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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 4  |  Issue : 2  |  Page : 111-113

Difficult retrieval of a bronchial foreign body in a patient with maxillofacial trauma


Department of Anaesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

Date of Submission28-Mar-2021
Date of Acceptance28-May-2021
Date of Web Publication10-Aug-2021

Correspondence Address:
Dr. Deepak Chakravarthy
Plot No. 9, 3rd Main Road, Gokulam Nagar, Moovarasampet, Chennai - 600 091, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/arwy.arwy_17_21

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  Abstract 


Maxillofacial trauma is often associated with avulsion of the tooth and an attendant risk of aspiration of the tooth. Delay in diagnosis and intervention can pose a serious threat to life if the central airway is obstructed. Bronchoscopy-guided retrieval of the aspirated tooth in patients with maxillofacial trauma poses a significant challenge to anaesthesiologists in maintaining the airway without compromising oxygenation and ventilation. We report a case of delayed yet difficult bronchoscopic retrieval of a tooth in the right bronchus in a patient with maxillofacial trauma.

Keywords: Aspirated tooth, bronchoscopy, difficult airway, extensive facial trauma, foreign body


How to cite this article:
Arikrishnan T, Chakravarthy D, Vinayagam S. Difficult retrieval of a bronchial foreign body in a patient with maxillofacial trauma. Airway 2021;4:111-3

How to cite this URL:
Arikrishnan T, Chakravarthy D, Vinayagam S. Difficult retrieval of a bronchial foreign body in a patient with maxillofacial trauma. Airway [serial online] 2021 [cited 2021 Dec 2];4:111-3. Available from: https://www.arwy.org/text.asp?2021/4/2/111/323567




  Introduction Top


Maxillofacial trauma is frequently associated with avulsion of the tooth, and there is an increased risk of aspiration of the tooth.[1] It can occur either spontaneously in patients with altered sensorium or during emergency intubation. Hence, it is prudent to rule out foreign body aspiration in patients with maxillofacial trauma, particularly in patients with dento-alveolar fractures. We report a case where difficulty was encountered for retrieval of a tooth in the right bronchus in a patient with maxillofacial trauma.


  Case Report Top


A 28-year-old male presented to the emergency room with an alleged history of assault on the face with a sickle. On presentation, he had a Glasgow Coma Score (ENTV2M5), multiple lacerations over the face (precluding testing of eye opening), hypovolaemic shock, respiratory distress and subcutaneous emphysema over the neck [Figure 1]. He was intubated and resuscitated with fluids and blood products. Computerised tomography (CT) of the brain revealed left Sylvian subarachnoid haemorrhage, multiple facial fractures, left depressed frontal bone fracture and impacted tooth in left choana. CT thorax showed a tooth in the right intermediate bronchus without any evidence of pneumothorax [Figure 2]. The patient was posted for left frontal craniotomy and maxillofacial soft tissue repair along with foreign body removal. On arrival in the operating room, standard monitors were attached and baseline haemodynamic parameters were recorded. Air entry was reduced over the right lung, and the patient maintained a saturation of 80% while breathing 100% oxygen, and had a blood pressure of 100/60 mmHg and heart rate of 130/min.
Figure 1: Multiple lacerations over the face showing grossly distorted anatomy

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Figure 2: Computerised tomography of chest showing tooth located in the right bronchus

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Since the size of the molar tooth in the bronchus was greater than the inner diameter of the endotracheal tube, a flexible bronchoscopy-guided removal of tooth would have necessitated the removal of the endotracheal tube along with the foreign body leading to a potential loss of the airway in this setting. Rigid bronchoscopy was also deferred due to multiple facial fractures, airway oedema and airway bleeding. Hence, flexible fibreoptic bronchoscope-guided foreign body removal through the tracheal stoma was planned. Tracheostomy was done and the tooth was visualised in the right upper lobe bronchus. However, as the tooth could not be removed despite multiple attempts, it was decided to postpone the removal of the bronchial foreign body. After initial flexible bronchoscopy, saturation improved to 100% on 60% oxygen. Hence, we decided to proceed with left frontal craniotomy and elevation of the bone flap was done along with facial soft-tissue repair. The patient was shifted to the intensive care unit (ICU) for further management. Serial chest X-rays and vigilant monitoring for possible tooth migration were continued throughout the ICU stay. On day 3, the possibility of performing a rigid bronchoscopy to retrieve the tooth was discussed with the surgeons but was deferred in view of the extensive facial trauma and possibility of worsening airway oedema, both of which could have posed technical difficulties. Therefore, a flexible fibreoptic-guided foreign body removal was attempted in the ICU on day 3 but was unsuccessful. On day 9, the patient was shifted to the operating room for rigid bronchoscopy as there was no fresh bleeding and airway oedema had resolved. After intravenous induction, the patient was paralysed and ventilated with 100% oxygen through the tracheostomy tube. The rigid bronchoscope was inserted from the upper airway. When the tip reached the tracheostomy level, the tracheostomy tube was removed and ventilation was continued through the ventilating port of the rigid bronchoscope. The foreign body was found in the right main bronchus and it was removed in the first attempt. After the removal of the bronchoscope, the tracheostomy tube was replaced.


