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CASE REPORT
Year : 2015  |  Volume : 18  |  Issue : 4  |  Page : 207-209

Delayed diagnosis of an aspirated tooth in an adolescent


1 Department of Radiology, Irrua Specialist Teaching Hospital, Edo, Nigeria
2 Department of Radiology, University of Benin Teaching Hospital, Benin City, Nigeria

Date of Web Publication16-Feb-2016

Correspondence Address:
Eloho Benedicta Obi-Egbedi-Ejakpovi
Department of Radiology, Irrua Specialist Teaching Hospital, Edo
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1118-8561.176592

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  Abstract 

A case of a 13 year old unconscious girl who aspirated her molar tooth when she sustained a fall is presented. Chest radiograph demonstrated the aspirated tooth in the left main bronchus but it was unidentified by the attending pediatricians because the radiograph was not reported. The value of radiology in the diagnosis and management of such a case, the complications of this life threatening condition and the role of the pathologist is discussed.

Keywords: Aspirated, foreign body, radiograph, tooth


How to cite this article:
Obi-Egbedi-Ejakpovi EB, Ogbeide E. Delayed diagnosis of an aspirated tooth in an adolescent. Sahel Med J 2015;18:207-9

How to cite this URL:
Obi-Egbedi-Ejakpovi EB, Ogbeide E. Delayed diagnosis of an aspirated tooth in an adolescent. Sahel Med J [serial online] 2015 [cited 2024 Mar 29];18:207-9. Available from: https://www.smjonline.org/text.asp?2015/18/4/207/176592


  Introduction Top


Amongst causes of accidental injuries in children, foreign body (FB) aspiration has the highest case fatality rate (40%).[1] In Nigeria, the mean age at presentation is 13.0 ± 17.3 years.[2] Organic materials such as nuts, seeds and bones are most frequently aspirated (83.8%).[3],[4] The three most common factors predisposing to aspiration are accidental ingestion (37.4%), altered consciousness (34.6%) and neurologic disorders (29%).[5] There is a wide range of clinical presentation and often there is no reliable witness to supply the clinical history especially in young children, thus maintaining a high index of suspicion is necessary for prompt diagnosis.

Radiodiagnosis of aspirated FB can be made using chest radiography, with or without fluoroscopy and helical computed tomography scanning with virtual bronchoscopy. However, the definitive diagnosis and treatment modality is bronchoscopy.

The aim of this case report is to emphasize the importance of early diagnosis of a FB in the airway, emphasizing the reliability of radiological investigative modalities in prompt diagnosis and also the role of the pathologists in aiding in management in many clinical cases.


  Case Report Top


A 13-year-old girl presented at the Children's Emergency Unit of the University of Benin Teaching Hospital with complaints of difficulty in breathing, chest pain and cough productive of foul smelling sputum which started 3 weeks prior to presentation when she allegedly fell from a height with loss of consciousness. On regaining consciousness she complained of generalised, persistent chest pain worse on the left. She subsequently became dyspnoeic, associated with orthopnoea and cough which was productive of mucoid sputum, not bloody, becoming foul smelling and mucopurulent. On physical examination, patient was foul smelling and febrile (temperature 38.7°C). Cardiovascular system examination was essentially normal. Respiratory rate was 54 cycles/min and notably, marked tenderness was elicited on the left chest wall although there were no obvious areas of chest swelling. Auscultation revealed reduced air entry in the left lung and bronchial breath sounds in the right lung. Abdominal and central nervous system examinations were essentially normal.

A provisional impression of rib fractures secondary to trauma with left lung contusion was made. A frontal chest radiograph showed collapse of the left lung with complete shift of the heart and mediastinum ipsilaterally [Figure 1]. There was a radiopaque FB in the left main bronchus. The cardiothoracic surgeons were informed, a left pneumonectomy was contemplated as the best surgical treatment. The patient however became comatose the next day and was certified dead same day.
Figure 1: Chest radiograph (frontal projection) showing the radiopaque foreign body in the left main bronchus (arrow) with collapse consolidation of the left lung and ipsilateral shift of the mediastinum

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Postmortem examination revealed collapse of the left lung with multiple microabscesses and copious amount of pus. In addition, a molar tooth was found in the right main bronchus, occluding the lumen. Cause of death was hypoxic encephalopathy.


  Discussion Top


Foreign body aspiration in an airway is a medical emergency and without early diagnosis and proper treatment, it remains a major cause of morbidity and mortality in children. Serious complications from aspirated FB such as severe airway obstruction and death tend to occur in infants and children because of their small airway size.[6] It usually presents with a history of chocking (in about 87% of cases),[6] with subsequent respiratory symptoms like sudden cough, dyspnoea, wheezing, and fever.[2],[6]

Late diagnosis of FB aspiration is defined as occurring beyond 3 days between the aspiration of the FB or onset of symptoms and correct diagnosis.[7] Causes creating late diagnosis of FB aspiration are: Parental negligence (50%), misdiagnosis by the fellow professionals and paediatricians (19%), normal chest roentgenographic findings (14%), lack of typical symptoms and signs (12%), mismanagement (4%) and a negative bronchoscopic finding (1%).[8] Delayed arrival of a child with a suspected FB aspiration at the hospital and delayed bronchoscopy has been found to be related to higher rate of complication.[8]

Radiographic imaging as demonstrated in our patient can be helpful if the object aspirated is radiopaque or if there are indirect radiographic signs of a bronchial FB such as: Air trapping, consolidation, atelectasis, lung abscess, bronchiectatic changes, mediastinal shift.[2],[4],[6] A chest radiograph is the first radiological investigation in suspected cases of FB aspiration for reasons of availability, sensitivity and cost.

