3.13 Foreign Body in Throat
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agk's Library of Common Simple Emergencies

Presentation
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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:
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- 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, pneumomedia- 
   stinum, 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 nasopharyngoscopy is preferred 
   when available. Further treatment is probab- 
   ly 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 divertic- 
   ulum, 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 prefer- 
   able 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, 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 
   mucosa 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:
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- 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 incident- 
   ally 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
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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.

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