  Discussion Top


Aspiration of a tooth following maxillofacial trauma often goes unnoticed. It can happen during or following trauma, and at tracheal intubation.[2] Clinical examination in concurrence with radiological findings will confirm tooth aspiration. In a case of polytrauma, many factors such as bleeding, hypovolaemic shock, low Glasgow Coma Score and severe respiratory distress necessitate emergency intubation to save life. In such scenarios, aspiration of multiple teeth can occur. Sometimes patients can have associated rib fracture with pneumothorax that further delays the diagnosis of possible aspiration of a tooth, sometimes even leading to the condition going unrecognised.

In patients with maxillofacial trauma, rigid bronchoscopy for foreign body retrieval in an acute setting is not recommended due to various reasons. First, there is a high chance of losing the airway during the procedure, since these are potentially difficult airways. Second, there is an increased risk of aspiration of blood from the traumatised upper airway. Third, the presence of multiple loose teeth increases the risk of further dislodgement and aspiration during the procedure. The presence of airway oedema makes the procedure difficult even in the hands of experienced surgeons. Moreover, rigid bronchoscopy through a fresh tracheostome increases the risk of bleeding into the airway, pneumothorax, pneumomediastinum, subcutaneous emphysema and the creation of a false passage.[3] Thus, elective tracheostomy followed by flexible fibreoptic bronchoscopy-guided foreign body retrieval is one of the recommended techniques[4] and was planned in our case. Since the size of the molar tooth was larger than the inner diameter of the tracheostomy tube, there occurred a necessity to remove the tooth in situ along with the tracheostomy tube. Since there was a high chance of losing the airway if this was attempted in a fresh tracheostomy, the procedure was deferred. Another option was to secure maturation sutures around the tracheostome while performing the procedure which would have created a more secure airway and helped perform rigid bronchoscopy through the tracheal stoma in patients with central airway obstruction.

In the ICU, serial chest imaging revealed the dynamic nature of the foreign body, i.e., the tooth was found at different places at different points of time. Early removal of tooth was warranted, as there is a high risk of central airway obstruction due to migration of foreign bodies within the trachea. Hence on day 3, we attempted a fibreoptic bronchoscope-guided tooth removal through the tracheostomy tube. However, the tooth was found deep in the right lower lobe bronchus and could not be removed. On day 9, when the airway oedema had entirely resolved and the tracheostomy tract was reasonably well formed, rigid bronchoscope-guided foreign body removal was performed successfully. Although in our case, retrieval of foreign body was delayed due to multiple failed attempts, we recommend that every effort should be made for early retrieval in order to avoid potential complications such as lung collapse, accumulation of secretions leading to pneumonia and migration of foreign body with catastrophic airway obstruction.

Thus foreign body aspiration should be suspected in maxillofacial trauma patients with unexplained pulmonary findings. Appropriate intervention at the right time can prevent devastating complications and reduce morbidity.

Declaration of patient consent

The authors certify that they have obtained appropriate patient consent forms. In the forms, the patient has given his consent for images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Rao SS, Baliga SD. Tooth aspiration following maxillofacial trauma: Report of a rare case. Indian J Health Sci Biomed Res 2016;9:324-7.  Back to cited text no. 1
  [Full text]  
2.
Zhang M, Zhou GJ, Zhao S, Yang JX, Lu X, Gan JX, et al. Delayed diagnosis of tooth aspiration in three multiple trauma patients with mechanical ventilation. Crit Care 2011;15:424.  Back to cited text no. 2
    
3.
Ahmed Z, Alalami A, Haupert M, Rajan S, Durgham N, Zestos MM. Airway management for rigid bronchoscopy via a freshly performed tracheostomy in a child with Goldenhar syndrome. J Clin Anesth 2012;24:234-7.  Back to cited text no. 3
    
4.
Kim DW, Jang JY, Shim H, Jung JY, Kim EY, Nam W, et al. Removal of aspirated teeth in a multiple trauma patient, using fiberoptic bronchoscopy with simultaneous tracheostomy: Review of 2 cases. Respir Care 2014;59:e1-4.  Back to cited text no. 4
    


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