Retrieval of Aspirated Teeth in an Adult Polytrauma Patient using Pediatric Flexible Fiberoptic Bronchoscopy Allied with Endoscopic Rat Tooth Alligator Jaw Grasping Forceps
Department of Intensive Care Unit, King Khalid University, Aseer Central Hospital, Abha, Aseer Region, Kingdom of Saudi Arabia
Address for correspondence: Mr. Omprakash Palanivel, Department of Intensive Care Unit, Cardio-Respiratory Division, Aseer Central Hospital, Abha, Aseer Region, Kingdom of Saudi Arabia. E-mail: email@example.com
Foreign body (FB) aspiration in maxillofacial injuries is a life-threatening event. A long-time interval between the aspiration and retrieval results in the formation of granulation tissue and mucosal inflammation around the FB, which could restrict the visual field of bronchoscopy and its retrieval. In addition, it can affect the lung structure with fatal complications. Herein, we present a case of unique FB retrieval (2 joined crown teeth - measuring 19 mm) within 8 h following aspiration in a 24-year-old male polytrauma victim. Further, we discuss our successful modified retrieval technique accordingly without resulting in any complications.
Keywords: Computed tomography, endotracheal tube, flexible fiberoptic bronchoscopy, foreign body, pediatric flexible fiberoptic bronchoscopy, rat tooth alligator jaw
How to cite this article: Al Bshabshe A, Assiri AH, Alwadai NM, Palanivel O. Retrieval of aspirated teeth in an adult polytrauma patient using pediatric flexible fiberoptic bronchoscopy allied with endoscopic rat tooth alligator jaw grasping forceps. Indian J Respir Care 2020;9:236-9.
Foreign body (FB) aspiration is unusual in adults. Any high-velocity facial trauma can result in dentoalveolar fractures and tooth avulsion. A trauma victim with altered consciousness associated with maxillofacial injuries remains at high risk of aspiration of the FB. Any unattended aspirated FB can be a medical emergency. In due course, early diagnosis and management play a vital role in the prevention and reduction of the granulation tissues and mucosal inflammation around the FB, along with related complications, surgical interventions, and even deaths. Bronchoscopic extraction through a rigid scope is the most preferred treatment of the FB. However, advancement of modern technology has enabled the use of flexible fiberoptic bronchoscopy (FFOB) with its standard retrieval tools in the removal of FB in the intensive care unit (ICU) patients with artificial airways. Here, we present a unique case of FB retrieval in a patient with artificial airways, wherein two joined avulsed crown teeth detained in the right bronchus intermedius were extracted. After multiple failure of attempts of using adult flexible fiberoptic bronchoscopy (AFFOB) along with various standard retrieval tools, the team decided to approach FB, through endoscopic rat tooth alligator grasping forceps placed next to pediatric flexible fiberoptic bronchoscopy (PFFOB) and not within the working channel of the PFFOB. This is a new modified approach for the removal of FB from trachea hitherto undescribed in any clinical setting of Saudi Arabia.
A 24-year-old male polytrauma victim with associated maxillofacial injuries reported to our hospital. On arrival, his Glasgow coma scale (GCS) was 5, heart rate was 113 beats per minute, blood pressure was 153/80 mmHg, respiratory rate was 13 breaths per minute, and O2 saturation was 86% on room air. On examination, profuse oropharyngeal bleeding and several abrasions on the face and thorax, including long bone fractures in the lower limbs, were seen. Endotracheal intubation (7.5-mm internal diameter endotracheal tube [ETT]) was done, and invasive mechanical ventilation was initiated. Immediate postintubation, X-ray confirmed the proper placement of the ETT. In addition, it also showed a radiopaque shadow in the mid-zone close to the hilum of the right lung [Figure 1]. A computed tomography (CT) scan of the brain revealed the bilateral brain contusions with less severity. He also sustained fracture involving spinous process, lamina, facet joints of C6 and C7, left maxillary arc fracture, mandible parasymphyseal fracture, mild lung contusion with collapsed right middle lobe, and bilateral eye ecchymosis with edema. CT authenticated the presence of an FB, measuring about 19 mm in the right bronchus intermedius [Figure 2]. The patient developed sudden bradycardia (50 beats/min) after 30 min of arrival. Therefore, a femoral venous line inserted to start dopamine infusion and transferred to the ICU. The patient was monitored closely the following 8 h to ensure stable hemodynamics.
Meanwhile, the FFOB was prepared at the patient bedside to visualize the airway and remove the FB. We preferred AFFOB [Karl Storz, Germany, Series No: 11301 BN1, outer diameter - 5.2 mm, working channel - 2.0 mm, Figure 3] rather than rigid bronchoscopy. Sedation was maintained with fentanyl 150 mcg and propofol 50 mg/h infusion. Arterial blood gas (ABG) analysis was within the normal range before bronchoscopy. The patient was receiving synchronized intermittent mandatory ventilation with pressure support ventilation with a FiO2 of 0.8 and a PEEP of 8 cmH2O. The AFFOB was advanced toward FB through ETT via a swivel connector (Portex - 150 mm), placed between ETT and ventilator circuit. FB identified the two teeth joined together on the initial airway examination. A complete plan for FB removal was formulated based on its size and shape of the tooth. Retrieval using standard tools such as biopsy forceps, fishnet basket, and Fogarty balloon introduced one after other through the working channel of FFOB, and all retrieving forceps failed to grasp the two teeth due to slippery nature and huge size variance measuring about 19 mm. Simultaneously, ABGs revealed respiratory acidosis. Therefore, the procedure was withheld. The respiratory acidosis was corrected by increasing the tidal volume and respiratory rate. After 30 min, repeated ABG was satisfactory.
