|Year : 2016 | Volume
| Issue : 3 | Page : 324-327
Tooth aspiration following maxillofacial trauma: Report of a rare case
Sanjay S Rao, Sridhar D Baliga
Department of Oral and Maxillofacial Surgery, KLE VK Institute of Dental Sciences, Belgaum, Karnataka, India
|Date of Web Publication||21-Dec-2016|
Dr. Sanjay S Rao
Department of Oral and Maxillofacial Surgery, KLE VK Institute of Dental Sciences, KLE University, Belgaum - 590 010, Karnataka
Source of Support: None, Conflict of Interest: None
Maxillofacial trauma is often associated with avulsion of teeth. Occasionally, there may be tooth aspiration either spontaneously or following intubation. We report a case of tooth aspiration in a patient of head injury and maxillofacial soft tissue injury following motor vehicle accident and have discussed regarding its incidence, sequelae, and management.
Keywords: Bronchoscopy, maxillofacial trauma, tooth aspiration
|How to cite this article:|
Rao SS, Baliga SD. Tooth aspiration following maxillofacial trauma: Report of a rare case. Indian J Health Sci Biomed Res 2016;9:324-7
Many casualties from road traffic accidents demand emergency intubation due to airway compromise from either head injury or maxillofacial injury. Such an intubation may act as a life-saving procedure. Trauma to the face is often associated with dentoalveolar fractures or avulsed teeth., Occasionally, this avulsed tooth or prosthesis may be aspirated spontaneously or during an emergency intubation. We present one such rare case of avulsed tooth aspiration following maxillofacial trauma in a patient with diffuse axonal injury in the brain and soft tissue injury of the face.
| Case Report|| |
A 34-year-old male patient reported to casualty following road traffic accident wherein the motorcycle he was driving, collided into a truck. Patient immediately lost consciousness. When he arrived at casualty, he was semiconscious, irritable, disoriented and had severe dyspnea. Patient underwent emergency intubation at the emergency set up and was placed on oropharyngeal airway as an aid to maintain oxygen saturation.
On examination, he had multiple contused lacerated wounds on his face extending from the hairline on the right side involving the nose and up to the right commissure of the mouth, measuring approximately 12 cm. He was advised computed tomography scan of brain which revealed no findings thereby indicating underlying diffuse axonal injury. Maxillofacial X-rays showed no evidence of fractures in this region. Chest X-ray revealed a suspicious radiopacity in right principal bronchus. Patient's oral cavity could not be examined as he was intubated and on an airway. He was neurologically unstable and hence could not be taken up for immediate primary suturing. He was kept under observation for 48 h. Patient was started on antibiotics, anticonvulsants, mannitol, analgesics, and an antacid. Once the neurological fitness was obtained, patient was taken up for suturing under general anesthesia [Figure 1]. Here, when a definitive examination was carried out, it was observed that there were multiple missing teeth namely 11, 12, 43, 44, 45. Following this; the chest X-ray was reviewed critically to reveal a radiopaque foreign body (FB) akin to a tooth in the right principal bronchus [Figure 2]. When still under general anaesthetic, rigid bronchoscopy with the aid of a C-arm was carried out. When three repeated attempts to remove the tooth failed leading to further displacement into the lower lobe of right lung, a decision was made to stop intervention. Patient was maintained on ventilator postoperative owing to the surgical trauma to the lung. He was weaned off the ventilator by 2nd postoperative day. Patient recovered uneventfully. Healing of sutured wounds was satisfactory. He has been on regular follow-up for 6 months till date with no evidence of any complication.
|Figure 1: Clinical photograph of the patient following maxillofacial trauma involving the nose and oral cavity|
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|Figure 2: Chest radiograph demonstrates tooth (arrows) aspirated in the lungs|
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| Discussion|| |
Maxillofacial trauma is often associated with fracture or avulsion of teeth. Occasionally, this avulsed tooth or prosthesis may be aspirated spontaneously or during an emergency intubation.,, Dental damage contributes to 11% of the litigation related to airway complications of anesthesia., Upper incisors contribute to 85% of injured teeth. Aspiration of FBs has been described extensively in literature. However, incidence of tooth aspiration is rare., The earliest case of tooth aspiration was reported in a mummy dating back to 950 AD. Aspiration of primary tooth following avulsion in the pedodontic age group has been reported. In dental practice, aspiration of teeth, dental materials, and prosthesis have been described., Rarely, the aspirated tooth may be discovered secondarily at the time of reintubation or even after death.,
A complete dental examination on arrival of the patient at the trauma center by the anesthesiologist and the surgeon prior to intubation is important, given the constraints of a low conscious state and urgency. Number of avulsed teeth on arrival must be noted. In the aforementioned case, the patient arrived in a semiconscious, irritable state, and a nasoendotracheal tube as well as oropharyngeal airway was secured immediately thereby making intraoral examination difficult. The various possible events following avulsion are expulsion of the avulsed tooth, its ingestion or aspiration. Aspirated FBs can be diagnosed on radiographs and with bronchoscopy, the latter being the diagnostic aid of choice in case of nonradiopaque objects. Diagnosis of tooth aspiration has been missed repeatedly even in the presence of ideal radiographs, emphasizing the importance of suspicious assessment by the avid clinician.,, FB aspiration must be suspected in unresponsive patients with unexplained pulmonary findings., An aspirated tracheobronchial FB must be diagnosed, assessed, and managed early. Delay in treatment may be dangerous and fatal.,
Management of an aspirated FB would be in early diagnosis and removal of the same. However, the position of the FB in the tracheobronchial tree and clinical condition of the patient is important parameters in the choice of treatment and timing of procedure. FBs lying along the trachea and upper bronchus may be spontaneously coughed out or expelled by the Heimlich maneuver. A patient with primary respiratory compromise tending toward distress must be considered for removal of the object. This may be accomplished by rigid or flexible bronchoscopy, though this is a difficult proposition owing to the slippery nature of the tooth.,, Death following bronchial perforation as a complication of an attempted flexible bronchoscopy has been reported. In this case, the decision of dropping the bronchoscopic retrieval after three failed attempts can thus be justified. Recently techniques such as attachment of an endoscopic hood attachment and use of tracheal backflow air in difficult or failed cases of traditional bronchoscopic retrieval have been described.,
When a FB is situated such that it does not cause functional impairment to the patient, one might choose to observe the patient without any active intervention to remove the same. Among the described sequelae of an aspirated tooth retained in the lung are early complications such as respiratory distress, emphysema, and death  and late complications such as pneumonia, atelectasis, bronchiectasis, empyema, endobronchial actinomycosis, and lung abscess.,, In the described case, the patient recovered his respiratory efficiency gradually after he was weaned off the ventilator following a course of antibiotics to prevent respiratory infection. He received active chest physiotherapy and has on regular follow-up. No further complications observed in 6 months.
| Conclusion|| |
Avulsion of teeth or dental prosthesis can be expected in cases of maxillofacial trauma. The same may be expelled from the oral cavity or may be aspirated or ingested either spontaneously or as a result of intubation or manipulation of the jaws. Aspiration may result in acute respiratory obstruction and risk for death. When associated with other head injury or systemic injury, primary management is directed toward saving the patient. Once patient is stabilized, a detailed examination with due suspicion in cases with avulsed teeth and unexplained respiratory symptoms aid in diagnosis of an aspirated tooth. Attempt must be made toward removal of the tooth from the accessible areas of the lung using bronchoscopy or other described methods. However, a deep seated FB or failed attempts at removal justifies leaving the same in situ. Periodic follow-up with special attention to respiratory symptoms and secondary management is advocated.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]