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Unusual complication associated with severe maxillofacial trauma
Unusual complication associated with severe maxillofacial trauma L. Kullbom, B.A., D.D.S., B.S., M.D.,*” Omaha, Neb. Terrence
UNIVERSITY
OF
NEBRASKA
MEDICAL
M.S.,” and James Adwers, CENTER
The aspiration or inhalation of foreign objects during severe maxillofacial trauma is a rare occurrence, but is usually manifested by various clinical signs and symptoms. It is important that a careful examination of chest roentgenograms be made whenever missing teeth cannot be located. This case report presents a rare example of aspiration of a tooth fragment during maxillofacial trauma without any evidence of clinical signs or symptoms.
T
he possibility of inhalation or aspiration of foreign objects, such as teeth, dentures, amalgam fragments, bone, mucus, vomitus, and blood, should always be considered in the initial evaluation of maxillofacial trauma. The aspiration of foreign objects is usually associated with loss of consciousness and loss of protective reflexes. However, the conscious patient can aspirate foreign material without producing sympt0ms.l Aspirated foreign objects which are radiolucent are a particular hazard, because the chest roentgenogram may not reveal their presence.2 The clinical manifestations may vary from inability to carry out adequate respiratory exchange, to a cough, to complete absence of any signs or symptoms. Hemoptysis may occur in some cases. Initial x-ray examination of the lungs may give normal findings or show atelectasis or obstructive emphysema. The treatment in all suspected cases is endoscopic examination and removal. Removal is feasible in most cases except when a small object has lodged in a peripheral bronchus. It is important that early removal of foreign bodies be accomplished before inflammatory complications, such as bronchiectasis and pulmonary abscess, occur.2 In a review of the literature, it appears that aspiration of foreign bodies is *Former ‘*Assistant
Chief Resident, Section Instructor and Chief
of Oral Resident,
Surgery, Department of General Department of General Surgery.
Surgery.
355
356
Kullbom
Oral March,
and Adwers
Fig. 1. Portion
of crown
of maxillary
Burg. 1974
cuspid.
a rare complication of maxillofacial trauma. Four casesof aspiration of teeth due to maxillofacial trauma have been reported. Booth3 reported a case in which two teeth were aspirated during an auto accident. The teeth were discovered by chest x-ray examination. The patient developed a severe coughing spell on the fourth day and coughed up the teeth and then swallowed them. Bowerman and Buschinger5 have reported similar cases in which patients aspirated teeth during an accident and were unconscious for a short period of time. Gilliland and associates1reported a case in which a patient aspirated a tooth and a fragment of bone but did not lose consciousnessat any time or develop coughing or other reflex activity. Bronchoscopy was performed, and the tooth and alveolar bone were removed from the right intermediate bronchus. CASE REPORT A 34-year-old man crashed his automobile into a concrete abutment at a high rate of speed. He was brought into the emergency room, awake, alert, and in a stable condition with a pulse of 110 and a blood pressure of X0/90 mm. Hg. Examination showed multiple facial lacerations, avulsion and fracture of seven anterior maxillary teeth, avulsion of a large portion of the maxillary alveolus, fracture of the left mandibular condyle, an open comminuted fracture of the mandibular symphysis, and a closed fracture of the midportion of left femur. The patient underwent open reduction and fixation of the facial fracture, which was accomplished with intraosseous wiring and Erich arch bars. Closed reduction and tibia1 traction were employed for the femur fracture. The postoperative course was unremarkable until the patient had a coughing spell on the third day and found what he thought was a tooth in his mouth (Fig. 1). It proved to be a. portion of the crown of the maxillary cuspid. Subsequent comparison of this fragment with the initial chest x-ray film (Fig. 2) and a follow-up film (Fig. 3) showed that this foreign body had been present in the left main stem bronchus and had been asymptomatic. No pulmonary complications resulted.
SUMMARY Aspiration of foreign material subsequent to maxillofacial trauma is rare. It is especially uncommon in the conscious patient. This case illustrates the importance of careful scrutiny of chest roentgenograms in any casesof suspected aspiration of foreign bodies.
Volume Number
Fig. Fig.
37 3
Unusual
complication
during
8. Initial x-ray film of chest showing portion 3. Follow-up x-ray film taken on the third day.
of
maxillofacial
tooth
in left
main
trauma
stem
357
bronc :hus.
REFERENCES
1. Gilliland, R. F., Taylor, C. G., and Wade, facial Injury: Report of Case, J. Oral Surg. 2. Swartz, 5. I.: Principles of Surgery, New 3. Booth, N. A.: Complications Associated Oral Cavity-Aspiration of Teeth: Report
W. M.: Inhalation of a Tooth During Ma> cilloSO: 839-840, 1972. York, 1969, McGraw-Hill Book Co., Inc., p. 503. With Treatment of Traumatic Injuries of the of Case, J. Oral Burg. 11: 242-244, 1953.
358
Kullbom
Oral March,
and Adwers
4. Bowerman, J. E.: The Inhalation of Teeth Following Maxillo-Facial Injuries, 127: 132-134, 1969. 5. Buschinger, K.: A Tooth in the Lung, Dtsch. Zahnaerztl. Z. 10: 1032, 1955. Reprint requests to : Dr. James Adwers Department of General University of Nebraska Omaha, Neb. 68105
Surgery Medical
Center
Br.
