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Authors: Dr. Prashant Saxena, Dr. Arun Dewan, Dr. Ajay Sharma

Abstract

Aspiration of foreign bodies during dental procedures is relatively uncommon but potentially serious complication. Here we present a case of 56yearold man who accidentally aspirated a dental endodontic file used during root canal treatment which eventually required flexible video bronchoscopic retrieval of endodontic file .

Such aspiration cases are usually serious and less common than ingestion.Although such accidents are rare , the associated morbidity is high. Moreover, practitioners are also liable for medical negligencecases as some of these cases are often avoidable. Dental practitioners should be extremely careful in handling of minor instruments during dental interventions.Expertise for Bronchoscopic retrieval of such foreign bodies must be readily and timely available to avoid serious complications.

Introduction

Foreign body aspiration mostly occur after either maxillofacial injuries or displaced dental implants. Iatrogenic accidents during routine clinical procedures are unpredictable and can occur sometimes regardless of all the possible precautions taken. These foreign objects can be of various sizes and shapes, ranging from small, large, elongated, round, sharp, and blunt and can get wedged anywhere either in the gastrointestinal (GI) or the respiratory tract. Approximately 92.5% of the swallowed foreign bodies enters the GI tract and 7.5% of these instances in the tracheobronchial tree1.
 
Figure 1:Chest Xray PA view:Linear radioopaque shadows seen in medial aspect of right lower lobe
Figure 1:Chest Xray PA view:Linear radioopaque shadows seen in medial aspect of right lower lobe

CASE REPORT:

A 56-year-old male presented to us with dry cough and chest pain on inspiration since last 2 days.The patient’s past medical history was unremarkable. A physical examination revealed expiratory and inspiratory wheezing localised to the right lower lobe. The laboratory routine blood investigations were normal.Patient had a recent history of root canal treatment for dental caries tooth done 2 days back.A chest radiograph( Figure 1 and Figure 2) was taken which revealed the presence of dense elongated object impacted in the right lower lobe of lung.Subsequently Computed Tomography (CT )Thorax was done that revealed a metallic density foreign body of approximately size 23 x 6 mm just at the origin of lateral basal segmental branch of right lower lobe bronchus( Figure 3)

A flexible fiberoptic bronchoscopy was performed under sedation with midazolam and topical anaesthesia with 2% lidocaine . It was a difficult retrieval but we were able to successfully remove the dental endodontic file ( Figure 4) , however, if this had failed, then a thoracotomy and pulmonary lobectomy would have been necessary. The patient tolerated the procedure well with no oxygen desaturation, or bleeding occurred during the procedure. After a few hours of observation, a postprocedural radiograph confirmed the removal of the foreign body without any evidence of pneumothorax. The patient was discharged, and 24 hours after the removal remained asymptomatic without chest pain, cough, hemoptysisor fever.

Foreign body aspiration is a common complication of some routine dental procedures. The incidence of aspiration is increased by the patient lying in a supine position for dental treatment.Increased risk of aspiration include the elderly age group, denture wearers, sedated patients, patients with organic brain disease .These patients may have a decreased gag reflex, functional swallowing impairment or other abnormalities of the protective airway mechanism.1,2
 
Figure 2:Chest Xray PA magnified view: showing threads of endodontic file used during RCT
Figure 2:Chest Xray PA magnified view: showing threads of endodontic file used during RCT

A wide variety of aspirated foreign bodies have been reported from teeth and restorative materials to instruments.3 .Dental implants have been reported as the second most commonly ingested/aspirated foreign objects in adults4. Common early signs of foreign body inhalation include bouts of coughing, choking sensation, stridor, paradoxical breathing, decreased oxygen saturation and cyanosis2 which can be life threatening. Long term retention of a foreign body in the lung can lead to vocal cord paralysis, pneumonia, pneumothorax and death.2 If one encounters such and emergency, the patient should be quickly put into the reverse Trendelenburg position2 and encouraged to cough. If coughing fails to relieve the obstruction, then back slaps and abdominal thrusts must be performed. If this is not rapidly successful then the patient must be immediately transferred to a tertiary care hospital .An asymptomatic patient must still be referred to a specialised centreand one should not assume that the object has been swallowed. Radiographic findings include direct visualisation of a radio-opaque foreign body or identifying its effects such as atelectasis, lobar collapse, or distal hyperinflation. 5,6

