Fish Bones: watch out! They can be lethal!
Welcome back to Dr Euan's Blog Post 😁
Did you know that even today Fish Bones (FB)s still kill people? You see, FB's are like little daggers and they can move / migrate deep into the tissues of your neck or even chest & abdomen; they can even pierce vital structures like the Aorta (the main artery which comes out directly from the heart ❤). As you can imagine, such an event would lead to catastrophic bleeding & exsanguination.
So here are some DANGER signs if you have swallowed a FB:
persistent throat pain or poking / tingling sensation
pain in your chest / abdomen
any bleeding / blood in your phlegm or sputum
fever or persistent cough
If you develop ANY of these symptoms, please seek medical attention as soon as possible.
Also, please do NOT follow the myth to take and ingest a large ball of rice, in an attempt to dislodge the FB! in fact, doing so may only push the FB deeper in, making it even more dangerous for you.
We ENT surgeons all have our "killer" FB tales to tell, if we have been in practice long enough!
Q: Did you notice that FB ingestion is VERY RARE in the West?
Well, that is because they tend to eat mostly FISH 🐠 FILLET or deboned fish.
Unlike here in Singapore, we love our Curry Fish 🐠 Head and to suck on the meat and bones!
Well, looking at the wonderful fish head curry dishes on offer, it's no surprise that this humble dish has become recognised as one of our National heritage foods!
Photo illustration showing the various FISH HEAD CURRY dishes available to us here in Singapore 🇸🇬
but look at the large number of FISH BONES in each dish!
The risk goes up significantly if you are edentulous and wear dentures especially in the elderly. This is because with the dentures on, the patient does not feel the bone in the mouth or oropharynx, and tends to swallow the FB more readily.
I still recall a former patient, she was 88 years old who had ingested a FB the week before ............by which time the FB had already migrated inwards and downwards, in the end we had to perform an external surgery (lateral pharyngotomy) to cut into the neck to remove the bone, which was firmly embedded inside the wall of the oesophagus (the tube which connects the mouth to the stomach). In the end she recovered well, but it was a long ordeal for her, her 10 children, 24 Grandchildren and 12 great-grandchildren as they waited anxiously whilst we had to hunt for this "needle in a haystack"! Sometimes the FB is never found, despite several surgeries.
We have also removed FB's from the thyroid gland, as the FB migrated out of the pharynx into the thyroid gland which is located at the front of the neck. So these little "daggers" can really move!
So, please beware when you are next eating BONY fish!
If you can, look & inspect carefully the piece of fish you are about to ingest and try to pick out any bones you can see BEFORE you place the fish into your mouth! For your elderly parents / relatives, perhaps it is best that you take charge too, especially as their eye sight is not so good; also most of them are wearing dentures, so they will not feel any bone and just swallow, along with the FB.
Q: So what should you do if you think you have ingested a FB?
don't panic! remain calm ☺️
stop eating; do not try to swallow a rice ball to dislodge the FB
alert a family member / dinner companion about the incident
arrange to go to the nearest A & E or Medical Clinic for attention
expect to undergo an examination and likely a Soft Tissue Lateral Neck X Ray or CT scan (if available) to identify the FB location
If a FB is identified, you will be referred to see us in ENT to try and remove the FB. For FB which are embedded further down the Gastro-intestinal tract, you will be referred to the General Surgeons.
At the ENT clinic, we will perform a Naso-Endoscopy to look precisely at where the FB is impacted.
Quiz Time, folks!
Q: Can you spot the embedded fish bone (FB) in the photo below?
Scary.....isn't it? This was a long (3 cm) needle like FB ingested the day before; it was already deeply embedded in the left tongue base area.
For a good overview of the current local situation, here is a very recent article on FB ingestion cases at one of our local hospitals in Singapore 🇸🇬 in 2020:
Singapore Med J 2020; 61(11): 578-583 doi: https://doi.org/10.11622/smedj.2020152
Fish bone ingestion presenting to a local institution in Singapore
Sabrina Cheok, MBBS, MRCSI, Malcolm Han Wen Mak, MBBS, MRCSEd, Singh Dinesh Rambachan, MBBS, FRCR, Clement Luck Khng Chia, MBBS, FRCSEd
To Quote the Authors:
Fish bones are the most commonly ingested foreign bodies in Singapore, accounting for up to 83.9% of ingested foreign bodies. The use of chopsticks to consume fish, the personal habit of deboning fish in the mouth and denture usage in the elderly have been described as risk factors for the ingestion of fish bones.
