CT-Negative Fish Bone Impaction in the Pyriform Sinus Requiring Operative Removal: A Case Report

Fish bone impaction in the oropharynx is a common cause of foreign body sensation and odynophagia. While computed tomography (CT) has the highest sensitivity and specificity among radiologic imaging modalities in the detection of fish bone foreign bodies, false negatives still occur. This case demonstrates the critical importance of clinical judgement and further evaluation when foreign body symptoms persist despite negative imaging findings. A 67-year-old woman presented to the emergency department (ED) twice within 24 hours with persistent odynophagia and foreign body sensation after eating catfish. CT imaging demonstrated no foreign body on both occasions. Oral examination and flexible endoscopy under anesthesia were subsequently performed due to persistent symptoms. Inspection of the oral cavity revealed a 4-cm fish bone embedded in the left pyriform sinus. The bone was extracted without difficulty. The patient recovered without complication and had immediate resolution of her symptoms. This case highlights that fish bones can be radiologically occult and that persistent symptoms of odynophagia and foreign body sensation following fish ingestion warrant further evaluation regardless of negative imaging findings. Clinical judgement should supersede imaging results in suspected foreign body cases, as delayed removal increases complication risk (esophageal laceration and perforation, ulceration, mediastinitis, as well as abscess formation). Emergency physicians and otolaryngologists should maintain a high index of suspicion when clinical presentation strongly suggests fish bone foreign body impaction despite negative imaging findings.