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Egyptian Journal of Ear, Nose, Throat and Allied Sciences 18 (2017) 27–30

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Egyptian Journal of Ear, Nose, Throat and Allied Sciences


journal homepage: www.ejentas.com

Original article

Management of fish bone impaction in throat – Our experiences in a


tertiary care hospital of eastern India
Santosh Kumar Swain a,⇑, Santosh Kumar Pani a, Mahesh Chandra Sahu b
a
Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha ‘‘O” Anusandhan University, K8, Kalinganagar, Bhubaneswar 751003, Odisha, India
b
Directorate of Medical Research, IMS and SUM Hospital, Siksha ‘‘O” Anusandhan University, K8, Kalinganagar, Bhubaneswar 751003, Odisha, India

a r t i c l e i n f o a b s t r a c t

Article history: Objective: To find out prevalence of accidental ingestion of fish bones and its management in a tertiary
Received 29 September 2016 care hospital of eastern India.
Accepted 8 December 2016 Materials & methods: This is a prospective observational study. Three hundred thirty patients with com-
Available online 18 December 2016
plains of fish bone in throat who presented to the out patients department of Otorhinolaryngology and
the emergency department of a Medical college between January 2008 to December 2015 were short-
Keywords: listed for study. Followed by conventional examination, most were subjected to endoscopic examination
Foreign body
and removal. The parameters analyzed were age and sex distribution, clinical presentation, duration of
Fish bone
Pharynx
symptoms, location of impaction, conventional and endoscopic removal techniques.
Endoscopy Result: Among three hundred thirty patients, no foreign body was found in eighty patients. Patients in
age group of 21–30 years were affected mostly with almost equal sex distribution. Most patients pre-
sented with foreign body sensation in throat of short duration with precise finger point localization.
Both conventional and endoscopic methods were employed with successful results but with definite
advantage of endoscopic method.
Conclusion: Fish bone in throat is a common occurrence in Otorhinolaryngological practice. Fish bone
impaction is a common foreign body in the pharynx. Endoscopic removal is distinctly more helpful than
the conventional ones.
Ó 2016 Egyptian Society of Ear, Nose, Throat and Allied Sciences. Production and hosting by Elsevier B.V.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-
nd/4.0/).

1. Introduction pushes a bolus of food posteriorly during the act of swallowing


and any sharp object hidden in that bolus may become embedded
Fish bone is a common foreign body seen in upper digestive in the tonsil, the tonsillar pillar, the pharyngeal wall, or the tongue
tract encountered at outpatient department of Otorhinolaryngol- base itself. The correct diagnosis is best done with the help of fiber
ogy and emergency room.1 Accidental ingestion of fish bone optic laryngopharyngoscope or rigid endoscope. Availability of rod
(Fig. 1) and its impaction in pharynx is very common among the lens telescope, video-endoscopy, varieties of forceps and safer
fish eating communities in this coastal belt of eastern India. The anesthesia facility has facilitated removal of fish bone in throat.
common fish consumed in this belt are Rohu (Labeo rohita), Bhekti All patients who complain of a fish bone stuck in the throat should
(Latus calcarifer), Hilsa (Tenualosa ilisha) besides others. If fish be taken seriously as a fish bone can perforate the oesophagus in
bone is not removed timely, it may lead to significant morbidity only a few days leading to several complications. All possible fish
and complications like deep neck infection, mediastinitis, perfora- bone in throat patients need to be subjected for endoscopy to avoid
tion of oesophagus, retropharyngeal hematoma, pyopneumothorax complications and morbidity. This study analyses the fish bone
and even death.2 All are having poorly radio-opaque bones and are ingestion in our region and find out the safe and easy method to
therefore likely not to be seen on X-ray. The base of the tongue take out fish bone from throat at out patient department (OPD).

