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Case of the Month 3/06

The NewYork-Presbyterian Emergency Department radiology teaching files database has been built up over the last several years. All cases in the database were seen at the NewYork-Presbyterian Emergency Department. This case is drawn from the database. Review the image and read the corresponding case before going on to the answers.

This patient presented complaining of a foreign body sensation in the throat after eating fish the day before. She has throat pain but denies before or trouble swallowing. The x-ray is read as no foreign body.

Q: What are some of your next options?

View answer

Contrast esophagram – involved patient swallowing contrast to help identify the location of a foreign body (rarely used since the advent of easily accessible CT scanning.) This procedure may interfere with future direct visualization.
CT neck (non-contrast) – may also help to diagnose associated complications (i.e. abscess, perforation) of esophageal foreign body.
Direct visualization and removal with endoscopy.

Q: How may your reading of the x-ray help you decide which one is best?

View answer

Upon closer visualization, you notice the bone just above the hyoid bone. You may now go straight to endocscopy for removal. This patient had a fish bone removed from the vallecula by ENT without difficulty.

Q: How useful are plain films in cases of suspected fish or chicken bone stuck in the esophagus?

View answer

A: Not very. Calcification of fish and chicken bones is often incomplete and so they cannot always be visualized on plain films. Also, there is a high amount of false positivity of plain films for foreign body due to calcified airway cartilages. (This begins in the third decade of life and progresses with age.)