Foreign Bodies on Lateral Neck Radiographs in Adults: Imaging Findings and Common Pitfalls

Abstract

Foreign-body (FB) ingestion is less common in adults than in children, but still occurs. Diagnostic management of patients with suspected FB ingestion in emergency departments depends on FB type and location, both of which are related to the patient profile. In adults, fish and chicken bones are the most common FB types, and the oropharynx and cricopharyngeal muscle are the most common locations. Once accidentally swallowed, an FB may become lodged in the oropharynx, and in such cases indirect or fiberoptic laryngoscopy is the first clinical management option. For FBs that have passed beyond this location, radiologic study is recommended, including anteroposterior and lateral neck radiographs (LNRs) using the soft-tissue technique. This is a quick and simple imaging method that in emergency departments achieves detection rates of 70%-80% in assessing FBs in the hypopharynx and upper cervical esophagus. Careful initial evaluation using LNRs can determine the presence and nature of an FB, which helps with predicting the location and risk assessment, making further imaging-including computed tomography-unnecessary. Prevertebral soft-tissue swelling is a nonspecific indirect sign, which in the appropriate clinical context raises suspicion of a radiolucent FB or related complications. LNRs can sometimes be difficult to interpret due to the presence of multiple overlapping soft-tissue structures and variable patterns of laryngeal cartilage calcification in adults. Adequate performance in interpreting LNRs along with familiarity with the full diagnostic process in these patients will enable radiologists to use the right imaging technique for the right patient, as described in the clinical algorithm proposed by the authors. RSNA, 2017.

Ingested Fish Bone Lodged in the Vallecula

“…History of fish consumption is an obvious contributor; however, it is important to consider differing cultural practices in fish consumption that may elevate the risk of fish bone ingestion, as some people customarily cook and consume fish with bones intact [2]. If clinical suspicion remains high, fiberoptic laryngoscopy is the preferred next step in diagnosis, but a lateral neck radiograph is normally obtained in addition or substitute [9]. Any obvious foreign body, inappropriate gas or fluid in soft tissue, or prevertebral soft-tissue swelling should raise suspicion for an ingested foreign body [9].…”

“…If clinical suspicion remains high, fiberoptic laryngoscopy is the preferred next step in diagnosis, but a lateral neck radiograph is normally obtained in addition or substitute [9]. Any obvious foreign body, inappropriate gas or fluid in soft tissue, or prevertebral soft-tissue swelling should raise suspicion for an ingested foreign body [9]. Lateral neck radiographs have two major disadvantages.…”

“…In fact, one study reported that 21 of 28 fish or meat bones remained undiagnosed by radiograph [6]. Second, normal calcification or ossification of the styloid process, styloid ligament, tracheal cartilage, thyroid cartilage anterior longitudinal ligament, spinal osteophytes, sialolith, vasculature, or lymph tissue may lead to a false-positive radiograph and potentially unnecessary procedures [8,9].…”

“…Because of these scenarios, CT and flexible laryngoesophagoscopy are the superior diagnostic modalities for definitive diagnosis [9,10]. In the case that CT identifies a foreign body, a novel method for risk stratification of these patients can be made by shape of the foreign body.…”

Lost and found: missing denture in an amnesic elderly man

“…Accidental FB ingestion is not uncommon among the elderly. FB impaction can occur at the narrowing of the oesophagus and potentially culminate in life-threatening complications, such as asphyxiation, oesophageal perforation and mediastinitis 1. A radiopaque FB can be readily visualised on X-rays.…”