Dear Sirs

I read the above article with interest, but was struck by a number of flaws in its design and presentation. Surely, in order to evaluate the ‘usefulness’ of an investigation such as the lateral soft tissue neck X-ray, it should be performed on all patients presenting with a history or symptoms of an upper aero-digestive tract foreign body, and their positive or negative features compared with a real ‘gold standard’ such as findings at endoscopy? I am still not clear as to whether the ‘soft signs’ mentioned were actually significant in indicating the presence of a radiopaque foreign body or whether they were merely local irritation – without direct correlation and some measure of sensitivity and specificity, they are not helpful in determining management.

It was not clear from the article whether the radiological report described was produced at the time of the patient's attendance or whether the films were scrutinised again for the purposes of the study. If the latter, this could be a source of bias, particularly with regards to soft signs.

There is also an error in the presentation of the results. It is stated that, overall, ‘24 (38.7 per cent) of the patients had positive findings on lateral soft tissue neck X-rays’; however, later in the article, the subgroup of patients with non-radiopaque foreign bodies was reported to contain 27 with ‘soft signs’.

In addition, the first inclusion criterion described in the abstract is ‘patients referred to the ENT team’; however, in the Discussion it is suggested that those with potential fish bones who were discharged should have had an ENT referral.

In summary, the study retrospectively examined a group of patients who had an investigation arbitrarily performed, and demonstrated that it was sometimes ‘useful’ and also that junior doctors were not as skilled at examining X-rays as consultant radiologists!