An Assessment of Management Strategies for Adult Patients with Foreign-Body Sensation in the Neck.

OBJECTIVES: Patients come to the emergency department (ED) for the evaluation of foreign-body sensation in the neck. Given the dearth of clinical studies for this complaint, these patients are treated subjectively by different providers. We aim to propose a treatment approach that results in the timely diagnosis and removal of foreign bodies by comparing the common radiologic studies used in the ED for this complaint, determining the utility of consults, and providing an approach that minimizes length of stay.
METHODS: We conducted a retrospective cohort study of adults between January 2014 and December 2015 presenting to LIJ and NSUH EDs with a chief complaint of foreign-body sensation in the pharynx, larynx, or esophagus. Fifty unique cases were studied. Consultations with ear, nose, and throat (ENT) and/or gastrointestinal, any imaging studies used, and time until discharge from the hospital were the primary exposures studied. The time for each diagnostic path for successful removal of a foreign body was compared for each case.
RESULTS: Three common diagnostic approaches were identified. The most common pathway (six cases) had an ENT consult for removal of the foreign body, with an average time to discharge of 188 min. Another common pathway (four cases) began with a neck X-ray followed by an ENT consult, with an average time of 327 min. The third common approach (6 cases) involved no imaging studies or consults, with an average time of 166 min. Neck X-ray (20 cases) was found to have a sensitivity of 43% and a specificity of 83%. The sensitivity of neck computed tomography (CT) (15 cases) had a sensitivity of 91% and a specificity of 50%. Chest X-ray (15 cases) was found to have a sensitivity of just 17%. Chest CT (3 cases) had a sensitivity of 67%.
CONCLUSION: Based on our data, we recommend that an attempt to localize the foreign body be completed by the emergency physician. If an initial attempt does not resolve the sensation, an ENT consult to remove the possible object should be initiated. Only after failure by ENT should radiological imaging be considered. Copyright:

INTRODUCTION

Background/rationale

Although foreign-body sensation in the neck is a common presenting symptom among patients reporting to the emergency department (ED), there are no specific studies that evaluated the best diagnostic and management strategies for this chief complaint.[12] Case studies have revealed that laryngeal foreign bodies can present with less severe symptoms as compared with lower respiratory tract foreign bodies.[3] This can result in misdiagnosis, confusion, and delay in diagnosis. This is confounded by the observation that patients are generally unable to determine the exact location of the foreign body based on the pain.[4] Given the dearth of clinical studies and recommendations on how to manage patients with foreign-body sensation in the neck, treatment of these patients is widely variable. Past studies have suggested that lateral neck radiographs had a low sensitivity and were not useful in the diagnosis of foreign-body ingestion.[56] Other prior studies have suggested that noncontrast computed tomography (CT) could be sufficient in guiding management. However, these studies did not consider the time-cost in management.[789]

Objectives

We aim to study the various diagnostic pathways currently utilized by emergency medicine physicians. By examining the different strategies for evaluating foreign-body sensation in the throat, we hope to determine the radiologic studies that are most beneficial for the patient. We hypothesize that X-rays of the head and neck will have low utility in evaluating and diagnosing foreign body sensation in the throat. Additionally, we aim to study how ear, nose, and throat (ENT) and gastrointestinal (GI) consults can be best utilized emergently or in the outpatient setting. The goal is to suggest a workup for this chief complaint that results in timely diagnosis and removal of any foreign bodies in the throat.

METHODS

Study design

A retrospective cohort study was performed to evaluate current management trends in patients presenting with foreign-body sensation of the throat. All adults (≥18 years old) who presented to two academic, tertiary EDs with a combined ED volume of 184,000 with a chief complaint of foreign-body sensation in the pharynx, larynx, or esophagus were included in the study.

Participants

Patients were identified by review of International Classification of Diseases (ICD)-9 and ICD-10 codes. This complaint corresponds to the ICD-9 codes 933.0 for foreign body in the pharynx, 933.1 for foreign body in the larynx, and 935.1 for foreign body in the esophagus. Due to overlap with ICD-10 codes, any cases with an equivalent ICD-10 code that fell within this time period were also included.

Setting

All cases identified between January 1, 2014 and December 31, 2015 were included in this study. All cases included in this study presented at urban academic hospitals, either North-Shore University Hospital or Long Island Jewish Medical Center.

Variables

For each patient that met the inclusion criteria, variables corresponding to the basic steps in evaluation and management were collected as well as basic patient demographics (age, race, and gender). Clinical factors, including vital signs and examination findings, such as the presence or absence of respiratory distress were abstracted.