Surg. 1974 Dent.
J.
UNIVERSITY
OF
NEBRASKA
MEDICAL
M.S.,” and James Adwers, CENTER
The aspiration or inhalation of foreign objects during severe maxillofacial trauma is a rare occurrence, but is usually manifested by various clinical signs and symptoms. It is important that a careful examination of chest roentgenograms be made whenever missing teeth cannot be located. This case report presents a rare example of aspiration of a tooth fragment during maxillofacial trauma without any evidence of clinical signs or symptoms.
T
he possibility of inhalation or aspiration of foreign objects, such as teeth, dentures, amalgam fragments, bone, mucus, vomitus, and blood, should always be considered in the initial evaluation of maxillofacial trauma. The aspiration of foreign objects is usually associated with loss of consciousness and loss of protective reflexes. However, the conscious patient can aspirate foreign material without producing sympt0ms.l Aspirated foreign objects which are radiolucent are a particular hazard, because the chest roentgenogram may not reveal their presence.2 The clinical manifestations may vary from inability to carry out adequate respiratory exchange, to a cough, to complete absence of any signs or symptoms. Hemoptysis may occur in some cases. Initial x-ray examination of the lungs may give normal findings or show atelectasis or obstructive emphysema. The treatment in all suspected cases is endoscopic examination and removal. Removal is feasible in most cases except when a small object has lodged in a peripheral bronchus. It is important that early removal of foreign bodies be accomplished before inflammatory complications, such as bronchiectasis and pulmonary abscess, occur.2 In a review of the literature, it appears that aspiration of foreign bodies is *Former ‘*Assistant
Chief Resident, Section Instructor and Chief
of Oral Resident,
Surgery, Department of General Department of General Surgery.
Surgery.
355
356
Kullbom
Oral March,
and Adwers
Fig. 1. Portion
of crown
of maxillary
Burg. 1974
cuspid.
a rare complication of maxillofacial trauma. Four casesof aspiration of teeth due to maxillofacial trauma have been reported. Booth3 reported a case in which two teeth were aspirated during an auto accident. The teeth were discovered by chest x-ray examination. The patient developed a severe coughing spell on the fourth day and coughed up the teeth and then swallowed them. Bowerman and Buschinger5 have reported similar cases in which patients aspirated teeth during an accident and were unconscious for a short period of time. Gilliland and associates1reported a case in which a patient aspirated a tooth and a fragment of bone but did not lose consciousnessat any time or develop coughing or other reflex activity. Bronchoscopy was performed, and the tooth and alveolar bone were removed from the right intermediate bronchus. CASE REPORT A 34-year-old man crashed his automobile into a concrete abutment at a high rate of speed. He was brought into the emergency room, awake, alert, and in a stable condition with a pulse of 110 and a blood pressure of X0/90 mm. Hg. Examination showed multiple facial lacerations, avulsion and fracture of seven anterior maxillary teeth, avulsion of a large portion of the maxillary alveolus, fracture of the left mandibular condyle, an open comminuted fracture of the mandibular symphysis, and a closed fracture of the midportion of left femur. The patient underwent open reduction and fixation of the facial fracture, which was accomplished with intraosseous wiring and Erich arch bars. Closed reduction and tibia1 traction were employed for the femur fracture. The postoperative course was unremarkable until the patient had a coughing spell on the third day and found what he thought was a tooth in his mouth (Fig. 1). It proved to be a. portion of the crown of the maxillary cuspid. Subsequent comparison of this fragment with the initial chest x-ray film (Fig. 2) and a follow-up film (Fig. 3) showed that this foreign body had been present in the left main stem bronchus and had been asymptomatic. No pulmonary complications resulted.
SUMMARY Aspiration of foreign material subsequent to maxillofacial trauma is rare. It is especially uncommon in the conscious patient. This case illustrates the importance of careful scrutiny of chest roentgenograms in any casesof suspected aspiration of foreign bodies.
Volume Number
Fig. Fig.
37 3
Unusual
complication
during
8. Initial x-ray film of chest showing portion 3. Follow-up x-ray film taken on the third day.
of
maxillofacial
tooth
in left
main
trauma
stem
357
bronc :hus.
REFERENCES
1. Gilliland, R. F., Taylor, C. G., and Wade, facial Injury: Report of Case, J. Oral Surg. 2. Swartz, 5. I.: Principles of Surgery, New 3. Booth, N. A.: Complications Associated Oral Cavity-Aspiration of Teeth: Report
W. M.: Inhalation of a Tooth During Ma> cilloSO: 839-840, 1972. York, 1969, McGraw-Hill Book Co., Inc., p. 503. With Treatment of Traumatic Injuries of the of Case, J. Oral Burg. 11: 242-244, 1953.
358
Kullbom
Oral March,
and Adwers
4. Bowerman, J. E.: The Inhalation of Teeth Following Maxillo-Facial Injuries, 127: 132-134, 1969. 5. Buschinger, K.: A Tooth in the Lung, Dtsch. Zahnaerztl. Z. 10: 1032, 1955. Reprint requests to : Dr. James Adwers Department of General University of Nebraska Omaha, Neb. 68105
Surgery Medical
Center
Br.
Surg. 1974 Dent.
J.