Education: Images in Anesthesiology
AN 86-yr-old woman who had suffered a C6–7 discoligamental injury underwent surgical stabilization and was successfully weaned from the ventilator. However, her level of consciousness was reduced, and she required intermittent noninvasive ventilation with continuous positive airway pressure. Three days after extubation, she developed severe pneumonia and was reintubated. Right upper lobe atelectasis was noted on chest radiography, and flexible bronchoscopy revealed copious secretions and a narrowing of the right mainstem bronchus, which could not be passed. Two follow-up radiographs showed the pneumonic infiltrates, yet the foreign body in the right mainstem bronchus was misinterpreted as an artifact and its true nature missed. During multiprofessional radiology rounds the repeated presence of an “artifact” projecting in the right mainstem bronchus (fig., arrow) was finally noticed and identified as a tooth. Rigid bronchoscopic extraction was successful. Aspiration of the loose tooth occurred unobserved during the period of noninvasive ventilation.
This case highlights the importance of monitoring of patients' dental status during critical care therapy and for thorough review of chest radiographs by radiologists and clinicians with detailed knowledge of the clinical course, ideally during daily x-ray rounds.
Aspiration of teeth seems rare in the adult critical care population and is mostly related to maxillofacial trauma, whereas other case studies report delayed diagnosis even to the point of postmortem findings.1
That underlines the need for vigilance to detect this complication.
1. Zhang M, Zhou GJ, Zhao S, Yang JX, Lu X, Gan JX, Xu SW: Delayed diagnosis of tooth aspiration in three multiple trauma patients with mechanical ventilation. Crit Care 2011; 15:424.
2. Nadjem H, Pollak S, Windisch W, Perdekamp MG, Thierauf A: Tooth aspiration: Its relevance in medicolegal autopsies. Forensic Sci Int 2010; 200:e25–9.
© 2012 American Society of Anesthesiologists, Inc.