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Aspiration of radiolucent foreign body
CORRESPONDENCE
Aspiration of Radiolucent Foreign Body To the Editor. We describe a unique case of an aspiration of a radiolucent foreign body in a patient who presentedto our emergencydepartment. A 56-year-oldman with a history of amyotrophic lateral sclerosis presentedto the ED after having a choking episodethe previousday. His complaints were of throat pain and increaseddifficulty swallowing, but on arrival in the ED, he denied dysphagiaor shortness of breath. The physicalexaminationwas unremarkable.A barium swallow revealedaspiration into the tracheobronchial tree with barium trapping in the vallecula and piriform sinuses. The patient remainedasymptomatic in the department,and was discharged to follow-up with an ear, nose, and thioat surgeon in two days. At this outpatientvisit, indirect laryngoscopy revealedonly laryngeal edema.The following day, the patient returned to the EDwith shortness of breath. His dysphagiahad returned,and he had been unable to sleep. At this point, he was able to swallow solids but not liquids. On physicalexamination,the patient had stridorous breathing, with a respiratory rate of 24; blood pressure, 140/80 mm Hg; pLtlse,90; and temperature,36.3 C. Chest examination revealed bibasilar diminished breath sounds.There was a question of a mass on the left side of the neck just superiorto the clavicle. Symmetricalweaknesswas noted in both upper and lower extremities, presumablysecondary to amyotrophic lateral sclerosis. Arterial blood gas obtained at this time while on 2 L by nasal cannula revealed a pH of 7.36; Po2, 120 mm Hg; Pco2, 49 mm Hg; and 100% saturation. Electrolytes,CBC,and blood glucose were within normal limits. Soft tissue films of the neck suggested a mass impinging on the trachea and esophagus.Chestradiograph revealed bibasilar infiltrates.
172/771
The patient was intubated in the ED as his respiratory status worsened. Antibiotics were initiated for possible pneumonia,and IV steroids were given to prevent airway swelling. Ear, nose, and throat was consulted for tracheostomyand possible biopsy. In the operating room, a tracheostomy and direct laryngoscopy were performed. Laryngoscopy revealed a portion of upper dentures that had been overgrown by tissue in the cricopharyngealarea. The foreign body was removed,and the patient was soon breathing without ventilator assistance.A direct laryngoscopyfour days postoperatively showed almost no residual supraglottic swelling; three days later, the tracheostomytube was removedand the patient was discharged,able to swallow normally. Two to three thousand people in the United States die each year from foreign body aspiration.1 The most commonforeign body involved is a food bolusJ There are many conditions that predisposeto aspiration, including alcohol or drug intoxication, seizures, strokes, trauma, coma, cardiopulmonaryarrest, general anesthesia,debilitating disease, and esophagealdisease.2Also, specific disorders involving the oropharynx,the esophagus,and the nervous system may increasethe risk of aspiration.2 In the case presented, the patient certainly was predisposedto aspiration because of his history of amyotrophic lateral sclerosis. Aspirations of dental prostheses have been describedpreviously,s-8 Reportedcomplications include laryngospasm,asphyxia,lung abscesses, and pneumonia.7 The patient describedis of particular interest in that his partial denture was entirelyradiolucent.If radiopaque material had been present in this prosthesis, the foreign body would have been identified at the initial ED visit and would have been removed prior to the decline in his respiratory status. This case promptedus to notify the Departmentof Health and Huruan Servicesof the need for
radiopaquematerial on all dental prostheses. One must include foreign body aspiration in the differential diagnosis of any patient presentingwith symptoms of upper airway obstruction, either acute or chronic in duration. A physical examination must include careful examination of the oral cavity, including presenceand absence of teeth, bridges, and dentures. All patients should be asked about the possibility of denture aspiration. Moreover, one must especiaily be alerted to this possibility in any patient with seizures,decreased mental status, or any other neurologic impairment.The absenceof any radiographicfindings may be very misleading,as some foreign bodies are radiolucent.
Lawrence W Schenden, MD William F PeacockIII, MD, FACEP Judith E Tintinalli, MD, FACEP William BeaumontHospital Royal Oak,Michigan 1. Wolkove N: Occult foreign body aspiration in adults. JAMA 1982;248:1350-1352. 2. Newman GE: Pulmonary aspiration complexes in adults. Curt Probl Diagn Radio11982;11:1-47. 3. Peters TE: Dental prosthesis as a n unsuspected foreign body. Ann Emerg Med 1984;13:60-62. 4. Strassler HE: Ingestion and aspiration of foreign bodies in dental practice: Two case reports. J Baltimore Coll Dent Surg 1983;36:1-5. 5. E1Badrany HE: Aspiration of foreign bodies during dental procedures. Can Dent Assoc J 1985;51:145-147. 6. Giovannitti JA: Aspiration of a partial denture during a epileptic seizure. JADA 1981;103:895. 7. Jacobi R: A method to prevent swallowing or aspiration of cast restorations. J Prosth Dent 1981 ;46:642-645. 8. Nishioka GJ: Aspiration of a n intermaxillary fixation wire fragment. Anesth Prog 1987;34:14-16.
