that if a fish bone is accidentally lodged, they should not force it to be swallowed or be spit out by inducing vomiting, which are incorrect methods and may aggravate the condition or even cause it to migrate outside the cavity, leading to serious complications, as in this reported case.

The Transition of Pediatric Tracheobronchial Foreign Body Cases in the Past 36 Years: A Retrospective Single-Center Study in Japan

Tracheobronchial foreign bodies (TFBs) are pediatric airway emergencies frequently seen. We aimed to examine the changes in the clinical characteristics of pediatric TFB patients in a single institution within the past 36 years. We retrospectively reviewed the data of 85 patients aged 0-10 years with TFBs lodged in the trachea or bronchus admitted at the Department of Otolaryngology-Head and Neck Surgery at Tohoku University Hospital between 1986 and 2021. We also compared the characteristics, diagnostic methods, and treatments of the previous 64 cases (1986-2005) with those of the recent 21 cases (2006-2021). The number of TFB patients decreased later in this study (3.2 vs. 1.3 patients per year). The proportion of TFB patients aged > 3 years was significantly higher in the later period (6.3% vs. 23.8%, p = 0.038). Peanut was the most common cause of TFBs in both periods, and the overall incidence of peanut aspiration significantly decreased in the later period (68.8% vs. 38.1%, p = 0.019). No patient had an undetected TFB for more than 1 month after the onset of symptoms in the later period. Foreign body extraction using rigid bronchoscopy was performed in all patients earlier, whereas flexible bronchoscopy was used in 14.3% later. Our study revealed a recent trend in the clinical characteristics of pediatric TFB patients in a single institution in Northeast Japan. The prevention and treatment of pediatric TFBs should be considered following the recent trends.

Delayed pathological finding of a small fish bone causing a purulent cyst in the pharynx: a case report

We describe the case of a patient who swallowed a small fish bone and felt it lodge in her pharynx, but failed to seek medical attention in a timely manner. One week later, no foreign body was found in the hypopharynx or larynx, but a small purulent cyst was present in the epiglottic vallecula. A computed tomography scan showed a high-density area on the lingual surface of the epiglottis, which was considered to represent an embedded fish bone. A week later, the patient's discomfort had subsided, and flexible videoendoscopy showed that the purulent cyst in the epiglottic vallecula had disappeared. We surmise that the purulent cyst had ruptured spontaneously and the foreign body had been discharged. This represents an example of how an impacted small foreign body may be spontaneously discharged from the body.

Endoscopic Removal of a Nasopharyngeal Foreign Body Stuck Within the Sphenoid Bone Using the Endonasal Transseptal Approach

ABSTRACT

Nasopharyngeal foreign bodies (FBs), which are generally caused by a strong, external force, are seldomly encountered. Removing these FBs is challenging for otorhinolaryngological surgeons because of the vital structures surrounding the nasopharynx, such as the skull base, cranial nerves, and internal carotid artery. Here, the authors report the case of a 69-year-old man referred to our hospital after accidentally cutting his face while using a grinder. Grinder fragments were deeply embedded in the face, thus becoming nasopharyngeal FBs. The authors evaluated three-dimensional volume rendering images and immediately removed these FBs using an endoscopic endonasal transseptal approach under general anesthesia. The postoperative course was uneventful. Using the endoscopic endonasal transseptal approach after evaluating preoperative three-dimensional volume rendering images may help eliminate nasopharyngeal FBs safely.

Fish bone migration after pancreaticoduodenectomy: Incidence and treatment options

OBJECTIVE

Migration of a fish bone to the bile duct or pancreatic duct is a possible complication after pancreaticoduodenectomy (PD). The aim of this study was to clarify the incidence and indications for intervention in such cases.

METHODS

We reviewed the cases with fish bone migration after PD detected on computed tomography (CT) scan between October 2000 and October 2020 were reviewed and the incidence of fish bone migration, presence of symptoms and signs, therapeutic modalities and patient outcomes were analyzed.

RESULTS

Among the 1475 PD procedures performed at our institution during the study period, 14 cases of fish bone migration were noted on CT, the incidence of which was 0.95% (14/1475). The time duration from surgery to the detection of fish bone ranged from 88 to 5902 days (median 917 d). Ten patients remained asymptomatic without therapeutic intervention for up to 2919 days (median 509 d). Four patients were treated by endoscopy, either at the patient's request (n = 1) or because of their symptoms (n = 3), and removal was successful in three cases but failed in one case in which the fish bone migrated to the right intrahepatic bile duct. No surgical treatment was required in any case.

CONCLUSIONS

The incidence of fish bone migration on CT after PD was about 1%. Some cases resolved spontaneously, and most of the asymptomatic cases required no intervention. For symptomatic cases, endoscopic treatment should be considered first. It is important to confirm the location of the fish bone by CT and determine whether it can be removed.

Hypopharyngeal Perforation Following Foreign Body Ingestion: A Case Report

Foreign body ingestion is a common complaint frequently seen in otolaryngology. Some sharp foreign bodies may get impacted in the aerodigestive tract causing a perforation. However, hypopharyngeal perforation is a rare injury that needs early recognition due to its significant morbidity. In this case report, we report a case of hypopharyngeal perforation caused by foreign body ingestion in an adult patient. A 60-year-old female presented with a foreign body sensation in the throat, dysphagia, and odynophagia. A neck CT scan showed a foreign body in the hypopharynx with a collection of free air along the posterior pharyngeal wall. She underwent laryngoscopy and esophagoscopy for examination and foreign body removal. Following the procedure, the patient was treated conservatively for a week and then discharged home in a stable condition. Hypopharyngeal perforation following foreign body ingestion is uncommon. A high index of suspicion is required to reach an early diagnosis and treatment.