2. Material and methods


Peer review under responsibility of Egyptian Society of Ear, Nose, Throat and Allied
Sciences.
⇑ Corresponding author at: Department of Otorhinolaryngology, IMS&SUM All the three hundred thirty patients presenting with complains
Hospital, Kalinga Nagar, Bhubaneswar 3, Odisha, India. of a pricking sensation in their throat or sharp pain in throat with a
E-mail address: santoshvoltaire@yahoo.co.in (S.K. Swain). history of ingestion of fish in the Out patients department(OPD) of

http://dx.doi.org/10.1016/j.ejenta.2016.12.001
2090-0740/Ó 2016 Egyptian Society of Ear, Nose, Throat and Allied Sciences. Production and hosting by Elsevier B.V.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
28 S.K. Swain et al. / Egyptian Journal of Ear, Nose, Throat and Allied Sciences 18 (2017) 27–30

clinical examination under a good light source whereas pharyngo-


laryngoscopes are very much helpful in detecting foreign bodies in
the tongue base and valleculae and some cases of cryptic fish bones
in the tonsils (Table 5). Most fish bones are found to be lodged in
the tonsillar region (31.6%) followed by tongue base (20.4%) and
valleculae (18.4%) (Table 6). Conventional methods using head
light, tongue depressor and different forceps helped to remove fish
bones lodged especially in oral cavity (7.2%), tonsils (17.6%), but
endoscopic removal is more convenient in cases of cryptic foreign
bodies in tonsillar pillar region (10.4% 0 and tongue base (15.2%) as
well as vallecular area (13.6%) (Table 7). For fish bone impaction at
tonsils and below, the comparison of two techniques of conven-
tional and endoscopic methods with t-test was carried out. It
was revealed p = 0.03 which is statistically significant. Thus endo-
scopic method is more effective in comparison to conventional
technique. Out of 250 cases of fish bone impaction, 221 foreign
bodies were removed on initial visit (88.4%) and only in 29 cases
fish bones were removed on subsequent visit (Table 8). In total,
250 cases of fish bone FB identified out of 330 suspected cases with
prevalence 75.75%.
Fig. 1. Fish bone extracted from the patient.

4. Discussion
Otorhinolaryngology and emergency department were included in
this study between January 2008 and August 2016. This study was
Impaction of fish bone at upper digestive tract is a common
approved from the competent authority of our Institutional Ethics
clinical problem in Otorhinolaryngology practice. The most com-
Committee. Patient’s prescription tickets and case records were
mon foreign body in upper digestive tract is fish bone.3 Accidental
collected from the Medical Records Section and the data were
Ingestion of fish bone is very common in fish eating communities
entered in a prepared database and were analyzed. The parameters
and usually the swallowed bone is small and sometime passes
analyzed in this study were age and sex distribution, history of
down the gut without consequences. Often fish bone if found to
duration of complains symptoms and signs, diagnostic investiga-
be stuck mostly in the throat or penetrating the mucosa of phar-
tions, location of foreign body, removal techniques, removal on ini-
ynx. In rare cases it may penetrate oesophagus or stomach4 caus-
tial & subsequent visits. Removal of fish bone in throat was done in
ing retropharyngeal abscesses,5–7 or even penetrating the
Outpatient department as a standard procedure under local anes-
pericardium causing cardiac tamponade.8 Hence careful inspection
thesia. In some cases however removal was done after investiga-
and endoscopic review should be followed in all cases. The com-
tions and under general anesthesia.
mon locations for fish bone lodgment are palatine tonsils, base of
tongue and vallecula. Sharp foreign bodies like fish bone when
3. Results ingested, often cause abrasion to pharyngeal mucosa and may
cause perforation to the wall of the oesophagus.9 The patient
Impaction of fish bone in throat most commonly seen in the age should be thoroughly examined with a complete visual inspection
group of 21–30 years (48%), however fish bone was also found in of the oral cavity, oropharynx and hypopharynx. Out of a total of
throat in children as young as 1–10 years (4%) and in older people three hundred thirty cases who attended the hospital with com-
in the age group above 50 years (9%) (Table 1). Out of 250 patients plains of fish bone in throat, in eighty patients (24.2%) no foreign
with fish bone, 130 (52%) are males and 120 (48%) are females body was found and their symptoms settled. In 80% of these cases
(Table 2). A t-test was compared between male and female cases this had occurred by 48 h. It is likely that their symptoms were due
of fish bone foreign body (FB). It was revealed that p = 0.8457 either to minor abrasions to the mucosa which healed rapidly and
which was statistically insignificant. Thus fish bone FB equally dis- spontaneously or possibly an undetected fish bone passing down
tributed in both gender. Early presentation is within 24 h irrespec- without any harm.10 In this study, 24.2%of patients presenting with
tive of sites of fish bone impaction (Table 3). Most of the patients symptoms of an impacted fish bone had no demonstrated pathol-
presented with foreign body sensation with finger point localiza- ogy, and their symptoms resolved in 48 h where as 76.8% per cent
tion (87%) followed by pain in throat (74%) and pain during swal- did have an impacted fish bone, and 56% of these were easily iden-
lowing (58%) (Table 4). Foreign body lodged in oral cavity and tified and removed on initial visit by endoscopic method and rest
tonsillar region in the oropharynx are easily diagnosed by careful were removed by conventional methods. In our study, fish bone