ANNALS OF EMERGENCY MEDICINE 21:6 J U N E 1 9 9 2
Aspiration of Radiolucent Foreign Body To the Editor. We describe a unique case of an aspiration of a radiolucent foreign body in a patient who presentedto our emergencydepartment. A 56-year-oldman with a history of amyotrophic lateral sclerosis presentedto the ED after having a choking episodethe previousday. His complaints were of throat pain and increaseddifficulty swallowing, but on arrival in the ED, he denied dysphagiaor shortness of breath. The physicalexaminationwas unremarkable.A barium swallow revealedaspiration into the tracheobronchial tree with barium trapping in the vallecula and piriform sinuses. The patient remainedasymptomatic in the department,and was discharged to follow-up with an ear, nose, and thioat surgeon in two days. At this outpatientvisit, indirect laryngoscopy revealedonly laryngeal edema.The following day, the patient returned to the EDwith shortness of breath. His dysphagiahad returned,and he had been unable to sleep. At this point, he was able to swallow solids but not liquids. On physicalexamination,the patient had stridorous breathing, with a respiratory rate of 24; blood pressure, 140/80 mm Hg; pLtlse,90; and temperature,36.3 C. Chest examination revealed bibasilar diminished breath sounds.There was a question of a mass on the left side of the neck just superiorto the clavicle. Symmetricalweaknesswas noted in both upper and lower extremities, presumablysecondary to amyotrophic lateral sclerosis. Arterial blood gas obtained at this time while on 2 L by nasal cannula revealed a pH of 7.36; Po2, 120 mm Hg; Pco2, 49 mm Hg; and 100% saturation. Electrolytes,CBC,and blood glucose were within normal limits. Soft tissue films of the neck suggested a mass impinging on the trachea and esophagus.Chestradiograph revealed bibasilar infiltrates.
172/771
The patient was intubated in the ED as his respiratory status worsened. Antibiotics were initiated for possible pneumonia,and IV steroids were given to prevent airway swelling. Ear, nose, and throat was consulted for tracheostomyand possible biopsy. In the operating room, a tracheostomy and direct laryngoscopy were performed. Laryngoscopy revealed a portion of upper dentures that had been overgrown by tissue in the cricopharyngealarea. The foreign body was removed,and the patient was soon breathing without ventilator assistance.A direct laryngoscopyfour days postoperatively showed almost no residual supraglottic swelling; three days later, the tracheostomytube was removedand the patient was discharged,able to swallow normally. Two to three thousand people in the United States die each year from foreign body aspiration.1 The most commonforeign body involved is a food bolusJ There are many conditions that predisposeto aspiration, including alcohol or drug intoxication, seizures, strokes, trauma, coma, cardiopulmonaryarrest, general anesthesia,debilitating disease, and esophagealdisease.2Also, specific disorders involving the oropharynx,the esophagus,and the nervous system may increasethe risk of aspiration.2 In the case presented, the patient certainly was predisposedto aspiration because of his history of amyotrophic lateral sclerosis. Aspirations of dental prostheses have been describedpreviously,s-8 Reportedcomplications include laryngospasm,asphyxia,lung abscesses, and pneumonia.7 The patient describedis of particular interest in that his partial denture was entirelyradiolucent.If radiopaque material had been present in this prosthesis, the foreign body would have been identified at the initial ED visit and would have been removed prior to the decline in his respiratory status. This case promptedus to notify the Departmentof Health and Huruan Servicesof the need for
radiopaquematerial on all dental prostheses. One must include foreign body aspiration in the differential diagnosis of any patient presentingwith symptoms of upper airway obstruction, either acute or chronic in duration. A physical examination must include careful examination of the oral cavity, including presenceand absence of teeth, bridges, and dentures. All patients should be asked about the possibility of denture aspiration. Moreover, one must especiaily be alerted to this possibility in any patient with seizures,decreased mental status, or any other neurologic impairment.The absenceof any radiographicfindings may be very misleading,as some foreign bodies are radiolucent.
Lawrence W Schenden, MD William F PeacockIII, MD, FACEP Judith E Tintinalli, MD, FACEP William BeaumontHospital Royal Oak,Michigan 1. Wolkove N: Occult foreign body aspiration in adults. JAMA 1982;248:1350-1352. 2. Newman GE: Pulmonary aspiration complexes in adults. Curt Probl Diagn Radio11982;11:1-47. 3. Peters TE: Dental prosthesis as a n unsuspected foreign body. Ann Emerg Med 1984;13:60-62. 4. Strassler HE: Ingestion and aspiration of foreign bodies in dental practice: Two case reports. J Baltimore Coll Dent Surg 1983;36:1-5. 5. E1Badrany HE: Aspiration of foreign bodies during dental procedures. Can Dent Assoc J 1985;51:145-147. 6. Giovannitti JA: Aspiration of a partial denture during a epileptic seizure. JADA 1981;103:895. 7. Jacobi R: A method to prevent swallowing or aspiration of cast restorations. J Prosth Dent 1981 ;46:642-645. 8. Nishioka GJ: Aspiration of a n intermaxillary fixation wire fragment. Anesth Prog 1987;34:14-16.
ANNALS OF EMERGENCY MEDICINE 21:6 J U N E 1 9 9 2