All imaging studies, including neck CT, neck X-ray, chest CT, and chest X-ray were analyzed. Sensitivities, specificities, positive predictive values, and negative predictive values (NPVs) were calculated for each of these radiologic studies. The gold standard for these calculations was the successful removal of a foreign body in the ED or in the operation room (OR). If no foreign body was removed, it was assumed that none was present, and the foreign body sensation was simply an abrasion. Additionally, the success rate of foreign-body removal was compared between patients with GI or ENT consults. Visualization and removal techniques, including flexible laryngoscopy and flexible endoscopy, were compared as well. A finding of the scope was considered positive if a foreign body was identified using the procedure, while a finding was negative if no foreign body was found. Other data collected included the number of attempts at foreign-body removal and any ED return visits with the same chief complaint. Additionally, the time between imaging studies, consults, and any invasive procedures was collected to find possible optimal management pathways in the ED.

Bias

There was very little potential for bias in this retrospective chart review. There was no direct contact with patients during the study, and there were no changes of management throughout the review. The data were objectively collected and analyzed.

Study size

There were a total of 51 adult patients in this study. Although 53 patients fit the inclusion criteria of the study, two patients were excluded. In one case, the foreign-body sensation was relieved with the utilization of glucagon. In the other case, the chief complaint was actually chest pain.

Quantitative variables

Descriptive statistics (mean ± standard deviation for continuous variables; frequency and percent for categorical variables) were used to describe the data collected. The project was IRB approved, and the data were stored in Health Insurance Portability and Accountability Act-approved Research Electronic Data Capture database.

RESULTS

Table 1 describes the general demographics and clinical factors of the 51 adult patients:

Table 1

Demographics

Factor	n
Age (years), mean±SD	51	55.08±18.84
Gender, n (%)	50
Male		18 (36.00)
Female		32 (64.00)
Race, n (%)	51
Asian		12 (23.53)
Black		14 (27.45)
White		21 (41.18)
Other		4 (7.84)
Temperature, mean±SD	50	36.72±0.19
Systolic BP, mean±SD	51	141.39±22.67
Diastolic BP, mean±SD	51	81.69±12.24
RR, mean±SD	51	17.06±1.64
HR, mean±SD	51	79.92±13.84
SPO2, mean±SD	50	98.82±1.45
Chief complaint – choking, n (%)	51	1 (1.96)
Chief complaint – foreign body, n (%)	51	49 (96.08)
Chief complaint – others, n (%)	51	3 (5.88)
General appearance, n (%)	51
Acute distress		0 (0.00)
No acute distress		51 (100.00)
Location of pain, n (%)	51
Throat		46 (90.20)
Neck		2 (3.92)
Chest		3 (5.88)
Consult, n (%)	51
No consult		13 (25.49)
ENT consult only		23 (45.10)
GI consult only		8 (15.69)
Both ENT and GI consult		7 (13.73)
Outpatient follow-up, n (%)	51	19 (37.25)
Laryngoscope, n (%)	51	4 (7.84)
Bronchoscopy, n (%)	51	0 (0.00)
Endoscopy, n (%)	51	20 (39.22)
Chest X-ray, n (%)	51	15 (29.41)
Neck X-ray, n (%)	51	20 (39.22)
Chest CT, n (%)	51	3 (5.88)
Neck CT, n (%)	51	15 (29.41)

SD: Standard deviation, BP: Blood pressure, CT: Computed tomography, GI: Gastrointestinal, HR: Hazard ratio, RR: Relative risk, ENT: Ear, nose, and throat

Descriptive data

There were 29 patients (56.86%) who had a foreign body visualized in the ED on radiologic imaging (either CT or X-ray); 14 (51.85%) were located above the cricoid, and 15 (55.56%) were located below the cricoid.

There were a total of 30 patients (58.82%) with an ENT consult. Among the n = 30 with an ENT consult, 27 (90%) used a flexible fiber-optic laryngoscopy. Of these, 13/27 (48.15%) had positive findings and 14/27 (51.85%) had negative findings.

There were a total of 15 patients (29.41%) with a GI consult. Among the n = 15 with a GI consult, 14 (93.33%) used a flexible endoscope. Of these, 11/14 (78.57%) had positive findings and 3/11 (21.43%) had negative findings.

There were 22 patients that had at least one attempt of removal in the ED; 81.82% (n = 18) had successful removal in the ED, and 18.18% (n = 4) did not have successful removal in the ED.

Successful removal in the ED by consult status is shown in Table 2 (Fisher's exact, P = 0.6206).