Table 1
Table showing fish bone by site and age group.

Site 1–10 years 11–20 years 21–30 years 31–40 years 41–50 years Above 50 years Total
Oral cavity 11 5 2 18 (7.2%)
Tonsil 4 11 41 14 6 3 79 (31.6%)
Tonsillar pillar 3 20 14 3 1 41 (16.4%)
Pharyngeal wall 8 4 1 13 (5.2%)
Tongue base 7 27 15 2 51 (20.4%)
Vallecula 19 17 7 3 46 (18.4%)
PYRIFORM SINUS 1 1 (0.4%)
Oesophagus 1 1 (0.4%)
Total 4 (1.6%) 32 (12.8%) 120 (48.0%) 64 (25.6%) 21 (8.4%) 9 (3.6%) 250 (100%)
S.K. Swain et al. / Egyptian Journal of Ear, Nose, Throat and Allied Sciences 18 (2017) 27–30 29

Table 2
Table showing fish bone by site and sex.

Sex Oral cavity Tonsil Tonsillar pillar Pharyngeal wall Tongue base Vallecula Pyriform Sinus & oesophagus Total
Male 10 43 21 6 22 26 2 130
Female 8 36 20 7 29 20 0 120

Table 3
Table showing duration of presentation in respect to site of fish bone.

Site <6 HRS 6–12 HRS 12–24 HRS 24–48 HRS 48 HRS–1 WK 1 WK–2 WK
Oral cavity 12 4 1 1
Tonsil 34 22 10 8 5
Tonsillar pillar 18 14 4 3 2
Pharyngeal wall 6 4 3
Tongue base 22 14 8 5 2
Vallecula 18 16 6 2 3 1
Pyriform sinus 1
Oesophagus 1
Total 110 (44%) 74 (29.6%) 32 (12.8%) 19 (7.6%) 13 (5.2%) 2 (0.8%)

