Of Fishbones And More

Fish eaters, be aware! Fishbones are one of the most common foreign bodies in the throat. They are often a nightmare for us, the surgeons and of course for the patient, once he realises the gravity of the situation. I feel that there is a lack of regard for the fishbone. Often the cavalier attitude of the patient seems to suggest,  ‘Oh come on! It’s only a fishbone!’. Its slender size and transparency often make it more difficult to locate and remove than say a chicken bone or a pin. These, unlike the fishbone, are easily seen both with the naked eyes and on X-rays. Let me advise you that the utmost care must be taken while consuming fish. Though a variety of foreign bodies may be ingested like the seeds of fruits, bones, needles, coconut shell chips etc., the fishbone needs a special mention due to the challenges it presents to the surgeon and of course to the suffering patient. These are also, by far, the commonest foreign body found in the throat. A fishbone covered by food may pass through the entire gastrointestinal tract without a problem, and this happens in a good number of cases. Occasionally, it may pierce the mucosa (the inner lining) of the food pipe, to lodge in it and may trigger a local reaction with resultant pain, fever and pus formation. Sharp foreign bodies also tend to migrate to other parts of the body, and it is not surprising that a fishbone that was swallowed and forgotten may present itself at some other part of the body days or months later.

I recollect the instance of a man presenting with hoarseness of voice. Endoscopy revealed and a small granular lesion over his left vocal cord. Surprisingly, on a CT scan of his neck, a linear opacity was noted to lie parallel to his left vocal cord suggestive of a foreign body. On further interrogation, he had a vague memory of a swallowed fish bone which had not caused significant distress at the time. In retrospect, the timelines matched and a migrated foreign body was diagnosed and removed. Several thyroid abscesses treated by me over the years were also caused by migrated foreign bodies, mainly fish bones. On drainage of the pus, the fishbone presents itself to the alert surgeon. Not all swallowed fishbones cause problems, but in approximately10-20% of cases, the complications may even be life-threatening.

Realisation dawns almost instantaneously with the pricking pain during the act of swallowing a fishbone. A common reaction is to swallow more food in the hope of pushing it down the throat. Swallowing a mouthful of rice or plantain is often suggested as a home remedy. However, this is not advisable as it may further push in a penetrating fishbone deeper into the tissues. Some people even try to hook out the fishbone from the depths of the throat using a finger. This often causes further injury and the resultant pain, swelling and bleeding make the visualization of the foreign body an onerous task for the surgeon.  It is best to present to the doctor immediately without attempting to eat any further. An empty stomach will also facilitate early removal in case general anaesthesia is mandated.

The tonsils or the tongue are the usual sites where the fish bones lodge. Here visualization and removal are easy if the tip is projecting out, as is usually the case when the patient presents without any self-attempts at removal. Often, patients keep waiting for days or even weeks wishing the problem away, and of course, this only worsens the situation. It may even prove catastrophic, especially in the case of diabetic patients where soon infection sets in with pus formation. If not treated early and effectively, the inflammation may spread from the neck spaces to the chest and may even be fatal. 

The difficulty that the surgeon faces in locating the fishbone, even with the most modern scans and endoscopes, due to its transparency and slender size, cannot be overstressed. In my opinion, the proverbial searching for a needle in the haystack is easier in many cases. Once visualised, the removal is usually not difficult. Fishbones in the throat are a common cause of litigation too due to the mismatch between the patient’s expectations and the actual magnitude of the problem. I have the personal experience of one such case which dragged on for almost a decade before the patient realised her folly and withdrew, leaving behind agonising memories and bitterness for me.