Table 2

Pattern of Consultation in ED

Consult	n=22	Successful removal in the ED, n (%)
No consult/ED provider alone	3	2 (66.67)
ENT consult only	10	8 (80.00)
GI consult only	5	5 (100.00)
Both ENT and GI consult	4	3 (75.00)

GI: Gastrointestinal, ENT: Ear, nose, and throat, ED: Emergency department

Statistical methods

Among all patients, 62.75% (n = 32) had a foreign body successfully removed at some point during their hospital visit, either in the ED or in the OR, and 37.25% (n = 19) did not have a foreign body removed during their hospital visit.

Table 3 describes the predictive and statistical values for the radiologic studies collected.

Table 3

Rate of Imaging

Imaging	n	Positive findings, n (%)	PPV (%)	NPV (%)	Sensitivity (%)	Specificity (%)
Chest X-ray	15	2 (13.33)	50.00	61.54	16.67	88.89
Neck X-ray	20	7 (35.00)	85.71	38.46	42.86	83.33
Chest CT	3	2 (66.67)	100.00	0.00	66.67	N/A*
Neck CT	15	12 (80.00)	83.33	66.67	90.91	50.00

*All three patients who received a chest CT ultimately had a foreign body removed. Therefore, there were no “true negatives” in the group of three patients who received the chest CT. CT: Computed tomography, NPV: Negative predictive values, PPV: Positive predictive values, N/A: Not available

Outcome data

Table 4 describes the average time from triage until discharge from the ED. These values do not include any time that a patient may have spent as an inpatient or in the OR. The appendix lists the times between key activities such as imaging, invasive procedures, and discharge for each case. There were ten cases in which patients were transferred from one hospital to another.

Table 4

Disposition Times

	Disposition Time in ED
Average time from triage to discharge (all)	405.8 min (range: 38–1094 min)
Average time (nontransfer cases only)	297.5 min (range: 38–1582 min)
Average time (transfer cases only)*	790.0 min (range: 267–1582 min)

*These times begin from triage at the original hospital and end at discharge of the final hospital

DISCUSSION

Key results

There were three common approaches to foreign-body sensation in the throat identified in these 51 cases. One common approach is initial ENT consultation without any accompanying radiologic imaging studies. The consult is followed by ED discharge (this is seen in cases 1 [with a follow-up neck X-ray], 4, 11, 29, 34, and 38). All of these cases were successful as the foreign body was either removed or not found. None of these cases had a repeat visit to the ED. The average time from triage until discharge for a patient seen only with ENT, and no imaging studies were 188 min.

Another common pathway begins with a neck X-ray followed by an ENT consult for removal and discharge (this is seen in cases 16, 17, 23, and 33). In these cases, imaging was not always helpful. For example, in cases 16 and 33, the neck X-ray was falsely negative. The ENT was still able to visualize and remove a foreign body despite the negative X-ray. Utilization of a neck X-ray was noncontributory in half of these cases. The average time until discharge for this pathway was 327 min.

Interpretation

Comparing these two approaches, it is clear that adding one imaging study can greatly lengthen the time spent in the ED. The addition of 1 simple imaging technique (neck X-ray) led to an average increase of 139 min of extra time in the ED. This may be related to waiting for a preliminary or official read to return with the X-ray before further evaluation is taken. The low sensitivity of the neck X-ray (43%) and low NPV (38%) suggest that further attempts at visualization should be taken if nothing is seen on the X-ray. Moreover, given that the approach using ENT with and without neck X-ray both led to discharges without readmission for the same chief complaint, it may be that imaging only contributes to the crowding of the ED and longer wait times for other patients.

In multiple cases (3, 7, 13 [a transfer], 19, 20 [another transfer], 25, 26, 30, 37, 44, 49 [transfer], and 50), both chest X-ray and neck X-ray were done, followed either by an invasive technique or discharge. Looking at the results of both imaging studies, chest X-ray provides little added value if a neck X-ray has been completed. The low sensitivity of chest X-ray (17%) already suggests that this form of imaging does contribute to the identification of a foreign body in the neck. Further, in every case in which both neck X-ray and chest X-ray were done concurrently, the chest X-ray did not provide any further diagnostic value. The percentage of identification of a foreign body in cases when both imaging studies were done was not higher compared to cases where only neck X-ray was done. Additionally, there were no cases where the chest X-ray picked up a foreign body when the neck X-ray did not.

In the cases utilizing a neck CT, the sensitivity of the imaging study improves over plain films. In the cases where only a CT was done (cases 9, 12, and 14), the CT was able to visualize the foreign body before ENT removed the object. Still, since the rate of overall success did not change compare to cases with an X-ray only, the increased sensitivity of CT may not outweigh the risks of increased radiation. Additionally, the average time until discharge was 649 min. It is unclear; however, if this greatly increased length of stay is due to other factors. For example, these patients may have appeared more unstable, warranting a CT instead, and hence, longer ED stay.

