Management of fish bone impaction in throat – Our experiences in a tertiary care hospital of eastern India

Egyptian Journal of Ear, Nose, Throat and Allied Sciences xxx (2016) xxx–xxx

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Original article

Management of fish bone impaction in throat – Our experiences in a tertiary care hospital of eastern India Santosh Kumar Swain a,⇑, Santosh Kumar Pani a, Mahesh Chandra Sahu b a b

Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha ‘‘O” Anusandhan University, K8, Kalinganagar, Bhubaneswar 751003, Odisha, India Directorate of Medical Research, IMS and SUM Hospital, Siksha ‘‘O” Anusandhan University, K8, Kalinganagar, Bhubaneswar 751003, Odisha, India

a r t i c l e

i n f o

Article history: Received 29 September 2016 Accepted 8 December 2016 Available online xxxx Keywords: Foreign body Fish bone Pharynx Endoscopy

a b s t r a c t Objective: To find out prevalence of accidental ingestion of fish bones and its management in a tertiary care hospital of eastern India. Materials & methods: This is a prospective observational study. Three hundred thirty patients with complains of fish bone in throat who presented to the out patients department of Otorhinolaryngology and the emergency department of a Medical college between January 2008 to December 2015 were shortlisted for study. Followed by conventional examination, most were subjected to endoscopic examination and removal. The parameters analyzed were age and sex distribution, clinical presentation, duration of symptoms, location of impaction, conventional and endoscopic removal techniques. Result: Among three hundred thirty patients, no foreign body was found in eighty patients. Patients in age group of 21–30 years were affected mostly with almost equal sex distribution. Most patients presented with foreign body sensation in throat of short duration with precise finger point localization. Both conventional and endoscopic methods were employed with successful results but with definite advantage of endoscopic method. Conclusion: Fish bone in throat is a common occurrence in Otorhinolaryngological practice. Fish bone impaction is a common foreign body in the pharynx. Endoscopic removal is distinctly more helpful than the conventional ones. Ó 2016 Egyptian Society of Ear, Nose, Throat and Allied Sciences. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-ncnd/4.0/).

1. Introduction Fish bone is a common foreign body seen in upper digestive tract encountered at outpatient department of Otorhinolaryngology and emergency room.1 Accidental ingestion of fish bone (Fig. 1) and its impaction in pharynx is very common among the fish eating communities in this coastal belt of eastern India. The common fish consumed in this belt are Rohu (Labeo rohita), Bhekti (Latus calcarifer), Hilsa (Tenualosa ilisha) besides others. If fish bone is not removed timely, it may lead to significant morbidity and complications like deep neck infection, mediastinitis, perforation of oesophagus, retropharyngeal hematoma, pyopneumothorax and even death.2 All are having poorly radio-opaque bones and are therefore likely not to be seen on X-ray. The base of the tongue

pushes a bolus of food posteriorly during the act of swallowing and any sharp object hidden in that bolus may become embedded in the tonsil, the tonsillar pillar, the pharyngeal wall, or the tongue base itself. The correct diagnosis is best done with the help of fiber optic laryngopharyngoscope or rigid endoscope. Availability of rod lens telescope, video-endoscopy, varieties of forceps and safer anesthesia facility has facilitated removal of fish bone in throat. All patients who complain of a fish bone stuck in the throat should be taken seriously as a fish bone can perforate the oesophagus in only a few days leading to several complications. All possible fish bone in throat patients need to be subjected for endoscopy to avoid complications and morbidity. This study analyses the fish bone ingestion in our region and find out the safe and easy method to take out fish bone from throat at out patient department (OPD). 2. Material and methods

Peer review under responsibility of Egyptian Society of Ear, Nose, Throat and Allied Sciences. ⇑ Corresponding author at: Department of Otorhinolaryngology, IMS&SUM Hospital, Kalinga Nagar, Bhubaneswar 3, Odisha, India. E-mail address: [email protected] (S.K. Swain).

