# Impacted Fish Bones: A National Survey

## TL;DR

This UK survey shows that most ENT clinicians are unaware of guidelines for managing fish bone impactions, leading to inconsistent practices and a need for updated guidance and education.

## Contribution

The study identifies significant gaps in knowledge and practice among UK ENT clinicians regarding fish bone foreign body management.

## Key findings

- 91% of surveyed clinicians were unaware of current ENT UK guidelines for fish bone foreign bodies.
- Only 6% of respondents correctly identified the ENT UK guideline for managing impacted fish bones.
- Computed tomography (CT) was the most common next step when initial assessments were inconclusive.

## Abstract

Background

Impacted fish bones are a common referral to the ear, nose, and throat (ENT) acute on-call service. Diagnosis is often challenging as neither lateral neck radiograph (X-ray) nor flexible nasendoscopy (FNE) is perfectly sensitive. Management dilemmas are common, particularly as bones can result in significant complications.

Objectives

The objective of the study is to assess awareness of current ENT UK guidelines, investigate practice patterns, and identify knowledge gaps in the management of patients presenting with suspected fish bone foreign bodies in the upper aerodigestive tract.

Design

This is a cross-sectional survey study.

Setting

A UK-wide survey was distributed across ENT departments.

Participants

Fifty-three respondents comprise consultants, higher specialty ENT trainees, core surgical trainees, general practice (GP) trainees, and foundation doctors.

Main outcome measures

The main outcome measures are clinician awareness of ENT UK guidelines, confidence in management, preferred investigation pathways, knowledge of radio-opaque versus radiolucent fish species, and common symptoms, findings, and complications associated with fish bone foreign bodies.

Results

Of the 53 clinicians surveyed, 48 (91%) were unaware of any guidelines for fish bone foreign body management, while only three (6%) identified the ENT UK guideline. Confidence in management was not significantly associated with seniority (p = 0.31). Knowledge of radiological characteristics of fish species was variable, with 35 (66%) correctly identifying radio-opaque species and six (11%) exclusively identifying radiolucent species. The most commonly reported presenting symptoms were odynophagia (n = 42, 79%), dysphagia (n = 38, 72%), and unilateral neck pain (n = 31, 58%). The palatine tonsils (n = 29, 55%) and tongue base (n = 24, 45%) were the most frequent anatomical sites for impaction. Computed tomography (CT) imaging was the most commonly selected subsequent investigation when initial assessments (FNE or X-ray) were inconclusive (n = 40, 75%).

Conclusions

This study reveals significant variability in the awareness, investigation, and management of fish bone foreign bodies among ENT clinicians in the UK. There is a need for updated, post-pandemic guidelines alongside targeted education to enhance clinical confidence, reduce unnecessary investigations, and improve patient outcomes.