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.

The Vulnerable Indian One Rupee Coin

Coins are the most commonly ingested foreign body encountered in the pediatric population, with a peak incidence between 6 months and 3 years of age. Although some ingested coins may be aspirated, most coins pass through the alimentary tract without causing any complications. Coins in the esophagus causing symptoms require immediate removal. The management of asymptomatic coins has been a perplexing problem to the clinicians for decades. We recently managed an interesting case of an impacted Indian one rupee coin in the esophagus of a 13-year-old girl, by performing a simple yet novel technique, by using a conventional flexible endoscopic biopsy forceps. Further, reviewing the literature we inferred that the rounded, stainless steel Indian one rupee coin with a diameter of 25 mm, by itself seems to be vulnerable for impaction in the esophagus and therefore needs to be promptly addressed even if asymptomatic.