Finally, the other common pathway involves no imaging studies and no consults. The patient is examined by the EP solely. In these cases (5, 8, 18, 21, 28, and 46), either the EP was able to remove the foreign body, no foreign body was found, or the sensation resolved spontaneously while in the ED. The average time in these encounters was 166 min. Not surprisingly, this represents the shortest time among the four common diagnostic pathways. Again, the success rate for these cases was good. There were no noted return visits to the ED for the same complaint. The Choosing Wisely campaign has 140 guidelines regarding imaging recommendations, all with the goal of reducing extraneous imaging procedures that provide little or no benefit to the patient. Importantly, any imaging studies with radiation are particularly scrutinized. Given the discussion on the limited role of neck X-ray, chest X-ray, and neck CT, an evaluation of foreign bodies in the neck with only EP visualization possibly with ENT consultation may be the safest and quickest approach for the patient.

The transfer cases in this study further support an initial ENT consult. In the majority of transfer cases, the reason for transfer was availability of ENT at the receiving hospital. This can be seen in cases 2, 13, 20, 32, 35, 36, and 41. Although an imaging study at the initial hospital may be required to justify a transfer, the utility of the imaging study itself, especially X-ray, is marginal. In a few cases (2, 31, 32, and 49) in which an imaging study was done at the initial hospital, a follow-up imaging study was still done at the receiving ED. In two of the four cases (31 and 49), the results of the imaging study changed, with the receiving hospital providing the accurate interpretation. The course of management for these patients also did not seem to differ between patients who had a prior imaging study and those who did not. In the sole case (36) where a transfer was done without imaging, the patient was still successfully treated. Given that the majority of patients were transferred due to specialist availability, the best course of action should be to use imaging studies minimally, whether at the initial or receiving ED (note that the full list of transfers are seen in cases 2, 13, 20, 31, 32, 35, 36, 41, 42, and 49).

With regard to the imaging studies, it is important to note that the analysis of imaging studies is limited because not all patients received all types of imaging. Cases may have been sent for different types of imaging depending on the perceived complexity and/or location of the foreign body. While the sensitivity of neck CT was found to be much higher than the sensitivity of neck X-ray (91% vs. 43%, respectively), the choice to use one form or another did not appear to change the outcome of the case. A more detailed cost-benefit analysis would be required to determine which imaging type should be used in this diagnostic setting.

Limitations

As a retrospective chart review, this study has several limitations. All information collected was limited by documentation. Some charts did not have a complete description of the full course of care. There may have been other clinical factors not documented that led the physician to choose a specific radiologic study. Recognizing that just 53 cases were isolated during the study's duration, there may have been missed cases as cases were identified using the ICD-9 and ICD-10 codes. Additionally, collection of the length of stay in the hospital was based on the notes written in the Electronic Medical Record and may not fully represent the exact times when a patient is triaged or discharged. Additionally, only a few of the charts specifically documented the method of removal of the foreign body, whether with laryngoscopy or video laryngoscopy or simple tongue blade exam. However, from anecdotal practice, Emergency Physicians (EPs) often utilize direct laryngoscopy using cetacaine spray to visualize the epiglottis and tonsillar pillars for patients with a Mallampati score of 0–3 with a presumed simply airway based on mouth opening and the American Society of Anesthesiologists physical status classification system.

Generalizability

This study findings have implications for emergency medicine physicians who want to efficiently evaluate patients coming to the ED with foreign body sensation in the throat. Based on the information collected from 51 cases on foreign-body sensation, the following recommendations can be made. For patients with foreign-body sensation in the neck, localization of the object should first be attempted by the emergency physician. As expected, the cases with no imaging studies and no consults had the shortest length of stay. If an initial attempt does not resolve the sensation, an ENT consult to localize and remove the possible object should be obtained next.

Further suggestions are relevant in instances in which a specialist is not readily available. In these cases, a transfer to another hospital without performing an imaging study is not unreasonable. However, the risk and cost-benefit analysis of transfer without imaging should be considered. In cases where CT neck can be done readily but ENT consult is not available, the foreign body can be visualized, and appropriate cases can be transferred. However, if transfer within the system can be arranged readily, then patients can be transferred before imaging. The rate of success with an ENT consult only compared to an ENT consult with imaging study was comparable. Only after unsuccessful attempts to retrieve the foreign body by the ENT, despite persistent clinical symptoms, should any imaging be ordered. It is not recommended that chest X-rays be ordered, as our data suggest that chest X-rays provide no added diagnostic value.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.