1 Introduction
Ingestion of fish bones is a common clinical problem encountered in otolaryngology practice. When removal is delayed or unsuccessful, patients may develop serious complications such as esophageal perforation, deep neck abscess formation, or migration of the foreign body to adjacent vital structures such as major vessels or the airway
[1]. Deeply embedded cervical fish bones that are not visible on direct laryngoscopy pose a particular diagnostic and therapeutic challenge. Traditional approaches, including open neck exploration, may fail to locate the foreign body when it is situated deep within the submucosal tissues. We report a case of a deeply embedded cervical fish bone that was successfully removed using ultrasound-guided endoscopic surgery after a prior open exploration had failed. This report highlighting the value of this minimally invasive salvage technique and provides a critical analysis of its indications, advantages, and limitations compared with conventional approaches.
2 Case Presentation
A 58-year-old man presented to the emergency department with a 6-week history of persistent throat pain following fish consumption. His medical history was notable for a prior diagnosis of a cervical foreign body on computed tomography (CT) at another hospital, which had prompted an open neck exploration; however, no foreign body was identified during the procedure. Subsequent esophagography performed at the referring institution suggested a left piriform fossa fistula (Figure 1a). The patient was referred to our department for further management of this suspected complication. Upon presentation, flexible laryngoscopy failed to visualize a foreign body in the hypopharynx or larynx (Figure 1b−c). A repeat cervical CT scan with thin-slice reconstruction revealed a 27-mm linear foreign body embedded deep to the mucosa of the left pyriform sinus (Figure 1d−e).
The patient provided written informed consent for the procedure and the report of this case. He subsequently underwent a second surgical procedure under general anesthesia. A self-retaining laryngoscope was inserted, providing a stable, hands-free operative field. And the patient was placed in the Rose position (supine with shoulder elevation to extend the neck), optimizing exposure of the hypopharynx and pyriform sinuses. External ultrasound guidance was employed to precisely locate the embedded fish bone. A high-frequency (7−15 MHz) linear array ultrasound probe was placed on the anterior neck. Using external anatomical landmarks—specifically the thyroid cartilage and hyoid bone—the probe was positioned to correspond with the left pyriform sinus visualized endoscopically. Under real-time ultrasound visualization, the fish bone was identified as a hyperechoic linear structure with posterior acoustic shadowing, embedded within the submucosal tissues. A foreign body grasping forceps was introduced through the laryngoscope and advanced toward the target. By simultaneously observing the real-time ultrasound image and the endoscopic view, the surgeon coordinated the external probe position with the internal anatomy to guide the forceps precisely to the fish bone. The foreign body was grasped and successfully removed (Figure 2; Supplementary video), avoiding the need for a second open surgical exploration.
3 Results
Following removal of the fish bone, the patient reported immediate relief of symptoms. He was managed postoperatively with a nasogastric tube for enteral feeding and a 7-day course of intravenous antibiotics to prevent infectious complications. A follow-up esophagogram performed 4 weeks later confirmed complete healing of the piriform fossa fistula, and the nasogastric tube was successfully removed. At the 3-month follow-up, the patient remained asymptomatic and had resumed normal oral intake and all daily activities without restrictions.
4 Discussion
Cervical fish bone impaction represents a potentially serious clinical entity that can lead to significant morbidity if not managed appropriately. Reported complications include local infection, deep neck abscess formation, pharyngoesophageal perforation, mediastinitis, migration to adjacent structures (e.g., carotid artery, internal jugular vein, thyroid gland), and persistent pain or dysphagia
[1,
2]. Early and accurate removal is therefore essential to prevent such complications.
When a foreign body is suspected based on clinical history but not identified on initial evaluation, clinicians must maintain a high index of suspicion and consider repeat imaging
[3]. In our patient, the fish bone remained symptomatic for 6 weeks despite an initial open exploration, underscoring the diagnostic difficulty posed by deeply embedded foreign bodies. The initial surgical failure likely resulted from a combination of factors. Based on the preoperative CT and intraoperative ultrasound findings, the fish bone was situated deep within the submucosal tissues of the pyriform sinus, approximately 3−4 mm beneath the mucosal surface. During an open neck exploration, the surgeon approaches the pharynx externally, making it extremely difficult to precisely localize a small foreign body within the complex, mobile musculature of the hypopharynx without real-time image guidance. The deep submucosal location prevented the bone from being palpated or visualized from an external approach, and in the absence of intraoperative guidance, the exploration was unsuccessful.
