Case 7

 

HPI: 20 y/o male presents to the ED c/o feeling a chicken bone stuck in his throat for the past 3 days. He’s able to take PO, and reports only mild odynophagia. He further denies CP/SOB/N/V/D/F/C.

 

PMH: none

Meds: none

All: NKDA

Soc: denies tobacco, EtOH or drug use

ROS: per HPI

 

PE: Vs  T 97.3,  P 80,  R 20,  BP 110/72, 97% sat on RA

Gen:  NAD

HEENT:  oropharynx normal, no FB noted, no trismus, drooling, deviation, edema or induration

Neck:  supple, nontender, no masses or crepitus

CV:  RRR

Resp:  CTAB, no W/C

Abd:  soft, NT/ND, good BS

Skin:  well hydrated

 

ED Course:  Soft-tissue films of the neck were obtained (Figures 1&2). The patient was able to drink fluids in the ED without any apparent problem. What would you do next?

 

Figure 1

Figure 2

 

 

 

Click here for the answer.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Answer:  The X-rays showed no fishbone. However, the sensitivity of plain radiographs at detecting fishbone can be as low as 15%, while Palme (Laryngoscope 109:1955, Dec 1999) & Lue (Otolarngol Head Neck Surg 123:435, 2000) have demonstrated the superiority of CT with sensitivity up to 97%. It is suspected that most sensation of an impacted fishbone is, in fact, due to a scratch on the esophageal mucosa as the bone is swallowed. If soft tissue films were negative, some physicians would have the patient return for a repeat evaluation if still symptomatic after a day or two for laryngoscopy by ENT. The availability of CT allows for immediate evaluation with a high sensitivity.

 

A CT scan of the neck was performed on this patient. It showed no fishbone, but demonstrated a lack of lung markings in the left upper lobe (Figure 3), suspicious for a pneumothorax. A CXR showed complete collapse of the left lung with shifting of the mediastinum & trachea (Figure 4). A thoracic vent was placed, re-expanding the lung (Figure 5).

 

Figure 3

 

 

 

 

Figure 4

 

 

 

 

Figure 5

 

 

Note that the PTX is under tension as the mediastinum & trachea are both shifted. Incredibly, this patient had no respiratory symptoms and was saturating 97% on room air. In retrospective review of the neck films, there was a paucity of lung markings in the left upper lobe, which was more evident when the image contrast is inverted on the monitor. This is a good reminder not to focus only on the areas of interest, but to look at the entire radiograph when reading a film.