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Background: Lateral neck radiographs are commonly used in the investigation and management of patients presenting with suspected fish bone impaction. The effectiveness of these is questioned, as many fish do not have radio-opaque bones., Objective: This study evaluated the utility of lateral neck radiographs in the management of patients presenting with fish bones retained in the upper aerodigestive tract, with the creation of a treatment algorithm to guide further management., Methods: An audit of practice was undertaken at the University Hospital of Southampton, identifying all patients admitted with potential fish bone impaction in the upper aerodigestive tract. Following analysis, a treatment algorithm was constructed for use by junior doctors., Results: In total, 34 per cent of patients with a normal radiograph were subsequently found to have a fish bone present under local or general anaesthetic assessment. The sensitivity of radiographs in the detection of fish bones was found to be 51.6 per cent., Conclusion: Lateral neck radiographs have limited value in the management of suspected fish bone impaction, and should only be used following detailed clinical examination of the upper aerodigestive tract.