31. A 50-year-old man presented to the emergency department with marked dysphagia,
dyspnea, and paroxysmal cough. He had swallowed a spoon while trying to extract a
fish bone that was stuck in his throat. The presence and position of the spoon were
verified in two radiographs (Panels A and B). With the patient under general
anesthesia and with the aid of a laryngoscope, the end of the tablespoon was
grabbed with forceps and safely extracted. No fish bone was detected on evaluation
with esophagogastroduodenoscopy. The spoon was 19 cm in overall length, and the
bowl of the spoon was 6.5 cm by 4 cm by 0.5 cm in its largest dimensions.

32. A 79-year-old man was evaluated for unintentional weight loss and dysphagia. He underwent a modified barium swallow. During the rapid-drinking phase, the
patient aspirated a large amount of barium (which did not elicit a cough reflex), which resulted in hypoxemic respiratory failure and subsequent intubation. He
was admitted to the intensive care unit, and a chest film was obtained. The film showed barium in both the right and left main stem bronchi, outlining the
bronchus intermedius, all four lower-lobe basal bronchi, and the segmental bronchi in the left upper and lower lobes. The barium also spread into the smaller
airways, producing a tree-in-bud appearance (arrow). The patient underwent bronchoscopy, which confirmed the presence of barium in the right and left lower
lobes and lingula. The barium was suctioned extensively. Circulatory shock developed, and the patient had severe anoxic brain injury after cardiac arrest.
Despite fluid resuscitation and treatment with inotropic agents and antibiotics, his clinical condition deteriorated, and his family opted for conservative care. He
died shortly thereafter.