Something fishy?
Fish bones and so-called ‘foreign bodies in the throat’ can be harmful

Text: Dr Ravi Seshadri

Swallowed or ingested foreign bodies (FB) are the most common emergency complaints seen at most Ear, Nose and Throat (ENT) centres. The most common FB is fish bones (about 85%). The culinary habit of eating a whole fish (cooked with the bones intact) makes it easier for this to happen.

In the context of Singapore, where everybody is always in a hurry and food is generally ingested in haste, getting a fish bone lodged in one’s throat is a risk one toys with at every meal. The elderly with dentures is also a group at risk of having a fish bones lodged in the throat. This is because with the dentures in place, it is difficult to feel the bone when it is being swallowed.

The bone typically tends to get lodged within the tonsil or the base of the tongue. Other sites where FBs tend to lodge are the epiglottis, valleculae (near the base of the tongue), larynx and pyriform fossa (the voice box and next to it respectively), and the esophagus (food passage).

Children make up another high risk group because many parents often tend to feed their children the same food that they eat. Adults should be very careful about what they give to their children. If it is highly uncomfortable to have a FB lodged in one’s throat, it is even more disconcerting to see a child in discomfort with a possible fish bone lodged in his throat.

In children it invariably tends to get lodged in the tonsils, as they tend to be bigger at a young age. Occasionally, children are also wont to swallow other objects that can get lodged in the throat too. These include coins, batteries, pins and other curiosities. Children occasionally also put foreign objects into their nostrils or ears. Sometimes they tend to put the FB into their siblings’ orifices or worse, in school, into other children’s orifices.

A child with a persistent nasal discharge from one nostril should be considered having a foreign body until proven otherwise. Usually the child or his friend will tell the parent or minder that they have put something into the ear or the nose. It would be wise for the parent or the minder to believe the child and take him to the doctor the doctor immediately.

In Picture 1, the faint line arrowed is a small and fine fish bone lodged within the uvula (piece of flesh hanging at the back of the throat).

What to do
If you accidentally swallow a FB or has a child who has done so, you should immediately see a doctor or go to the A&E.

Sometimes patients may try to swallow rice or get the child to do the same so as to try and dislodge the matter and swallow it down. This is not advisable as the bone may get lodged lower down in the throat and may necessitate a removal under general anaesthesia.

The symptoms to look out for are pain or discomfort in the throat on swallowing, chest pain and general uneasiness in the head and neck area after the incident. If drinking a cup of water causes pain or great discomfort, then this usually indicates a FB lodged in the oesophagus.

Children old enough to verbalise too would describe themselves as experiencing the same feelings of discomfort as an adult. If a child who is too young to complain stops feeding or vomits excessively on being fed after a suspected FB ingestion, then the parent should take heed and take him to the doctor.

The physician would generally try to examine the mouth and the throat to see if the bone is lodged and if so, try to remove it. Sometimes, it is not possible and may necessitate a specialist referral before the problem is solved.

The specialist, after examining the patient, may do a flexible pharyngoscopy under local anaesthesia to identify the position of the FB. If this is not possible, an x-ray may be done to identify the presence or absence of any FB (see Picture 2).

If the FB is too low down the food passage, it may be necessary for the patient to be admitted to have it removed endoscopically under general anaesthesia (Picture 3 shows the FB removed from the patient in Picture 2).

After examination, if the doctor or specialist deems that the patient’s FB is small, he may be sent home with antibiotics and asked to return frequently to be checked thoroughly. There have been cases of FBs lodged within the substance of the base of the tongue coming out after two to three days.

In addition, fish bones and other FBs lodged in the throat are considered semi-emergencies. However, on occasions when they get lodged in the airway, it then becomes an emergency (see Picture 4).

One should always see a doctor or get the child to see one if there is suspicion of a FB lodged in the throat. Do not wait for complications to arise because if they do, it may become difficult to treat and find the FB. Of course, the best way to solve the problem is to prevent it. So, please eat carefully and feed your children properly.

Dr Ravi Seshadri is consultant ENT surgeon at MDSpecialist Healthcare, Paragon Medical Centre, Singapore.