A patient with a foreign body in his pharynx, or oesophagus, usually knows what has happened and is usually right. It can stick in his tonsils, his vallecula, his pyriform fossa, or in his postcricoid region.
Most fish bones stick in accessible regions, usually the back of the tongue or tonsils. Foreign bodies seldom stick in the larynx itself, except when an affluent, elderly, and often intoxicated diner gets a piece of steak caught in his larynx, as a result of which he gasps and collapses. Treat him immediately, as described below.
FOREIGN BODIES [s8]IN ''THE THROAT' EMERGENCY TREATMENT. If a patient is obviously choking, and you are present at the time, sit him up, grasp his tongue with gauze, pull it forward, and ask him resist retching. Hook it out with your finger.
If there is a piece of food in his larynx, try Heimlich's manoeuvre[md]immediately, like this: Stand behind him, put your fist under his xiphoid and give a short sharp upward push, at the same time that you compress his chest with your arms. This will rapidly compress his lungs, and may push out the food.
If he is asphyxiating, put your finger into his larynx, and try to hook the foreign body out. If you fail, insert a wide-bore needle (or a blade) through the cricothyroid membrane of his larynx (52.2) to create an airway (not to remove the foreign body!).
EARLY PRESENTATION. This is the patient ''with something in his throat' who presents within 2 or 3 hours without severe dyspnoea. Take a careful history. Where and how severe is his pain? Feel his neck. Surgical emphysema? Take X-rays, especially a lateral view. Look for air in his tissues. If a large fish bone has stuck, you should see it, but you will not see a small one.
If there is no convincing evidence that it has lodged in his pharynx, and pain is mild, it probably only scratched him and passed on. Treat him expectantly. Persuade him to eat dry bread. A small sharp object may enter his oesophagus and pass on through him.
If you can see it, or there is air in his tissues, or if for any other reason you suspect it has lodged in his pharynx, examine his pharynx under general anaesthesia with tracheal intubation. Or, less satisfactorily, use intravenous ketamine and intermittent suxamethonium and oxygen (A 14.2). Have good suction available. Use a laryngoscope to carefully search his tonsils, his valleculae, and the back of his pharynx. Take the opportunity to have a look at his larynx, even though a foreign body here does cause different symptoms (25.12). Grasp it with Magill forceps.
CAUTION ! (1) Relaxants are dangerous unless you can inflate his lungs (A 13.1). (2) Keep his head well down all the time.
If you don't find it, proceed to oesophagoscopy.
If there is a perforation of the wall of his pharynx, spreading aerobic and anaerobic infection may be dangerous. If there is a large wound, try to suck it out (difficult). If necessary, consider opening up the tissues of his neck (also difficult). Refer him, or get more experienced help if you can. Give him chloramphenicol and metronidazole.
If symptoms are severe enough to threaten his life, do an urgent tracheostomy (52.2). It may save his life until you can refer him. The smaller he is the more difficult this will be, especially in an emergency. Try inserting a wide (1.8 mm) needle first to establish an airway. Follow this by laryngoscopy, and bronchoscopy, as soon as possible. Avoid passing the bronchoscope through the tracheostomy, which is difficult and dangerous. Only attempt it if the bronchoscope will not pass his cords.
If possible, refer him. Only attempt to remove a foreign body yourself, if his respiration is so distressed that referral is impossible.
LATE PRESENTATION (3 hours to several days later). If the foreign body has not caused a wound, his symptoms should have settled. If there is a wound, there will be signs of air in his tissues and/or infection, especially after 24 hours. Refer him if you can. Give him antibiotics and metronidazole. If you cannot refer him, proceed as above.