Table 4
Table showing magnitude of different clinical symptoms in fish bone ingestion. (31.6%) followed by tongue base (20.4%) and vallecula (18.4%). This
is comparable with the study by Knight LC et al.10 who reported
Clinical symptoms Number of cases Percentages
base of tongue and tonsils as the common sites for fish bone
Foreign body sensation 87 34.8% impaction. It also conforms to the findings in a study by Sam et al.14
Pain Throat 74 29.6%
Long standing missed fish bone can lead fatal complications like
Odynophagia 58 23.2%
Dysphagia 22 8.8% mediastinitis, mediastinal abscess, pyopneumothorax, retropha-
Spitting blood 7 2.8% ryngeal hematoma and pseudo-aneurysm of aorta.15 Considering
Fever 2 0.8% the potential life threatening complications of fish bone at upper
digestive tract, it is imperative to detect early and remove before
arising any complications. The following things should be in the
impaction was found in all age groups but mostly in the young mind during removal of foreign bodies: type and site of lodgment
people between 21 and 30 years of age (46.8%). This may be attrib- of foreign body, time interval between ingestion and clinical pre-
uted to rapid change in life style and carelessness in this group. The sentation and age of the patient.16 Management of fish bone at
sex distribution is almost equal 1.08:1 which is similar to studies upper digestive tract begins with direct visualization by light
by A. Poluri et al.11 Early presentation was found to be common source. If direct visualization is successful, fish bone will be
mostly within 24 h irrespective of sites of fish bone impaction. It removed by forceps. However, sometimes fish bone passed beyond
was found that patients who had impaction of fish bone in throat the level of direct visualization and need help of fibreoptic/rigid
mostly presented early i.e. within 6 h of ingestion (44%). In 2 cases laryngopharyngoscope. It will confirm the location of fish bone in
(0.8%) there was late presentation. Most of the patients presented pharyngeal area. Various removal techniques employed showed
with foreign body sensation with finger point localization (87%) that conventional methods using head light, tongue depressor
followed by pain in throat (74%) and pain during swallowing and different forceps helped to remove fish bones lodged especially
(58%). Foreign body lodged in oral cavity and tonsillar region in in oral cavity (7.2%), tonsils (17.6%), but endoscopic removal was
the oropharynx were easily diagnosed by careful clinical examina- more convenient in cases of cryptic foreign bodies in tonsillar pillar
tion under a good light source whereas pharyngolaryngoscopes region (10.4%) and tongue base (15.2%) as well as vallecular area
were very much helpful in detecting foreign bodies in the tongue (13.6%). Different studies have shown the advantage of endoscopic
base and vallecula and some cases of cryptic fish bones in the ton- removal.17 Out of 250 cases of fish bone impaction, 221 foreign
sils. Plain X-ray of the neck and chest can be done to find out the bodies were removed on initial visit (88.4%) and only in 29 cases
location of fish bone, but many authors have reported poor sensi- fish bones were removed on subsequent visit. This is comparable
tivity and specificity of X-ray on detecting the fish bone at the to most of the studies done by Knight et al.17 Polcrova et al.,4
upper digestive tract.12 Computed tomography (CT) scan is an use- Sam et al.14 and Lee et al.18 Removal of fish bones lodged at the ton-
ful radiological investigation to confirm the existence and location gue base, vallecula, and hypopharynx under video laryngeal tele-
of fish bone, also localize the damage of neighboring structures.13 scopic guidance has the advantages of good illumination, clear
Most fish bones were found to be lodged in the tonsillar region visualization, and precise extraction. Early diagnosis by locating

Table 5
Table showing different diagnostic modalities for finding fish bone in different locations.

Site Clinical exam/Pharyngoscopy Indirect laryngoscopy Pharyngo-laryngoscopy Oesophagoscopy Lateral soft tissue X-ray neck CT Scan
Oral cavity 18 0 0 0 0 0
Tonsil 71 0 8 0 0 0
Tonsillar pillar 38 0 3 0 0 0
Pharyngeal wall 12 0 1 0 0 0
Tongue base 6 15 29 0 1 0
Vallecula 0 11 35 0 0 0
Pyriform sinus 0 0 1 0 0 0
Oesophagus 0 0 0 1 1 1
30 S.K. Swain et al. / Egyptian Journal of Ear, Nose, Throat and Allied Sciences 18 (2017) 27–30

Table 6 5. Conclusion
Table showing fish bone in different locations of upper digestive tract.

Site Number Percentage Ingestion of foreign bodies is an avoidable incident. Fish bone
Oral cavity 18 7.2% impaction is commonly encountered clinical problem. The preva-
Tonsil 79 31.6% lence of fish bone impaction of 75.75% were identified in our
Tonsillar pillar 41 16.4% region. If it is not detected early may cause fatal complications.
Pharyngeal wall 13 5.2%
Early diagnosis and immediate removal of fish bone is the appro-
Tongue base 51 20.4%
Vallecula 46 18.4% priate treatment which is smoothly done by endoscope. Removal
Pyriform sinus 1 0.4% of fish bone from upper digestive tract under endoscopic guidance
Oesophagus 1 0.4% has the advantages of good illumination, clear visualization and
precise extraction. This technique has also proven to be efficient,
safe, well tolerated, and with low morbidity in case fish bone at
Table 7 oropharynx and hypoharyngeal area.
Table showing different techniques used for removal of fish bone from throat.

SITE Conventional method Endoscopy by Endoscopy by


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