Egyptian Journal of Ear, Nose, Throat and Allied Sciences (2016) 17, 27–29

H O S T E D BY
Egyptian Society of Ear, Nose, Throat and Allied Sciences

Egyptian Journal of Ear, Nose, Throat and Allied

Sciences
www.ejentas.com

CASE REPORT

From tooth extraction to fatal airway complication

in a child – A case report
Santosh K. Swain a,*, Sangeeta Sahoo b, Mahesh C. Sahu c

a
Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha ‘‘O” Anusandhan University, K8, Kalinganagar,
Bhubaneswar 751003, Odisha, India
b
Department of Anaesthesia, IMS and SUM Hospital, Siksha ‘‘O” Anusandhan University, K8, Kalinganagar,
Bhubaneswar 751003, Odisha, India
c
Central Research Laboratory, IMS and SUM Hospital, Siksha ‘‘O” Anusandhan University, K8, Kalinganagar,
Bhubaneswar 751003, Odisha, India

Received 6 October 2015; accepted 24 November 2015

KEYWORDS Abstract Exogenous foreign body (FB) in the tracheobronchial tree is not uncommon especially in
Airway; infants and children often present with respiratory obstruction that can lead to death if not removed
Tooth; in time. Despite public awareness and education, prevention of FB aspiration continues to a prob-
Foreign body; lem among children. FB inhalation is quite uncommon during conducting a surgical procedure in
Rigid bronchoscopy the oral cavity. This situation is a life threatening condition, affecting the patient and also may cre-
ate a legal issue to the concerned care givers. We report a case of an endogenous bronchial foreign
body in an 8 year old boy who had accidentally aspirated a tooth which occurred during tooth
extraction done by a medical quack. The FB was removed successfully without any complications.
Ó 2015 Egyptian Society of Ear, Nose, Throat and Allied Sciences. Production and hosting by Elsevier B.V.
All rights reserved.

