FOREIGN BODY - THROAT
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:
* 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, pneumomediastinum, 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 nasopharyngo- scopy is preferred when available. Further treatment is probably 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 diverticulum, 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 preferable 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 and 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 mucose 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:
* 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 incidentally 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.
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.