What foreign bodies tend to get stuck in the throat?

• Fish bones lodge at any level but tend to reside in the tonsil or vallecula

• Bigger bones (Chicken, rabbit, and chops) lodge in the post-croicoid region or proximal esophagus

• Occluding foreign bodies (sweets or meat bolus) can cause airway obstruction and sudden death

• Dentures often impact in the mid-esophagus

How do you manage the patient?

Depends on the level of impaction

Oropharynx

• With a headlight and tongue depressor look in the tonsillar fossa and base of tongue for buried fish bone

• Remove these lesions with angled forceps (Tilley’s) and LA spray

• Use a heated mirror (indirect laryngoscopy) to examine the back of tongue and laryngopharynx. Ask the patient to hold their own tongue with a gauze swab and pull it forwards.

• Fish bones are often not radio-opaque and so X-rays are of limited value.

Hypopharynx

• Usually found at or above the cricopharyngeus sphincter causing acute dysphagia (sometimes complete with inability to swallow saliva  - drooling), pain and voice change.

• Plain lateral cervical x-rays may demonstrate opacity opposite C6.

• An air shadow in the upper esophagus may indicate that it has been forced open. Surgical emphysema indicates perforation of the pharynx wall.

• The diagnosis can be confirmed by swallowing barium and a cotton ball soaked in barium will get caught on a speckle of bone.

• Hypopharynx foreign bodies should be removed under GA with a rigid endoscope

• If there is a suggestion of perforation either by the foreign body or removal then keep the patient nil by mouth and insert a NG tube and give Abx and monitor for mediastinitis.

• In the older patient, consider a hypopharynx cancer.

Esophagus foreign body

• Fish bones, false teeth and open safety pins all commonly become lodged in esophagus

• In general fibre-optic gastroscopic removal is the best tool. A flexible overtube is a useful adjunct

• Most foreign bodies can be removed with grasping forceps.

• Some foreign bodies may need to be cut using instruments introduced through a rigid scope

• Foreign bodies seen in the hypopharynx or upper esophagus on X-ray must be removed endoscopically under GA. Use the esophagoscope and suitable forceps to remove these foreign objects.

Laryngeal foreign bodies

Patient suddenly collapses, clutching the throat and becomes cyanosed

Heimlich manoeuvre may be used

A cricothryoidotomy may be used using a penknife or biro.

A child may be held upside down whilst the lungs are compressed.