1. Introduction cavity or oropharyngeal procedures, have oral appliances or

Accidental inhalation of a foreign body (FB) in the airway is a
common emergency in Otolaryngology. Accidental inhalation
of FBs to the airway continues to be a cause of childhood mor-
bidity and mortality and needs prompt identification and early
treatment of the potentially serious and sometimes fatal out-
come. Inhaled FBs are common in infants and small children
and can occur at any age. Those patients who undergo oral
* Corresponding author. Cell: +91 9556524887.
E-mail address: swainsantoshbbsr@yahoo.com (S.K. Swain).
Peer review under responsibility of Egyptian Society of Ear, Nose,
Throat and Allied Sciences.
http://dx.doi.org/10.1016/j.ejenta.2015.11.001
2090-0740 Ó 2015 Egyptian Society of Ear, Nose, Throat and Allied Sciences. Production and hosting by Elsevier B.V. All rights reserved.
poor dentition, who become intoxicated, those receiving seda-
tives, and those who have neurological or psychiatric diseases
or are mentally challenged are at high risk of inhalation of FB
into the airway.1
In airway FB, the most common symptoms and findings are
cough, dyspnea, decreased breath sounds, radio-opaque FB,
air trapping and atelectasis.2 Delayed diagnosis of FB may
mimic conditions such as asthma, croup, pneumonia and even
gastroesophageal reflux.3 Various types of FBs have been
reported in the air passage, organic and inorganic, metallic
and non-metallic. A tooth in the airway is an extremely rare
endogenous FB in the air passage. Here we have reported a
tooth in the bronchus, especially which occurs accidentally
28
during extraction of the tooth by a quack. The aim of this clin-
ical report is to present an unusual FB in the bronchus during
tooth extraction which will create awareness among care givers
or the person concerned doing the procedure in the oral cavity
or oropharynx in awake stages particularly in children.
2. Case report
An 8 year old child referred to the Outpatient Department of
Otorhinolaryngology for a sudden onset of cough and dyspnea
with complaints of aspiration of FB. There was a history of
accidental inhalation of a tooth during dental extraction and
slippage of the tooth into the airway the same day. On clinical
examination, child was presenting with breathlessness and
coughing. On chest auscultation, there was reduced air entry
into the left lungs. On examination, nose, ear, oral cavity,
oropharynx and neck were within normal limits. Immediately
X-ray of the neck and chest was done, and showed a radio-
opaque foreign body at the lower left bronchus conforming a
tooth (Fig. 1). Since the child was dyspneic, bronchodilators
were started and he was immediately taken to the operation
theater for rigid bronchoscopy under general anesthesia. The
foreign body was successfully removed out by rigid ventilating
bronchoscopy and optical forceps from the left bronchus with-
out any complications. The patient was given antibiotics and
nebulisation with bronchodilators. The child was discharged
after 48 h.
3. Discussion
FB is a substance foreign to the site where it is normally found.
FB in the airway is not an uncommon clinical situation. But
undiagnosed airway FBs may result in asphyxia, pneumonia,
bronchiectasis, atelectasis and even death. The severity of air-
Figure 1 Chest X-ray PA view showing a tooth (arrow mark) in
the left bronchus.
S.K. Swain et al.
way FB depends upon the age of the patient, site of lodgment,
size, composition of the FB and duration for which it has been
lodged. Most of the FB inhalation occurs in children between 1
and 3 years of age. This is because (1) they don’t have molars,
necessary for grinding of food (2) they have less controlled
coordinated swallowing and immaturity in laryngeal elevation
and glottis closure (3) they have a tendency to explore the envi-
ronment by placing the objects in the mouth (4) they often run
and play at the time of ingestion.4
A variety of FBs in the airway have been reported. Food or
food products are the majority among all, the reported inci-
dence being as high as 70% of all FBs.5 Unusual types of
FBs like broken tracheostomy, leech, broomstick, bubble
gums etc. also have been reported. A tooth inhaled into the air-
way during tooth extraction is extremely rare and creates a
dangerous situation. A child with a history of sudden onset
of cough, wheezy sounds in the chest especially in the absence
of any known pulmonary diseases like bronchial asthma or
chronic pulmonary infection should be suspected of having
an airway FB.6 The important issue in the air way FB is accu-
rate diagnosis and speedy safe removal procedure. History tak-
ing and clinical examination can provide diagnostic clues, but
a doubtful history of FB inhalation may delay the diagnosis.7
Sometimes, FB inhalation may escape the diagnosis, particu-
larly if there is no recollection of the episode. So, it is necessary
to screen and X-ray every patient who is coming to the outpa-
tient department with a history of swallowed FB presenting
with sudden cough or dyspnea.8 In the case of inhaled FB into
the airway, X-ray chest shows significant findings such as
atelectasis or air trapping. Even chest X-ray is generally the
first imaging modality used for the diagnosis; it may yield neg-
ative results up to 30% of children who aspirate FBs as most
are non-radiopaque.6 Since in our case, the patient had come
immediately after aspiration of the FB, no significant changes
in chest X-ray were seen except FB in the left bronchus. Nega-
tive imaging studies however, do not exclude the presence of
FB in the airway. Definitive diagnostic modality was often
made by rigid bronchoscopy but this is an invasive procedure,
which needs anesthesia.9 Alternate to bronchoscopic evalua-
tion, patient with suspected airway FB is computed tomogra-
phy (CT) scan. CT scan is strengthened by the use of
multislice CT scan with realistic 3-dimensional reconstruction
and virtual bronchoscopy.10
If a FB is inhaled, it can be removed with the help of rigid
or flexible bronchoscope. Rigid bronchoscopy is the main tech-
nique, permitting removal of the tracheobronchial FBs.11
Early identification and removal of FB is always better for a
successful outcome. After FB lodgement, local inflammation,
edema and granulation tissue formation may lead to further
airway obstruction and making a bronchoscopic identification
and removal of object will be more dificult.12 In our case, neg-
ligence and carelessness during tooth extraction caused this
type of unwanted incidence faced by the child. So optimum
care should be provided during dental extraction particularly
in children so that it will prevent this type of life threatening
condition. Prevention is the most important element in reduc-
ing morbidity. As prevention is the key behind FB inhalation,
more efforts should be given to educate the care givers and
parents. Small spherical shaped food items like seeds and nuts
may cause airway obstruction and asphyxia. All these types of
food should be avoided until the child is able to chew them
adequately while sitting. In our case, the situation gives a
Tooth extraction and fatal airway complication in a child
lesson to the doctors doing any procedure in the oral cavity or
oropharynx particularly in awake children that negligence can
lead to FB inhalation.
4. Conclusion
FB aspiration is a preventable mishap. It can be prevented by
giving proper education to parents, care givers and public at
large. High index of suspicion, careful history taking, meticu-
lous clinical examination and neck and chest radiograph are
essential for the early diagnosis of airway FB. Aspiration of
a tooth during dental extraction is a rare but potentially lethal
condition. Carefulness and alertness during tooth extraction
can help to prevent slippage of the tooth into the airway just
after extraction. Education of medical fraternity is essential
for the things for which one does not have expertise.
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