All the three hundred thirty patients presenting with complains of a pricking sensation in their throat or sharp pain in throat with a history of ingestion of fish in the Out patients department(OPD) of

http://dx.doi.org/10.1016/j.ejenta.2016.12.001 2090-0740/Ó 2016 Egyptian Society of Ear, Nose, Throat and Allied Sciences. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Please cite this article in press as: Swain S.K., et al. Management of fish bone impaction in throat – Our experiences in a tertiary care hospital of eastern India. Egypt J Ear Nose Throat Allied Sci (2016), http://dx.doi.org/10.1016/j.ejenta.2016.12.001

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S.K. Swain et al. / Egyptian Journal of Ear, Nose, Throat and Allied Sciences xxx (2016) xxx–xxx

clinical examination under a good light source whereas pharyngolaryngoscopes are very much helpful in detecting foreign bodies in the tongue base and valleculae and some cases of cryptic fish bones in the tonsils (Table 5). Most fish bones are found to be lodged in the tonsillar region (31.6%) followed by tongue base (20.4%) and valleculae (18.4%) (Table 6). Conventional methods using head light, tongue depressor and different forceps helped to remove fish bones lodged especially in oral cavity (7.2%), tonsils (17.6%), but endoscopic removal is more convenient in cases of cryptic foreign bodies in tonsillar pillar region (10.4% 0 and tongue base (15.2%) as well as vallecular area (13.6%) (Table 7). For fish bone impaction at tonsils and below, the comparison of two techniques of conventional and endoscopic methods with t-test was carried out. It was revealed p = 0.03 which is statistically significant. Thus endoscopic method is more effective in comparison to conventional technique. Out of 250 cases of fish bone impaction, 221 foreign bodies were removed on initial visit (88.4%) and only in 29 cases fish bones were removed on subsequent visit (Table 8). In total, 250 cases of fish bone FB identified out of 330 suspected cases with prevalence 75.75%. Fig. 1. Fish bone extracted from the patient.

Otorhinolaryngology and emergency department were included in this study between January 2008 and August 2016. This study was approved from the competent authority of our Institutional Ethics Committee. Patient’s prescription tickets and case records were collected from the Medical Records Section and the data were entered in a prepared database and were analyzed. The parameters analyzed in this study were age and sex distribution, history of duration of complains symptoms and signs, diagnostic investigations, location of foreign body, removal techniques, removal on initial & subsequent visits. Removal of fish bone in throat was done in Outpatient department as a standard procedure under local anesthesia. In some cases however removal was done after investigations and under general anesthesia. 3. Results Impaction of fish bone in throat most commonly seen in the age group of 21–30 years (48%), however fish bone was also found in throat in children as young as 1–10 years (4%) and in older people in the age group above 50 years (9%) (Table 1). Out of 250 patients with fish bone, 130 (52%) are males and 120 (48%) are females (Table 2). A t-test was compared between male and female cases of fish bone foreign body (FB). It was revealed that p = 0.8457 which was statistically insignificant. Thus fish bone FB equally distributed in both gender. Early presentation is within 24 h irrespective of sites of fish bone impaction (Table 3). Most of the patients presented with foreign body sensation with finger point localization (87%) followed by pain in throat (74%) and pain during swallowing (58%) (Table 4). Foreign body lodged in oral cavity and tonsillar region in the oropharynx are easily diagnosed by careful

4. Discussion Impaction of fish bone at upper digestive tract is a common clinical problem in Otorhinolaryngology practice. The most common foreign body in upper digestive tract is fish bone.3 Accidental Ingestion of fish bone is very common in fish eating communities and usually the swallowed bone is small and sometime passes down the gut without consequences. Often fish bone if found to be stuck mostly in the throat or penetrating the mucosa of pharynx. In rare cases it may penetrate oesophagus or stomach4 causing retropharyngeal abscesses,5–7 or even penetrating the pericardium causing cardiac tamponade.8 Hence careful inspection and endoscopic review should be followed in all cases. The common locations for fish bone lodgment are palatine tonsils, base of tongue and vallecula. Sharp foreign bodies like fish bone when ingested, often cause abrasion to pharyngeal mucosa and may cause perforation to the wall of the oesophagus.9 The patient should be thoroughly examined with a complete visual inspection of the oral cavity, oropharynx and hypopharynx. Out of a total of three hundred thirty cases who attended the hospital with complains of fish bone in throat, in eighty patients (24.2%) no foreign body was found and their symptoms settled. In 80% of these cases this had occurred by 48 h. It is likely that their symptoms were due either to minor abrasions to the mucosa which healed rapidly and spontaneously or possibly an undetected fish bone passing down without any harm.10 In this study, 24.2%of patients presenting with symptoms of an impacted fish bone had no demonstrated pathology, and their symptoms resolved in 48 h where as 76.8% per cent did have an impacted fish bone, and 56% of these were easily identified and removed on initial visit by endoscopic method and rest were removed by conventional methods. In our study, fish bone

Table 1 Table showing fish bone by site and age group. Site Oral cavity Tonsil Tonsillar pillar Pharyngeal wall Tongue base Vallecula PYRIFORM SINUS Oesophagus Total

