Dx: Use Video Laryngoscope to Remove Fish Bone
It is Friday night and the ED is boarding 35 patients, you just admitted five patients, and you have one open stabilization room. This patient will inevitably need to have visualization and removal the foreign body. Now what?
Option 1. Call ENT: Traditionally, at the University of Colorado Hospital, calling ENT has been our only option to visualize and remove a foreign body. A short flexible endoscope has been long lost, and in a teaching institution, the simplest solution is to ask our otolaryngology colleagues to remove the foreign body via direct visualization with a flexible endoscope. However, this is not always the most expeditious option. Our otolaryngology residents are rarely quickly available for non-emergent procedures.
Option 2. Let it Wait: This patient has had symptoms for four days without evidence of infection or airway compromise. A lodged fish bone in the oropharynx will rarely spontaneously expel or be dissolved. It has been suggested that these patients may be discharged home with outpatient endoscopy in 2-3 days if the patient is symptomatic. Unfortunately, our patient has no access to follow-up, with either a primary care provider, or a specialist within the next several months, let alone the next few days. Therefore, for our patient, bedside diagnosis and treatment is ideal. While no text offers emergent indications for endoscopy, symptoms such as stridor, drooling, or symptoms suggestive of a deep space infection in the neck would be situations in which direct visualization, with the help of a consultant, would be preferable.
Option 3. DIY: It will probably take at least 2-3 hours for our ENT colleagues to arrive for further evaluation. Is there something we can do to try to remove the foreign body in the meantime? The answer is yes. Here is a simple bedside procedure to safely remove a fish bone lodged in the oropharynx in the emergency department under direct visualization at the bedside.
Patient: We start with a very healthy patient, with a Mallampati Grade I, excellent pulmonary reserve, and no concern for airway obstruction.
Tools: To best visualize the patient’s oropharynx and proximal airway, a C-MAC® video laryngocope was used, allowing the operator to view the foreign body, as well as the supervising provider. A regular (non-video) MAC may be used for most cases. An alligator forceps was used to retrieve the foreign body.
Sedation: The patient provided written consent for both the procedure and photographic documentation. The patient’s oropharynx and proximal hypopharynx were first anesthetized with Benzocaine 20% Spray. The patient was given Midazolam (5 mg) IV and Fentanyl (100 mcg) IV for sedation – the medications were chosen based on physician preference, pain control properties, and decreased propensity for airway obstruction and depression (as opposed to Propofol).
Patient positioning: The patient was placed prone, in the sniffing position, with a towel bump beneath his shoulders. The C-MAC® was used visualize the complete oropharynx and proximal hypopharynx.
Foreign body identified: The foreign body was visualized within the right tonsillar crypt (Fig 4, Fig 5). The fish bone was removed using an alligator forceps, (Fig 6, Fig 7, Fig 8)
Recovery: The patient tolerated the procedure very well, without any respiratory depression, no loss of airway, and the patient noted immediate relief, and minimal soft tissue irritation after the procedure was completed.
Patients presenting to the ED with complaints of a ‘fish bone’ in their throat within the first several hours of symptom onset will generally be able to localize where the bone impacted. Our patient, for example, was able to localize his pain to the right submandibular area, correlating with where the fish bone was visualized on exam. Patients with an impacted bone will often complain of a foreign body sensation, pain with swallowing, and occasionally pain at rest or a ‘pricking sensation’ with swallowing. A close evaluation of the oropharynx, including the tonsils, and posterior tongue is warranted as these are common places for bones to lodge, and make removal a potentially simple procedure.
Utility of Plain Radiographs
How often are plain radiographs able to identify a fish bone in the upper airway? Plain radiographs are not routinely recommended, given the varying degree of radiolucency of fish bones, depending on species. In vitro studies have suggested that some species including cod, haddock, lemon sole, and red snapper are amongst the most reliably visualized species of fish bone on soft tissue neck radiographs. Given the variability of the utility of lateral neck plain radiographs, including high false-negative and false-positive rates, Computed Tomography (CT) is the preferred imaging modality to locate foreign bodies such as fish bones.
Approach to the patient
As with every patient in the ED, treatment and evaluation of each patient much be tailored to the individual patient. Roberts and Hedges (2010) suggests a systematic approach. A careful physical exam of the oropharynx, including the base of the tongue and tonsils should be completed. If the foreign body is visualized and removed, with resolution of symptoms, no further evaluation is needed. Patients who complain of symptoms below the pharynx, or with persistent symptoms should undergo CT scanning of the neck, and possibly chest. If a foreign body is located, endoscopic retrieval is recommended. If no foreign body is visualized, and there is no evidence of complication, the text suggests patients may be discharged home safely with 24 hour follow-up. If the patient is still symptomatic after a brief period of observation, endoscopy is warranted.
Food for thought
Considering up to 93% of retrieved fish bones are found within the oropharynx, direct visualization and removal with a simple bedside procedure would provide a quick and effective modality for treating patients. We propose a technique for removal of a foreign body in the oropharynx using direct visualization with a video laryngoscope, and removal with a forceps tolerated well by a patient with minimal sedation and local anesthesia. While this procedure is both diagnostic and curative at the same time, it is limited to healthy patients, with no contraindications to sedation, and no evidence of airway obstruction.