A 71-year-old female patient presented at the ear, nose and throat (ENT) emergency department with progressive stabbing pain and foreign body sensation in the throat after having consumed a gilthead earlier the same day. Accidental ingestion of fish bone was suspected although this could not be confirmed from the clinical examination alone, which included inspection of the oral cavity and throat. The persistence of symptoms led to hospitalization of the patient, where endoscopy of the upper respiratory tract and upper gastrointestinal tract and blood tests were performed on consecutive days, but revealed no abnormalities. Since the patient’s symptoms eventually improved, she was discharged from hospital. Four days later, the same patient returned to the ENT emergency department with a high fever (40.2 °C), general feelings of illness, progressively sore throat and odynophagia. Upon re-admission, blood tests revealed signs of ongoing inflammation with significantly increased C-reactive protein levels of 18.05 mg/dl (normal range ≤ 0.5 mg/dl) while leukocytes were in a high-normal range. Thyroid-stimulating-hormone (TSH) was slightly suppressed at 0.09mIU/l, (normal range of 0.3–4.0 mIU/l) while levels of T3 and T4 were fine. During clinical examination of the neck, the patient indicated tenderness upon palpation of the right side and swollen lymph nodes were detected. Ultrasound did not identify any signs of abscess formation. However, the right thyroid lobe appeared inhomogeneous and was enlarged compared to the left thyroid lobe despite normal perfusion. No other abnormalities were identified during a comprehensive diagnostic workup of the lung, abdomen, ears, nose or throat. Concerning the patient´s history, no pathologies of the thyroid gland, throat, neck and esophagus were diagnosed previously and no intervention was ever performed in this anatomic region. Based on the soft tissue inflammation of the neck, an intravenous antibiotic treatment with clindamycin was initiated. A CT scan of the neck was performed on the next day. This revealed a swollen right thyroid lobe with a 2.2 cm hypodense lesion lacking clear margins indicative of thyroiditis. Furthermore, the retrolaryngeal tissue adjacent to the esophagus was affected. The patient was then referred to the department of nuclear medicine for further evaluation of the thyroid gland. Another ultrasound was carried out by a specialist for nuclear medicine who diagnosed acute thyroiditis. The right lobe had a central, circumscribed area of altered thyroid tissue (2.0 × 1.9 × 3.1 cm) with mainly hypoechoic fractions and an area of paranodular homogenous thyroid tissue without increased perfusion. Moreover, a spiky and sharp hyperechoic structure spanning from the level of the trachea to the lateral thyroid border was identified. In view of these findings and considering that the patient consumed fish a week prior to the ultrasound scan, the migration of a fish bone into the right thyroid gland was suspected. Consequently, no continuative diagnostics like thyroid-scintigraphy were performed. The patient was then transferred to the surgical department and after interdisciplinary discussion, surgical exploration was indicated. Intraoperatively, the right thyroid lobe was found to be severely inflamed with adhesions to surrounding tissue especially the thyropharyngeal muscles and esophagus. Careful preparation was thus necessary to prevent surgical trauma of the recurrent laryngeal nerve or esophagus. Finally, the fish bone was identified penetrating the right thyroid lobe dorsally while still perforating the esophageal muscularis/pharynx. While the perforation zone was near the recurrent laryngeal nerve, it remained unscathed. The fish bone was removed gently. Afterwards, hemithyroidectomy of the inflamed right thyroid lobe was performed. It was not possible to detect parathyroid glands within the inflamed tissue. Intraoperative neuromonitoring of the recurrent laryngeal and the vagal nerves revealed normal electromyographic signals before and after the thyroid lobe was removed indicative of intact recurrent laryngeal nerve function. Macroscopically, no lesion of the esophagus was visible and therefore, no suture was needed. After extensive rinsing of the wound cavity, a wound (redon) drain was placed on the surgical site. Surgery was successfully completed, and the patient was observed postoperatively. The removed fishbone measured 2.6 cm. The resected thyroid tissue was sent to the pathologist for further histopathological examination. This revealed purulent inflammation with a focal foreign body giant cell reaction and lymphofollicular, partly chronic resorptive, histiocytic thyroiditis. Additionally, nodular goiter was detected. Retrospectively, neither pre- nor intraoperatively any lesion or pathology was found which could explain the unusual localization of the fishbone. Postoperatively, antibiotic treatment was terminated immediately. The patient reported an improvement of pain and recovered quickly. Vocal cord mobility was checked by an ENT specialist and was normal. Dysphagia was no longer reported and the patient was able to receive oral nutrition immediately. No fever occurred and blood tests revealed a normalization of inflammatory markers within 4 days and calcium levels at every timepoint. The drain was removed 3 days after surgery with no need for additional endoscopy. The patient was discharged in good condition and did not develop recurrent symptoms.