An uncommon cause of dyspnea after trauma in an adult male

Sir,

Aspiration of permanent dentition after avulsion or trauma is not uncommon and is usually associated with polytrauma, loss of consciousness, and reduced gag reflex.[1] Herein we intend to report a case of aspirated tooth after an assault in an adult male and the diagnostic dilemmas and respiratory complications associated with it.

A 54-year-old gentleman was brought to the emergency department in an inebriated state after an assault on his abdomen and legs (with no evident injury to the face and chest). The patient had a history of pulmonary tuberculosis and chronic obstructive pulmonary disease (COPD). On examination, he was haemodynamically stable, had multiple bruises over the abdominal wall, and regained consciousness within a few hours of admission. On evaluation, he had a closed fracture of the right tibia and fibula and was planned for surgery.

Over the next two days, the patient developed cough and breathlessness, which progressively worsened. He had bilateral polyphonic wheeze on auscultation, and chest radiography showed few reticular opacities in the right upper zone, suggestive of sequelae of pulmonary tuberculosis [Figure 1a]. Arterial blood gas analysis showed low PaO₂ (55 mmHg) and normal PaCO₂ (37 mmHg). He was diagnosed with acute exacerbation of COPD and was managed with intravenous glucocorticoids and bronchodilators. However, there was no significant improvement in symptoms within the next 48 hours. Computed tomography with pulmonary angiogram (CTPA) performed given a possibility of fat embolism syndrome or pulmonary thromboembolism revealed bilateral upper lobe cavities and fibrobronchiectatic changes; centrilobular nodules, tree in bud opacities, and ground glass opacities in right lower lobe; and a calcified foreign body (tooth) in right main bronchus [Figure 1b]. Under general anesthesia, a rigid endoscopic extraction of the impacted tooth was performed [Figure 1c and d], and the patient improved symptomatically within the next two days. Later, he was operated successfully for fracture of both bones of the leg and discharged.

Figure 1.

Panel (a): chest radiography showing a tooth in right main bronchus (demonstrated by a white arrow) with right upper zone reticular opacities. Panel (b): computed tomography of thorax showing tooth in right main bronchus (demonstrated by a black arrow). Panel (c): bronchoscopy demonstrating tooth in right main bronchus. Panel (d): extracted premolar tooth affected by caries

There are several learning points from this case. First, as the patient was under the influence of alcohol at the time of admission, a history of dental trauma and aspiration were not forthcoming. A clear history of foreign body aspiration is seen in only 30-50% of cases.[2] Comparably, our patient could also affirm missing one of his teeth only after the CT scan. Aspiration of permanent dentition after avulsion is not uncommon and usually occurs after fights or sports injuries. Severe trauma leading to loss of consciousness, and drug intoxication (alcohol: in our index case), can jeopardize the gag reflex leading to aspiration.

Chest radiography is typically diagnostic in case of metallic (pins, needles, and coins) or mineral foreign bodies (dentures and bones). In the case of organic foreign bodies, chest imaging is mostly normal. However, the tooth was missed initially in chest radiography by multiple physicians as it was just behind the rib shadow in the index case. Failure to elucidate the history of aspiration could be another plausible explanation. A lateral view chest radiography could have been helpful in such instances.

The examination may reveal a monophonic wheeze when the foreign body is lodged in a main bronchus. However, the index case had bilateral polyphonic wheeze, secondary to exacerbation of COPD. This led to further delay in the diagnosis of foreign body aspiration. Since the patient was not improving with bronchodilators and intravenous glucocorticoids and considering the possibility of pulmonary thromboembolism (or fat embolism syndrome), a CTPA was done. Further down the list of differential diagnoses considered were trauma-related acute respiratory distress syndrome and lung contusion. The CTPA showed centrilobular nodules with tree-in-bud opacities, and ground glass opacities in the right lower lobe; bilateral upper lobe cavities; a foreign body (tooth) in the right main bronchus; the overall findings consistent with foreign body aspiration with aspiration pneumonitis and sequela of pulmonary tuberculosis. A naïve interpreter can even suspect active pulmonary tuberculosis in lieu of the above findings in tuberculosis-endemic countries like India.

Flexible bronchoscopy has a high success rate of 89% for foreign body extraction.[3] However, rigid bronchoscopy is indicated primarily if the patient is in respiratory failure, to extract impacted foreign bodies (with rigid forceps) or large foreign bodies, or if the initial flexible bronchoscopy is unsuccessful. After multiple futile attempts with flexible bronchoscopy, we were able to successfully remove the impacted teeth with rigid endoscopy. To conclude, a thorough history and examination, knowledge of bony artifacts in chest imaging, and rigid bronchoscopy are invaluable for the effective and timely management of foreign body aspiration.

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