Esophageal Rupture Occurred During the Endoscopic Removal of a Lodged Denture

Question

A 56-year-old woman was admitted to our emergency department with complaints of left-sided facial paralysis, left arm weakness, and deviation of her lips to the left, which began on the morning of her admission. After the patient complained of a sore throat following chest radiography, ingestion of a foreign body was suspected. Therefore, the neck soft-tissue radiograph was obtained (Fig. 1A), which revealed a linear radiopaque lesion in the presumed upper esophagus. A chest computed tomography (CT) scan revealed a linear metallic foreign body in the esophagus, partially penetrating the esophageal wall (Fig. 1B). Upper endoscopy, performed 4 hours after arrival at the emergency department, revealed a 5-cm denture with sharp clasps in the esophagus (Fig. 2A). After removal using endoscopic retrieval net, deep laceration with bleeding was observed (Fig. 2B). A follow-up chest CT was performed 50 minutes after the endoscopic removal (Fig. 2C). What is the most likely diagnosis?

Fig. 1.

Radiologic findings of an esophageal metallic foreign body. A: A soft-tissue radiograph of the neck shows a linear radiopaque lesion in the left upper paratracheal area (arrow). B: An axial chest CT scan reveals a linear metallic foreign body in the esophagus, partially penetrating the esophageal wall (arrow).

Fig. 2.

Endoscopic and radiologic findings of denture-induced esophageal injury. A: Endoscopic examination reveals a denture with clasps in the upper esophagus. B: Endoscopic examination after removal of denture reveals deep laceration and bleeding in the upper esophageal wall. C: A follow-up axial chest CT (lung window) reveals extensive pneumomediastinum and subcutaneous emphysema in the chest wall.

Answer

A chest CT revealed extensive pneumomediastinum and subcutaneous emphysema in the chest wall. Subsequently, video-assisted thoracoscopic surgery confirmed esophageal perforation, and the surgical repair was performed the following day. Follow-up upper endoscopy performed at 1 month showed that the esophageal perforation site had healed (Fig. 3).

Fig. 3.

Follow-up endoscopic examination demonstrates scar formation at the site of perforation.

Although no radiologic or endoscopic evidence of perforation (e.g., free air or full-thickness defect) was observed prior to removal, a large mucosal laceration with active bleeding was noted immediately after extraction of the denture. This raises the possibility that significant perforation have occurred during the removal process itself. A retrieval net was selected as the removal device due to its ability to securely encompass large, irregularly shaped foreign bodies, such as denture clasps. However, in retrospect, a more controlled stepwise approach, such as initial partial mobilization with grasping forceps followed by net-assisted retrieval, may have minimized mucosal trauma.

Dentures account for 4% to 18% of esophageal foreign bodies and are the most commonly ingested objects after fish and animal bones [1]. While most esophageal foreign bodies can be removed endoscopically, but dentures with sharp clasps may embed in the esophageal mucosa, risking perforation and serious complications. The risk of perforation during endoscopic removal can be as high as 23% [2]. In managing esophageal foreign bodies, particularly sharp objects such as dentures with metal clasps, it is essential to approach each case with the understanding that surgical intervention may ultimately be required [3]. Nevertheless, in clinical practice, direct progression to surgery without first attempting endoscopic removal is uncommon, especially when the foreign body is endoscopically visible and retrievable. In our case, endoscopic removal was pursued because the denture was clearly visualized and accessible, and the patient presented within a relatively short time. This case highlights the importance of a multidisciplinary approach, with timely surgical backup available when endoscopic extraction is attempted for high-risk foreign bodies.