Oroesophageal Fish Bone Foreign Body

Abstract

Fish bone foreign body (FFB) is the most frequent food-associated foreign body (FB) in adults, especially in Asia, versus meat in Western countries. The esophageal sphincter is the most common lodging site. Esophageal FB disease tends to occur more frequently in men than in women. The first diagnostic method is laryngoscopic examination. Because simple radiography of the neck has low sensitivity, if perforation or severe complications requiring surgery are expected, computed tomography should be used. The risk factors associated with poor prognosis are long time lapse after FB involvement, bone type, and longer FB (>3 cm). Bleeding and perforation are more common in FFB disease than in other FB diseases. Esophageal FB disease requires urgent treatment within 24 hours. However, FFB disease needs emergent treatment, preferably within 2 hours, and definitely within 6 hours. Esophageal FFB disease usually occurs at the physiological stricture of the esophagus. The aortic arch eminence is the second physiological stricture. If the FB penetrates the esophageal wall, a life-threatening aortoesophageal fistula can develop. Therefore, it is better to consult a thoracic surgeon prior to endoscopic removal.

Keywords: Bone and bones; Esophagus; Foreign bodies; Pharynx; Seafood.

Fig. 1.

Complicated case of esophageal fish bone foreign body (FFB) of a 43-year-old man who had alcoholic liver cirrhosis and chronic pancreatitis and had complained of back pain since 3 days before. (A) Endoscopic photography shows a typical damselfish (“Jari ” in Korean) FFB near the aortic arch eminence. There was no evidence of an aortic arch injury on the first computed tomography (CT). During endoscopy, the FFB impacting one side of the esophageal wall was removed using foreign body forceps and the penetrated hole was sutured using a hemoclip. Approximately a 2.5-cm length of typical “anal fin spine-pterygiophore complex ” FFB was removed successfully. On the second hospital day, fever and dyspnea were aggravated. On the follow-up CT, pneumomediastinitis with abscess formation was seen (B, cross-section; C, coronal section; D, sagittal section). Note that free air and inflammatory material extended up to the retronasopharyngeal space. The patient transferred to the surgical ward and underwent surgery on hospital day 3. The postoperative course was uneventful and the patient was discharged on hospital day 30.

Fig. 2.

A typical case of upper esophageal fish bone foreign body (FFB) disease in a 62-year-old woman complaining odynophagia after eating a fish (Lateolabrax japonicus) 1 day before. (A) On the neck lateral X-ray (NLX) and (B) its magnified view, about 3 cm of linear opacity was seen. (C) The FFB was removed using cap-fitted endoscopy. In cases of upper esophageal FFB above the thoracic inlet, a simple NLX is a useful single modality to diagnose the FFB disease prior to do endoscopic examination without need to check computed tomography. Arrows denote FFB.

Fig. 3.

Neck lateral X-ray (NLX) and computed tomography (CT) to identify fish bone foreign bodies (FFBs). (A) Hypopharyngeal FFB. (B) Cervical esophageal FFB. (C) Thoracic esophageal FFB. The hypopharyngeal and cervical esophageal FFB are well detected on the NLX. However, below the thoracic inlet, only CT can detect the FFBs. Arrows denote FFBs.

Fig. 4.

(A-F) Serial endoscopic photos of removal of the esophageal flat fish bone foreign body (FFB) using an overtube. Many esophageal FFB are flat, large, and have a sharp polygonal edge. For this reason, esophageal laceration can be evoked during FFB retrieval, especially upper esophageal sphincter. Using an overtube not only protects the upper esophageal mucosa from laceration but also helps protect the airway from aspiration.

Fig. 5.

Usefulness of cap-fitted endoscopy in the collapsed pharyngeal space. A linear fish bone foreign body (FFB) is totally imbedded in the right vallecula on computed tomography (A). Serial photos to find, expose, and remove the imbedded FFB (B). The naked endoscopic tip cannot approach and visualized the collapsed space. The cap-fitted endoscopy is useful not only visualize the collapsed mucosa but also detect and expose the imbedded FFB by sweeping mucosa with the edge of the cap. Cap also makes the sufficient space to operate the forcep to remove the FFB in the collapsed space.