1–10 years

11–20 years

21–30 years

31–40 years

41–50 years

4

11 11 3

5 41 20 8 27 19

14 14 4 15 17

2 6 3 1 2 7

120 (48.0%)

64 (25.6%)

21 (8.4%)

7

4 (1.6%)

32 (12.8%)

Above 50 years 3 1

3 1 1 9 (3.6%)

Total 18 (7.2%) 79 (31.6%) 41 (16.4%) 13 (5.2%) 51 (20.4%) 46 (18.4%) 1 (0.4%) 1 (0.4%) 250 (100%)

Please cite this article in press as: Swain S.K., et al. Management of fish bone impaction in throat – Our experiences in a tertiary care hospital of eastern India. Egypt J Ear Nose Throat Allied Sci (2016), http://dx.doi.org/10.1016/j.ejenta.2016.12.001

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S.K. Swain et al. / Egyptian Journal of Ear, Nose, Throat and Allied Sciences xxx (2016) xxx–xxx Table 2 Table showing fish bone by site and sex. Sex

Oral cavity

Tonsil

Tonsillar pillar

Pharyngeal wall

Tongue base

Vallecula

Pyriform Sinus & oesophagus

Total

Male Female

10 8

43 36

21 20

6 7

22 29

26 20

2 0

130 120

Table 3 Table showing duration of presentation in respect to site of fish bone. Site

<6 HRS

6–12 HRS

12–24 HRS

24–48 HRS

48 HRS–1 WK

Oral cavity Tonsil Tonsillar pillar Pharyngeal wall Tongue base Vallecula Pyriform sinus Oesophagus Total

12 34 18 6 22 18

4 22 14 4 14 16

1 10 4 3 8 6

1 8 3

5 2

5 2

2 3 1

110 (44%)

74 (29.6%)

32 (12.8%)

19 (7.6%)

13 (5.2%)

Table 4 Table showing magnitude of different clinical symptoms in fish bone ingestion. Clinical symptoms

Number of cases

Percentages

Foreign body sensation Pain Throat Odynophagia Dysphagia Spitting blood Fever

87 74 58 22 7 2

34.8% 29.6% 23.2% 8.8% 2.8% 0.8%

impaction was found in all age groups but mostly in the young people between 21 and 30 years of age (46.8%). This may be attributed to rapid change in life style and carelessness in this group. The sex distribution is almost equal 1.08:1 which is similar to studies by A. Poluri et al.11 Early presentation was found to be common mostly within 24 h irrespective of sites of fish bone impaction. It was found that patients who had impaction of fish bone in throat mostly presented early i.e. within 6 h of ingestion (44%). In 2 cases (0.8%) there was late presentation. Most of the patients presented with foreign body sensation with finger point localization (87%) followed by pain in throat (74%) and pain during swallowing (58%). Foreign body lodged in oral cavity and tonsillar region in the oropharynx were easily diagnosed by careful clinical examination under a good light source whereas pharyngolaryngoscopes were very much helpful in detecting foreign bodies in the tongue base and vallecula and some cases of cryptic fish bones in the tonsils. Plain X-ray of the neck and chest can be done to find out the location of fish bone, but many authors have reported poor sensitivity and specificity of X-ray on detecting the fish bone at the upper digestive tract.12 Computed tomography (CT) scan is an useful radiological investigation to confirm the existence and location of fish bone, also localize the damage of neighboring structures.13 Most fish bones were found to be lodged in the tonsillar region

1 WK–2 WK

1 1 2 (0.8%)

(31.6%) followed by tongue base (20.4%) and vallecula (18.4%). This is comparable with the study by Knight LC et al.10 who reported base of tongue and tonsils as the common sites for fish bone impaction. It also conforms to the findings in a study by Sam et al.14 Long standing missed fish bone can lead fatal complications like mediastinitis, mediastinal abscess, pyopneumothorax, retropharyngeal hematoma and pseudo-aneurysm of aorta.15 Considering the potential life threatening complications of fish bone at upper digestive tract, it is imperative to detect early and remove before arising any complications. The following things should be in the mind during removal of foreign bodies: type and site of lodgment of foreign body, time interval between ingestion and clinical presentation and age of the patient.16 Management of fish bone at upper digestive tract begins with direct visualization by light source. If direct visualization is successful, fish bone will be removed by forceps. However, sometimes fish bone passed beyond the level of direct visualization and need help of fibreoptic/rigid laryngopharyngoscope. It will confirm the location of fish bone in pharyngeal area. Various removal techniques employed showed that conventional methods using head light, tongue depressor and different forceps helped to remove fish bones lodged especially in oral cavity (7.2%), tonsils (17.6%), but endoscopic removal was more convenient in cases of cryptic foreign bodies in tonsillar pillar region (10.4%) and tongue base (15.2%) as well as vallecular area (13.6%). Different studies have shown the advantage of endoscopic removal.17 Out of 250 cases of fish bone impaction, 221 foreign bodies were removed on initial visit (88.4%) and only in 29 cases fish bones were removed on subsequent visit. This is comparable to most of the studies done by Knight et al.17 Polcrova et al.,4 Sam et al.14 and Lee et al.18 Removal of fish bones lodged at the tongue base, vallecula, and hypopharynx under video laryngeal telescopic guidance has the advantages of good illumination, clear visualization, and precise extraction. Early diagnosis by locating

