Foreign body aspiration into the airways is less common in adults than in children.1 The left main bronchus is less frequently the site of foreign body lodgment. Clinical features may vary from trivial nonspecific symptoms to obstructive pneumonitis of the involved lung. Denture aspiration is uncommon and extremely alarming for the patient; hence, immediate consultation with the physician is the rule rather than the exception. Long-standing neglect of a denture aspiration is rarely reported. We report such a case that remained neglected for 15 years. To the best of our knowledge, this is the first case of longest neglect of denture in bronchus.
A 59-year-old man known asthmatic was admitted with a history of breathlessness, fever, cough, and hemoptysis for 10 days' duration. On examination, the patient was febrile, wheezing was present bilaterally, and reduced breath sounds were noted on the left side. A chest x-ray revealed consolidation on the left side and his sputum was negative for acid-fast bacilli. Past history revealed that he had suffered with similar recurrent attacks, treated as acute exacerbations of asthma or pneumonitis. Five months previously, he was treated with antituberculosis drugs, although the sputum was negative for acid-fast bacilli.
A flexible bronchoscopy was performed, which revealed a single tooth embedded in the granulations at the carina and extending into the left main bronchus. The tooth could not be removed by flexible bronchoscopy because of bleeding. Computerized tomography (CT) scan of the chest revealed a single tooth with a large denture plate abutting the wall of the left main bronchus and distal consolidation (Fig. 1). When the patient was specifically asked about a history of denture aspiration, he could not recall aspirating the denture, but gave a history of missing his denture 15 years previously.
The patient underwent rigid bronchoscopy. The denture was found impacted in massive granulations and thick pus, extending from crania to left main bronchus. The impacted denture was grasped with large alligator forceps, and with some traction force it was removed. The bleeding from the granulation tissue was easily controlled. The removed denture was about 4 cm×2 mm plate with a single tooth measuring 4×5×5 mm (Fig. 2). Postoperative period was uneventful.
Ingestion or aspiration in adults usually occurs after trauma, intoxication, sleep, loss of consciousness, dementia, alcoholism, mental and neurologic disorders, stroke, and altered states of consciousness associated with intravenous sedation; hence, there may not be a definitive history.1,2
Dental plates in contrast to natural teeth are radiolucent. This has been the case since the 1940s, when radiolucent acrylic materials replaced radiopaque vulcanite as the main denture material. The use of a radiopaque material in the manufacture of dental plates may reduce the incidence of missed or delayed diagnosis.3,4
The severity of foreign body aspiration is determined by the degree of airway obstruction. Patients with partial airway obstructions may present with a sudden onset of coughing, difficulty in breathing, wheezing, or stridor. After the acute episode, the patient may continue to experience episodes of persistent coughing and wheezing or they may become asymptomatic. Patients may present weeks to months later when the condition may be diagnosed because of sequelae, such as recurrent pneumonia, persistent cough, hemoptysis, wheezing, or atelectasis. Moreover, some patients experience recurrent episodes of pneumonia in the same topographic area.5 Retained foreign bodies need to be considered as a potential cause of difficulty in weaning a patient from the ventilator.6 Denture aspiration needs urgent attention as it may also result in death.7
Long-standing cases of denture as bronchial foreign bodies have been described. Poukkula et al8 reported 2 cases of denture aspiration into bronchus with histories of 4 and 6 years. To the best of our knowledge, this is the first case of aspiration of denture into the bronchus that remained undetected for 15 years.
In a patient with suspected foreign body aspiration, the radiographic studies should include soft tissue x-ray of the neck with anteroposterior and lateral views, and that of the chest with posteroanterior view in inspiration and expiration, along with the lateral view. Lateral decubitus chest x-ray and fluoroscopy may also be used. With radiolucent foreign bodies, secondary radiographic signs such as obstructive emphysema, atelectasis, pneumonia, and a mediastinal shift may help in diagnosing foreign body aspiration. Svedstrom et al9 studied the accuracy of chest x-ray in the diagnosis of tracheobronchial foreign bodies. They concluded that the diagnostic accuracy, sensitivity, and specificity of chest x-rays were 67%, 68%, and 67%, respectively, indicating that it is not reliable in excluding tracheobronchial foreign bodies.
As a result of its greater contrast resolution and cross-sectional perspective, CT scan has been used to demonstrate airway foreign bodies that are radiolucent.3,6 CT scan can depict the 3-dimensional position of the foreign body within the lumen of the tracheobronchial tree, the thorax, and the lung parenchyma.3,10 CT scan has some limitations as it may not differentiate a foreign body from neoplasm, granulomatous disease, mucous plug, and bronchial stenosis. Herget et al6 described an asymmetric crania sign on CT scan and reported that even large foreign bodies in the airways can be missed on CT scan, if they lodge at the carina and are mistaken for the tracheal bifurcation, as was also observed in the present case. The clue to the presence of such a foreign body lodged at this position is asymmetry in the size of the main stem bronchi at the carina. It is suggested that all cases with the asymmetric carina sign be carefully inspected at multiple window and level settings to exclude aspirated foreign bodies.
Rigid bronchoscopy still remains the procedure of choice for removal of foreign bodies. It has the advantage of a large working channel that permits the use of rigid forceps, which allows both pulling and rotation, and offers a better grip than the flexible forceps. This is advantageous if the foreign body is deeply embedded in the granulation tissue.11
Flexible bronchoscopy can be used in special situations involving small foreign bodies in peripheral airways, in patients on ventilators, and in those with trauma or disease involving jaw, cervical spine, neck, or skull.12
Denture aspiration can be prevented. Damaged or malfitting dentures should be discarded and replaced. In addition, the patients should be strongly advised against wearing them while sleeping.
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