Fish bone impaction in the oropharynx is a common cause of globus and odynophagia that is typically diagnosed with computed tomography (CT) imaging. While CT is considered the gold standard with reported sensitivities of 83.3%-100%, false negatives can occur with small or deeply embedded fish bones. This case demonstrates the critical importance of clinical judgement 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 globus sensation after eating catfish. CT imaging demonstrated no foreign body on both occasions. Upper gastrointestinal endoscopy and oral exam under anesthesia were performed because of her persistent symptoms. Palpation of the oral cavity revealed a 4 cm fishbone embedded in the left pyriform sinus. The bone was extracted without difficulty. Flexible endoscopy did not reveal esophageal injuries. The patient recovered without complication and had immediate resolution of her symptoms. This case demonstrates that fish bones can be radiologically occult on CT imaging and persistent symptoms of odynophagia and globus 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 foreign body impaction despite negative imaging findings.
