Answer WWWTP #13…

November 20, 2013

WWWTP


An elderly male with difficulty swallowing:

WWWTP #13

The differential diagonosis of an elderly person with dysphagia includes infectious sources, stroke, malignant sources, as well as foreign bodies.  On history the difficulty swallowing started hours after eating fish.  On the soft tissue lateral neck a thin, radiopaque foreign body can be seen just posterior to the larynx in the upper esophageal area (you may need to zoom to see it):

wwwtp-13 edit

This patient had nasopharyngoscopy which revealed a small fish bone.

How sensitive are radiographs at picking up fish bones?  Not very good.  There aren’t many studies out there assessing this question but based on my experience, CT is the diagnostic imaging-of-choice.  Alternatively you can perform nasopharyngoscopy at the bedside or esophagoscopy.  There was a study in 2000 by Lue and colleagues which explored this subject (1).  They took 10 cadavers and placed fishbones in various positions in the neck and found a very poor sensitivity of plain films (39%).  CT, on the other hand, performed well at identifying bones from most commonly-eaten species of fish.  It also correctly identified a bone lodged in the soft tissue that may not be correctly identified by nasopharyngoscopy.

They did have small numbers in the study but it does correlate with my experience that fish bones are difficult to detect on plain films.  Several other studies have found poor plain film performance in this area.  The conclusions in this article argue that plain films should not be used in looking for fish bones.

Author:  Russell Jones, MD

References

1.  Lue AJ, Fang WD, Manolidis S.  Use of plain radiography and computed tomography to identify fish bone foreign bodies. Otolarnygol Head Neck Surg. 2000 Oct; 123 (4): 435-8.

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