Pharyngoesophageal foreign bodies (FBs) are common otolaryngologic problems, but challenging cases cause significant patient and surgeon frustration. Extraluminal migration of an FB from the pharynx or esophagus is rare and usually necessitates external neck exploration. Approaching these complicated FBs endoscopically may avoid undue surgical morbidity. We present a case using real-time, intraoperative ultrasound (US) guidance for safe retrieval of a migrated submucosal FB. Intraoperative US is a widely available, powerful technology that can aid in the retrieval of difficult pharyngoesophageal FBs. In appropriate cases, this strategy may circumvent transcervical approaches and their associated risks.