Archives of Academic Emergency Medicine. 2021; 9(1): e12
https://doi.org/10.22037/aaem.v9i1.1068

LE T T E R TO ED I TO R

Video-Laryngoscopy-Assisted Fishbone Removal from the
Upper Digestive Tract; a Letter to the Editor
Petros V. Vlastarakos1∗, Konstantinos Chondrogiannis2

1. ENT Department, MITERA Infirmary, Athens, Greece.

2. Anaesthesiology Department, MITERA Infirmary, Athens, Greece.

Received: December 2020; Accepted: December 2020; Published online: 5 January 2021

Cite this article as: V. Vlastarakos P, Chondrogiannis K. Video-Laryngoscopy-Assisted Fishbone Removal from the Upper Digestive Tract; a

Letter to the Editor. Arch Acad Emerg Med. 2021; 9(1): e12.

Dear Editor,

Fish bones are frequently lodged in the upper digestive tract,

usually at the palatine tonsils, tongue base, valleculae, and

pyriform sinuses. The otorhinolaryngologist represents the

first point of contact in such cases, which may in fact account

for a sizeable percentage of ENT emergencies (1). Persistent

sharp pain in the throat, experienced by the patient following

eating fish, indicates that a fishbone has stuck. If the bone is

not removed in a timely manner, it may result in serious sep-

tic complications (2).

Fishbone removal requires dexterity on the part of the ENT

Surgeon and co-operation on the part of the patient. Re-

moval of fishbones in the oro-pharynx or base of tongue is

usually easy; bones lodged further down may require a three-

hand technique, i.e. the patient or an assistant holding the

tongue, and not infrequently, turn out to be an intolerable

task in the outpatient setting. We have succeeded in manag-

ing such cases under general anaesthesia without intubation,

with the use of a rigid anaesthetic video-laryngoscope and a

pair of Magill forceps.

Placed in supine position, the patient is pre-oxygenated. In-

duction to anesthesia with propofol and remifentanil is fol-

lowed by ventilation. The anaesthetist elevates the vallecu-

lar aspect of the epiglottis, using a blade with a steep curved

bend for alignment of the oral, pharyngeal, and laryngeal

axes, to fully expose and visualize the glottis and adjacent

areas of the hypopharynx. With the video image projected

from the distal end of the laryngoscope blade, the ENT Sur-

geon advances the Magill forceps (or any rigid instrument

felt appropriate) until the fishbone is grasped. The bone is

∗Corresponding Author: Petros V. Vlastarakos; 6 Erythrou Stavrou Street,
Marousi-Athens, Greece. Postal code: 15123, E-mail: pevlast@hotmail.com,
Tel: 00302114085386, Mobile: 00306977803852, Fax number: 00302106869161,
ORCID: https://orcid.org/0000-0002-2803-1971.

subsequently removed with a slight rotating movement. The

two-dimensional visualization of a three-dimensional area

and the need to interrupt for ventilation, require communi-

cation and co-ordination between the Anaesthetist and the

ENT Surgeon, but the respective learning curve is fairly short.

The advantages include good illumination, clear visualiza-

tion, and precise extraction (3). The technique itself is ef-

ficient, safe, well tolerated, and with low morbidity, being

analogous with the concept of the “four hands technique”

employed in various endoscopic surgeries (4). Despite the

limited indication, this method may reduce limitations asso-

ciated with non-invasive fishbone removal, the ingestion of

which would most likely continue to accompany the eating

habits of human societies.

1. Declarations

1.1. Conflicts of interest

None declared.

1.2. Funding

The authors have no financial interest and have not received

any financial support for this article.

1.3. Ethical approval

All procedures performed were in accordance with the ethi-

cal standards of the institutional and national research com-

mittee and with the 1964 Helsinki declaration and its later

amendments. The patients signed a consent form regard-

ing the publication of intra-operative photographs for edu-

cational or other purposes.

1.4. Authors’ contributions

Drs. Vlastarakos and Chondrogiannis contributed on

Constructing an idea or hypothesis for research and/or

manuscript; Planning methodology to reach the conclusion;

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P. V. Vlastarakos and K. Chondrogiannis 2

Figure 1: A: The dorsal fin of a cod horizontally lodged in the area of the pyriform sinuses. B: Fishbone grasped with a pair of Magill forceps

under video-laryngoscopic guidance (different case than figure 1). C: 3cm fishbone removed en-bloc from the hypopharynx via the video-

laryngoscopy-assisted technique.

Organizing and supervising the course of the project or the

article and taking the responsibility; Providing personnel, en-

vironmental and financial support and tools and instruments

that are vital for the project; Taking responsibility in logical

interpretation and presentation of the results; Taking respon-

sibility in this necessary function; Taking responsibility in the

construction of the whole or body of the manuscript; Review-

ing the article before submission not only for spelling and

grammar but also for its intellectual content.

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	Declarations
	References