Table 5 Table showing different diagnostic modalities for finding fish bone in different locations. Site

Clinical exam/Pharyngoscopy

Indirect laryngoscopy

Pharyngo-laryngoscopy

Oesophagoscopy

Lateral soft tissue X-ray neck

CT Scan

Oral cavity Tonsil Tonsillar pillar Pharyngeal wall Tongue base Vallecula Pyriform sinus Oesophagus

18 71 38 12 6 0 0 0

0 0 0 0 15 11 0 0

0 8 3 1 29 35 1 0

0 0 0 0 0 0 0 1

0 0 0 0 1 0 0 1

0 0 0 0 0 0 0 1

Please cite this article in press as: Swain S.K., et al. Management of fish bone impaction in throat – Our experiences in a tertiary care hospital of eastern India. Egypt J Ear Nose Throat Allied Sci (2016), http://dx.doi.org/10.1016/j.ejenta.2016.12.001

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S.K. Swain et al. / Egyptian Journal of Ear, Nose, Throat and Allied Sciences xxx (2016) xxx–xxx

Table 6 Table showing fish bone in different locations of upper digestive tract. Site

Number

Percentage

Oral cavity Tonsil Tonsillar pillar Pharyngeal wall Tongue base Vallecula Pyriform sinus Oesophagus

18 79 41 13 51 46 1 1

7.2% 31.6% 16.4% 5.2% 20.4% 18.4% 0.4% 0.4%

Table 7 Table showing different techniques used for removal of fish bone from throat. SITE

Oral cavity Tonsil Tonsillar pillar Pharyngeal wall Tongue base Vallecula Pyriform sinus Oesophagus

Conventional method using head light, tongue depressor, forceps

Endoscopy by pharyngo laryngoscopes

18 (7.2%) 44 (17.6%) 15 (6%)

35 (14%) 26 (10.4%)

8 (3.2%)

5 (2%)

13 (5.2%)

38 (15.2%)

12(4.8%)

34 (13.6%) 1 (0.4%)

Endoscopy by oesophagoscopy

1 (0.4%)

Table 8 Table showing fish bone removal in first and subsequent visit. Sites

Removed on initial visit

Removed on subsequent visit

Oral cavity Tonsil Tonsillar Pillar Pharyngeal wall Tongue Base Vallecula Pyriform sinus Oesophagus TOTAL

18 (7.2%) 71 (28.4%) 38 (15.2%) 11 (4.4%) 44(17.6%) 38 (15.2%) 1 (0.4%)

0 8 3 2 7 8

221 (88.4%)

(3.2%) (1.2%) (0.8%) (2.8%) (3.2%)

1 (0.4%) 29 (11.6%)

the fish bone and removing by endoscopic method gives easy and accessible method without any risk of complications. Antibiotics are not routinely prescribed after endoscopic removal of fish bone except in case of significant injury of mucosa by fish bone.19 This procedure is done at basis of outpatient department. Anyway prevention is still the best treatment for avoiding fish bone ingestion and its complications.

5. Conclusion Ingestion of foreign bodies is an avoidable incident. Fish bone impaction is commonly encountered clinical problem. The prevalence of fish bone impaction of 75.75% were identified in our region. If it is not detected early may cause fatal complications. Early diagnosis and immediate removal of fish bone is the appropriate treatment which is smoothly done by endoscope. Removal of fish bone from upper digestive tract under endoscopic guidance has the advantages of good illumination, clear visualization and precise extraction. This technique has also proven to be efficient, safe, well tolerated, and with low morbidity in case fish bone at oropharynx and hypoharyngeal area.

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Please cite this article in press as: Swain S.K., et al. Management of fish bone impaction in throat – Our experiences in a tertiary care hospital of eastern India. Egypt J Ear Nose Throat Allied Sci (2016), http://dx.doi.org/10.1016/j.ejenta.2016.12.001