Aspirated FB are more common in the right main bronchus (53.7%) than left (30.1%),[3] because it is shorter, steeper and wider than the left bronchus. It is known that a FB can migrate from one main bronchus to the other.[9] Tsikoudas and Sheikh [9] reported a case of an inhaled FB in the right main bronchus shown to move to the left main bronchus by repeat chest radiograph during a delay prior to removal. This was observed in our patient at postmortem. The FB was seen in the left main bronchus on serial chest radiographs but autopsy performed showed the molar tooth in the right bronchus, causing obstruction and subsequent death due to hypoxic encephalopathy.

Computed tomography virtual bronchoscopy, a noninvasive technique that provides an internal view of the trachea and major bronchi by three-dimensional reconstruction is another radiologic modality used in the investigation of suspected FB aspiration when the chest radiograph is normal.[3],[4] It can reveal the presence of aspirated FB and also reveal pulmonary complications such as hyperaeration of the ipsilateral lung, mediastinal shift, bronchiectatic changes, atelectasis, pneumonic infiltration, peribronchial thickening and paratracheal lymphadenopathy.[3],[4]

Negative findings on imaging studies do not however exclude the presence of a FB in the airway because it might not be radiopaque. The longer a FB resides in the airway the more likely it is to migrate distally. When this occurs, cough and wheezing may mimic an asthma–like condition.[6] Bronchoscopy is indicated on the basis of reliable history alone when symptoms are minimal and imaging studies are negative.[4] It is both diagnostic and therapeutic.[4] Flexible bronchoscopy is a useful first step when diagnosis is unclear, but FB removal is usually not possible during this procedure. Extraction is performed via the rigid bronchoscope under general anaesthesia.[2],[4]

The pathologist may also play an important role in confirming the diagnosis of FB aspiration. Histological identification of the aspirated material may be necessary for definitive diagnosis in those cases that result in death, as in this case.

When diagnosis is delayed, complications of a retained FB such as unresolving pneumonia, lung abscess, recurrent hemoptysis and bronchiectasis may necessitate a surgical resection such as lobectomy, segmectectomy, pneumonectomy. These complications may resolve completely after the retrieval of the FB.[2],[4]

Our case re-emphasises the need for careful examination of the oral cavity for signs of dental trauma in all patients with altered consciousness following head trauma. In addition, considering FB aspiration early in the differential diagnosis of unexplained pulmonary symptoms and signs, early radiologic imaging studies and bronchoscopy for such cases and prompt extraction of aspirated FB are important to reduce the high morbidity and mortality associated with FB aspiration in children.

 
  References Top

1.
Gedlu E. Accidental injuries among children in North-west Ethiopia. East Afr Med J 1994;71:807-10.  Back to cited text no. 1
    
2.
Adegboye VO, Osinowo O, Adebo OA. Bronchiectasis consequent upon prolonged foreign body retention. Cent Afr J Med 2003;49:53-8.  Back to cited text no. 2
    
3.
Brkic F, Delibegovic-Dedic S, Hajdarovic D. Bronchoscopic removal of foreign bodies from children in Bosnia and Herzegovina: Experience with 230 patients. Int J Pediatr Otorhinolaryngol 2001;60:193-6.  Back to cited text no. 3
    
4.
Dikensoy O, Usalan C, Filiz A. Foreign body aspiration: Clinical utility of flexible bronchoscopy. Postgrad Med J 2002;78:399-403.  Back to cited text no. 4
    
5.
Karim RM, Momin IA, Lalani II, Merchant SS, Sewani AA, Hassan BS, et al. Aspiration pneumonia in pediatric age group: Etiology, predisposing factors and clinical outcome. J Pak Med Assoc 1999;49:105-8.  Back to cited text no. 5
    
6.
Tan HK, Brown K, McGill T, Kenna MA, Lund DP, Healy GB. Airway foreign bodies (FB): A 10-year review. Int J Pediatr Otorhinolaryngol 2000;56:91-9.  Back to cited text no. 6
    
7.
Mu L, He P, Sun D. The causes and complications of late diagnosis of foreign body aspiration in children. Report of 210 cases. Arch Otolaryngol Head Neck Surg 1991;117:876-9.  Back to cited text no. 7
    
8.
Shlizerman L, Mazzawi S, Rakover Y, Ashkenazi D. Foreign body aspiration in children: The effects of delayed diagnosis. Am J Otolaryngol 2010;31:320-4.  Back to cited text no. 8
    
9.
Tsikoudas A, Sheikh S. An interesting case of a wandering foreign body in the tracheobronchial tree. Eur Arch Otorhinolaryngol 2005;262:426-7.  Back to cited text no. 9
    


    Figures

  [Figure 1]


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