The current gold standard radiological modality for diagnosis is fine-cut computed tomography (CT), which not only confirms the diagnosis and reveals associated complications but also boasts a superior sensitivity of 90.9%–100%. One should, however, note the caveat that the use of oral or intravenous contrast during CT can obscure the presence of a fish bone. Hence, for a patient with a high index of suspicion for fish bone ingestion, the ordering clinician should specifically communicate with the radiologist on the indication as well as the need for a non-contrast scan.
After the diagnosis of fish bone ingestion, endoscopic removal via laryngoscopy or oesophago-gastro-duodenoscopy (OGD) is usually sufficient in most cases, with open surgery only required in less than 1% of patients.
Possible Complications of ingested FB ingestion:
Most ingested fish bones pass through the gastrointestinal tract uneventfully. However, the sharp edges of fish bones predispose the patient to some serious complications eg: perforation, migration and consequent infection when the fish bone is impacted in adjacent organs.
The most common complication, hollow viscus perforation, tends to occur at immobile segments of the gastrointestinal tract such as the ileocecal or rectosigmoid junction. Unusual sites of perforation through a Meckel’s diverticulum or even the appendix have also been reported. Common radiological manifestations on CT include localised abscess collections, fat stranding, bowel thickening or direct visualisation of the calcified fish bone. The presence of extensive pneumo-peritoneum is rare due to the small calibre of fish bones.
So dear friends, beware the little FISH BONE! It is far from innocent!
Here are some references you may find useful:
1. Lim CT, Quah RF, Loh LE.A prospective study of ingested foreign bodies in Singapore.Arch Otolaryngol Head Neck Surg. 1994;120:96-101.
2. Arulanandam S, Das De S, Kanagalingam J.A prospective study of epidemiological risk factors for ingestion of fish bones in Singapore.Singapore Med J. 2015;56:329-33.
3. Evans MR, Ahuja A, Rhys Williams S, Van Hasselt CA.The lateral neck radiograph in suspected impacted fish bones--does it have a role?.Clin Radiol. 1992;46:121-3.
4. Watanabe K, Kikuchi T, Katori Y, et al. The usefulness of computed tomography in the diagnosis of impacted fish bones in the oesophagus.J Laryngol Otol. 1998;112:360-4.
5. Akazawa Y, Watanabe S, Nobukiyo S, et al. The management of possible fishbone ingestion.Aas Nasus Larynx. 2004;31:413-6.
6. Derowe A, Ophir D.Negative findings of esophagoscopy for suspected foreign bodies.Am J Otolaryngol. 1994;15:41-5.
7. Herranz-Gonzalez J, Martinez-Vidal J, Garcia-Sarandeses A, Vazquez-Barro C.Esophageal foreign bodies in adults.Otolaryngol Head Neck Surg. 1991;105:649-54.
8. Goh BK, Tan YM, Lin SE, et al. CT in the preoperative diagnosis of fish bone perforation of the gastrointestinal tract.AJR Am J Roentgenol. 2006;187:710-4.
9. Bathla G, Teo LL, Dhanda S.Pictorial essay:complications of a swallowed fish bone.Indian J Radiol Imaging. 2011;21:63-8.
10. Kim JP, Kwon OJ, Shim HS, et al. Analysis of clinical feature and management of fish bone ingestion of upper gastrointestinal tract.Clin Exp Otorhinolaryngol. 2015;8:261-7.
11. Johari HH, Khaw BL, Yusof Z, Mohamad I.Migrating fish bone piercing the common carotid artery, thyroid gland and causing deep neck abscess.World J Clin Cases. 2016;4:375-9.
12. Hsu SD, Chan DC, Liu YC.Small-bowel perforation caused by fish bone.World J Gastroenterol. 2005;11:1884-5.
13. Venkatesh SH, Karaddi NK.CT findings of accidental fish bone ingestion and its complications.Diagn Interv Radiol. 2016;22:156-60.
14. Pinero Madrona A, Fernández Hernández JA, Carrasco Prats M, Riquelme Riquelme J, Parilla Paricio P.Intestinal perforation by foreign bodies. Eur J Surg. 2000;166:307-9.
15. Beh JC, Uppala AS, Koh BF, Cheow PC.Fishbone perforated appendicitis.J Radiol Case Rep. 2016;10:14-22.