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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


poor dentition, who become intoxicated, those receiving seda-
Accidental inhalation of a foreign body (FB) in the airway is a tives, and those who have neurological or psychiatric diseases
common emergency in Otolaryngology. Accidental inhalation or are mentally challenged are at high risk of inhalation of FB
of FBs to the airway continues to be a cause of childhood mor- into the airway.1
bidity and mortality and needs prompt identification and early In airway FB, the most common symptoms and findings are
treatment of the potentially serious and sometimes fatal out- cough, dyspnea, decreased breath sounds, radio-opaque FB,
come. Inhaled FBs are common in infants and small children air trapping and atelectasis.2 Delayed diagnosis of FB may
and can occur at any age. Those patients who undergo oral 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
* Corresponding author. Cell: +91 9556524887.
and non-metallic. A tooth in the airway is an extremely rare
E-mail address: swainsantoshbbsr@yahoo.com (S.K. Swain).
endogenous FB in the air passage. Here we have reported a
Peer review under responsibility of Egyptian Society of Ear, Nose,
tooth in the bronchus, especially which occurs accidentally
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.
28 S.K. Swain et al.

during extraction of the tooth by a quack. The aim of this clin- way FB depends upon the age of the patient, site of lodgment,
ical report is to present an unusual FB in the bronchus during size, composition of the FB and duration for which it has been
tooth extraction which will create awareness among care givers lodged. Most of the FB inhalation occurs in children between 1
or the person concerned doing the procedure in the oral cavity and 3 years of age. This is because (1) they don’t have molars,
or oropharynx in awake stages particularly in children. necessary for grinding of food (2) they have less controlled
coordinated swallowing and immaturity in laryngeal elevation
2. Case report and glottis closure (3) they have a tendency to explore the envi-
ronment by placing the objects in the mouth (4) they often run
An 8 year old child referred to the Outpatient Department of and play at the time of ingestion.4
Otorhinolaryngology for a sudden onset of cough and dyspnea A variety of FBs in the airway have been reported. Food or
with complaints of aspiration of FB. There was a history of food products are the majority among all, the reported inci-
accidental inhalation of a tooth during dental extraction and dence being as high as 70% of all FBs.5 Unusual types of
slippage of the tooth into the airway the same day. On clinical FBs like broken tracheostomy, leech, broomstick, bubble
examination, child was presenting with breathlessness and gums etc. also have been reported. A tooth inhaled into the air-
coughing. On chest auscultation, there was reduced air entry way during tooth extraction is extremely rare and creates a
into the left lungs. On examination, nose, ear, oral cavity, dangerous situation. A child with a history of sudden onset
oropharynx and neck were within normal limits. Immediately of cough, wheezy sounds in the chest especially in the absence
X-ray of the neck and chest was done, and showed a radio- of any known pulmonary diseases like bronchial asthma or
opaque foreign body at the lower left bronchus conforming a chronic pulmonary infection should be suspected of having
tooth (Fig. 1). Since the child was dyspneic, bronchodilators an airway FB.6 The important issue in the air way FB is accu-
were started and he was immediately taken to the operation rate diagnosis and speedy safe removal procedure. History tak-
theater for rigid bronchoscopy under general anesthesia. The ing and clinical examination can provide diagnostic clues, but
foreign body was successfully removed out by rigid ventilating a doubtful history of FB inhalation may delay the diagnosis.7
bronchoscopy and optical forceps from the left bronchus with- Sometimes, FB inhalation may escape the diagnosis, particu-
out any complications. The patient was given antibiotics and larly if there is no recollection of the episode. So, it is necessary
nebulisation with bronchodilators. The child was discharged to screen and X-ray every patient who is coming to the outpa-
after 48 h. 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
3. Discussion
atelectasis or air trapping. Even chest X-ray is generally the
first imaging modality used for the diagnosis; it may yield neg-
FB is a substance foreign to the site where it is normally found. ative results up to 30% of children who aspirate FBs as most
FB in the airway is not an uncommon clinical situation. But are non-radiopaque.6 Since in our case, the patient had come
undiagnosed airway FBs may result in asphyxia, pneumonia, immediately after aspiration of the FB, no significant changes
bronchiectasis, atelectasis and even death. The severity of air- 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
Figure 1 Chest X-ray PA view showing a tooth (arrow mark) in food should be avoided until the child is able to chew them
the left bronchus. adequately while sitting. In our case, the situation gives a
Tooth extraction and fatal airway complication in a child 29

lesson to the doctors doing any procedure in the oral cavity or 4. Saquib M, Khan A, Al-Bassam A. Late presentation of tracheo-
oropharynx particularly in awake children that negligence can bronchial foreign body aspiration in children. J Trop Pediatr.
lead to FB inhalation. 2005;51(3):145–148.
5. Singh H, Parakh A. Tracheobronchial foreign body aspiration in
children. Clin Pediatr. 2014;53(5):415–419.
4. Conclusion 6. Metrangelo S, Monetti C, Meneghini L, Zadra N, Giusti F. Eight
years’ experience with foreign-body aspiration in children: what is
FB aspiration is a preventable mishap. It can be prevented by really important for a timely diagnosis? J Pediatr Surg.
giving proper education to parents, care givers and public at 1999;34:1229–1231.
large. High index of suspicion, careful history taking, meticu- 7. Skoulakis CE, Doxas PG, Papadakis CE, et al. Bronchoscopy for
foreign body removal in children. A review and analysis of 210
lous clinical examination and neck and chest radiograph are
cases. Int J Pediatr Otorhinolaryngol. 2000;53:143–148.
essential for the early diagnosis of airway FB. Aspiration of
8. Swain SK, Mishra S, Dash M. An unusual asymptomatic foreign
a tooth during dental extraction is a rare but potentially lethal body at tracheobronchial tree. Int J Phonosurg Laryngol. 2014;4
condition. Carefulness and alertness during tooth extraction (1):40–42.
can help to prevent slippage of the tooth into the airway just 9. Zerella JT, Dimler M, McGill LC, Pippus KJ. Foreign body
after extraction. Education of medical fraternity is essential aspiration in children: value of radiography and complications of
for the things for which one does not have expertise. bronchoscopy. J Pediatr Surg. 1998;33:1651–1654.
10. Adaletli I, Kurugoglu S, Ulus S, et al. Utilization of low-dose
multidetector CT and virtual bronchoscopy in children with
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