Ultrasound-guided endoscopic removal offers several distinct advantages in such challenging scenarios. First, it provides precise, real-time localization of foreign bodies that are not visible on direct endoscopic examination. Second, it minimizes surgical trauma compared with open exploration, preserving normal tissue planes and reducing postoperative pain. Third, it reduces the risk of iatrogenic injury to adjacent neurovascular structures by allowing continuous visualization of the instrument tip relative to critical anatomy. Fourth, it is associated with shorter operative time and faster recovery compared with open surgical approaches
[4]. In our case, the ultrasound-guided portion added minimal time to the procedure while enabling a targeted, minimally invasive retrieval that facilitated subsequent healing of the associated fistula.
When considering intraoperative localization options for deeply embedded cervical foreign bodies, several modalities are available, each with distinct advantages and limitations. Intraoperative X-ray or fluoroscopy can provide two-dimensional localization but exposes the patient and surgical team to ionizing radiation, offers limited soft tissue contrast, and cannot reliably distinguish the foreign body from surrounding bony structures
[5,
6]. Intraoperative CT offers excellent three-dimensional anatomical detail but is logistically challenging to implement in the operating room, exposes the patient to significant radiation, and lacks real-time capability
[7,
8]. Ultrasound, by contrast, offers several unique benefits for intraoperative navigation in the neck: (1) real-time dynamic guidance that allows tracking of instrument movement and subtle shifts in foreign body position; (2) superior soft tissue contrast that clearly delineates the fish bone from surrounding muscles, vessels, and fascia; (3) complete absence of ionizing radiation; (4) portability and accessibility in the operating room without logistical challenges; and (5) cost-effectiveness compared with intraoperative CT or fluoroscopy
[9,
10].
Despite these advantages, the ultrasound-guided endoscopic technique has important limitations that warrant consideration. First, ultrasound waves are poorly transmitted through air within the aerodigestive tract and through bone (e.g., hyoid bone, calcified thyroid cartilage), which can create acoustic shadowing and obscure the foreign body. Therefore, patient selection is critical, and the technique is most suitable for foreign bodies embedded in soft tissue away from large air pockets or bony structures. Second, the technique requires a collaborative effort between the endoscopist and the sonographer, with a learning curve involving mastery of coordinating two imaging planes. Third, obesity or extensive subcutaneous emphysema may degrade image quality and limit effectiveness. In our patient, the favorable anatomy—with the fish bone located in soft tissue away from major air interfaces—facilitated successful ultrasound-guided retrieval.
A growing body of literature supports the utility of ultrasound-guided techniques for foreign body removal in the head and neck region
[4,
11–
13]. Compared with previously reported cases, our patient is notable for the duration of symptoms (6 weeks), the failure of prior open exploration, and the presence of an associated pharyngeal fistula that subsequently healed following foreign body removal. These features underscore the potential of this salvage technique to resolve complex, previously refractory cases.
5 Conclusion
Our case demonstrates the utility of ultrasound-guided endoscopic removal as an effective minimally invasive salvage technique for deeply embedded cervical fish bones that have eluded identification during open exploration. This approach can improve diagnostic accuracy, reduce surgical morbidity, and promote faster recovery compared with repeated open surgery. It should be considered in select cases of difficult-to-reach pharyngeal foreign bodies, particularly when conventional methods have failed and when patient anatomy is favorable for ultrasound visualization. Further case series are warranted to better define the indications, success rates, and learning curve associated with this promising technique.
6 Author contributions
HL—Recorded the video, produced the figures, drafted the manuscript, and secured funding. LC—Assisted in the surgery, edited the video, reviewed and edited the manuscript, and secured funding. WBL—Provided supervision, and reviewed and edited the manuscript. ZFW—Designed the study, conducted the surgery, and reviewed and edited the manuscript. ZFW serves as the guarantor for this work and accept full responsibility for the overall content of the manuscript, ensuring its accuracy and integrity.
The Author(s). This article is published by Higher Education Press at journal.hep.com.cn.
This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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