The most common site of tracheobronchial foreign body aspiration in adults is the bronchus intermedius because of its larger diameter and straighter course, although other airways may be affected depending on body position at the time of aspiration 4.Computed tomography is often unnecessary, as many aspirated dental objects are radio-opaque and can be identified on a standard chest radiograph. Howeverthe absence of a foreign body on radiograph requires chest CT scan5,6 Bronchoscopy is the treatment of choice for removing inhaled dental foreign bodies.2 Flexible bronchoscopy can be performed rapidly and safely under local analgesia or mild sedation .In the case of occult aspiration with long latency before detection, granulation tissue around the foreign body which can make retrieval difficult. If flexible bronchoscopy is unsuccessful, rigid bronchoscopy under general anaesthesia may be required in some cases. Although the vast majority of aspirated foreign bodies can be retrieved bronchoscopically 7, occasionally a surgical approach may be necessary.

Before extracting the foreign object, its anatomic location, shape, composition, and extent of entrapment by granulation tissue, or edema must be identified to avoid the associated risks8. Although rigid bronchoscope offers better control and visualization of the airway and easier use of removal instruments with efficient airway suctioning in a massive bleed, the requirement of general anaesthesia is its primary disadvantage9and foreign bodies deep into the tracheobronchial tree are difficult to retrieve.
 
Figure 3: HRCT Thorax (arrow) showing a metallic density foreign body of approx. Size 23x6 mm just at the origin of lateral basal segmental branch of right lower lobe bronchus .
Figure 3: HRCT Thorax (arrow) showing a metallic density foreign body of approx. Size 23x6 mm just at the origin of lateral basal segmental branch of right lower lobe bronchus .

Flexible fiberoptic bronchoscopy is relatively safe, easy, cost-effective procedure in experienced hands and can be performed under local anaesthesia. It seems to be more efficient, especially in adults and has a higher success rate (>90%) than rigid bronchoscopy10.

A few simple preventive measures can help to decrease the risk of aspiration such as identification of high risk patients,2 the use of a rubber dam for endodontic file and restorative treatment,3 the use of a gauze partition at the back of the oral cavity.3
 
Figure 4: Endodontic file retrieved via Flexible bronchoscope
Figure 4: Endodontic file retrieved via Flexible bronchoscope

CONCLUSION

Early recognition of high-risk factors and location of swallowed foreign bodies during any procedure related to oral cavity are a must to avoid life threatening events.Referral to a tertiary health care facility with bronchoscopy facility goes a long way in preventing major complications.Dentists should always be aware of not only prevention but also the management of inhaled foreign bodies

REFERENCES:
 
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  2. Fields R T Jr , Schow S R . Aspiration and ingestion of foreign bodies in oral and maxillofacial surgery: a review of the literature and report of five cases. J oral maxillofac Surg.1998 Sep;56(9):1091-8.
  3. Zitzmann N U , Elsasser S , Fried R , Marinello C P . Foreign body ingestion and aspiration. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999 Dec; 88: 657–660.
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  7. R.E. Black, D.G. Johnson, M.E. Matlak:Bronchoscopic removal of aspirated foreign bodies in children
  8. Milton TM, Hearing SD, Ireland AJ. Ingested foreign bodies associated with orthodontic treatment: Report of three cases and review of ingestion/aspiration incident management. Br Dent J. 2001;190:592
  9. Dikensoy O, Usalan C, Filiz A. Foreign body aspiration: Clinical utility of flexible bronchoscopy.Postgrad Med J. 2002;78:399–403
  10. Clark PT, Williams TJ, Teichtahl H, Bowes G, Tuxen DV. Removal of proximal and peripheral endobronchial foreign bodies with the flexible fibreoptic bronchoscope. Anaesth Intensive Care.1989;17:205–8

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