In the subsequent attempts of retrieval, the team decided to use the rat tooth alligator jaw (RTAJ) endoscopic grasping forceps. This combines the features of alligator jaw and rat tooth forceps for optimal grasping, with a working length of 165 mm, an opening width of 11.3 mm, and a working channel size of 2.8 mm (OLYMPUS, USA) [Figure 4]. The RTAJ grasping forceps was not compatible with our AFFOB and PFFOB working channels. Hence, we decided to modify the approach by advancing PFFOB (Karl Storz, Germany, Series No: 11301 AA1, outer diameter - 2.8 mm, working channel - 1.2 mm) via the swivel connector through the ETT as a video light source and placed a few millimeter proximal to the FB site. The RTAJ was advanced not within the working channel, but it was advanced toward FB by keeping it next to the PFFOB [Figure 5]. A stat dose of the muscle relaxant pancuronium 25 mg was given intravenously to decrease airway pressure during mechanical ventilation.
The PFFOB-guided RTAJ endoscopic forceps was used to manipulate and hold the two joined crown teeth firmly and was rotatable in any direction. However, we failed multiple times in extracting the two joined crown teeth through the distal opening of ETT because of a large size variance measuring 19 mm [Figures 6 and 7]. Finally, we decided to withdraw PFFOB till the Murphy's eye of the ETT. We then withdrew the RTAJ endoscopic forceps along with the two joined crown teeth very cautiously till the point of the distal opening of ETT. By holding ventilation, the ETT, along with PFFOB, and the RTAJ, with the two joined crown teeth, were retrieved as a whole unit in a synchronized manner.
The patient was re-intubated with an ETT (7.5 mm) for mechanical ventilation. Re-intubation required less than 30 s from apnea onset. An AFFOB airway inspection showed the airway free from FB, and there was no formation of any granulation tissue and mucosal inflammation. There was a dramatic reduction in FiO2 requirements over the next hour. The patient's clinical status improved progressively. Later, he underwent an uneventful surgical fixation of the femur fracture, sustained during the initial episode of injury. He underwent tracheostomy and was weaned off completely from mechanical ventilation after 9 days and discharged to the ward on day 12.
In general, FB is classified into organic (chicken bones, fish bones, seeds, pieces of fruits, and vegetables) and inorganic substances (teeth, tablets, needles, screws, glass, and plastic pieces). [6,7] Any FB aspirated below vocal cords is defined as tracheobronchial FB. Although tooth aspiration is a rare event in adults, there are several reports of maxillofacial trauma being a high-risk factor for FB aspiration. More often, in adults, the FB is aspirated toward the right than a left bronchial tree, with an incidence of 71.5% due to their anatomic asymmetry.[7,9] Our patient chest X-ray also showed FB in the right bronchus intermedius, with collapse of the right middle lobe. CT is an additional and gold standard tool to get accurate location and surface measurement of FB, as well to plan airway interventions. A recent study concluded that an impacted FB evolves with 43% incidence of granulation tissue formation and 28% incidence of mucosal inflammation. Therefore, in patients with FB, early diagnosis and early bronchoscopy interventions may reduce or prevent granulation and mucosal inflammation. Till date, there are no standardized protocols addressed to manage FB.
Rigid bronchoscopy is a standard device for the diagnosis and treatment of FB. In comparison, flexible bronchoscopy can also be used for airway examination, with an overall 90% success rate in the FB retrieval. A recent study mentions that FFOB is the safest choice for patients with artificial airways and craniocervical injury. The rigid bronchoscope is the best choice for larger FB aspirates. Even so, the risk of airway occlusion by the rigid scope is found to be high. Likewise, the incidence of craniocervical injuries contraindicates the use of rigid scopes.[11–13] Hence, we used FFOB to retrieve FB lodged in the right bronchus intermedius. It is suggested that the FFOB is an appropriate choice in delivering continuous positive pressure ventilation to promote proper ventilation and oxygenation beyond FB. In addition, it minimizes the risk of total occlusion of the artificial airway. During our retrieval interventions, we experienced limited capability of standard retrieval tools in extracting 19-mm FB because of large slippery wedge-shaped FB. Usually, retrieval tools that can be passed through the working channel of FFOB are designed to extract smaller FB. In our setting, we overcame this obstacle by using endoscopic RTAJ grasping forceps, commonly used for endoscopic interventions. However, the RTAJ could only be placed next to the PFFOB and not within the working channel due to size discrepancy. The endoscopic RTAJ provided a firm grip to the FB, and it was rotatable in any direction. It also served as an adjunct path for retrieving large FB of 19 mm without any interruption in mechanical ventilation. Furthermore, the risk of complete occlusion in the primary airway was found to be low in this technique.
Our case report emphasizes that the early diagnosis of FB provides more flexibility for medical personnel to alter the standard FFOB retrieval technique into an innovative approach at the bedside. It may reduce the occurrence of granulomatous hyperplasia from 83.1% to 22.3% and related complications. Our modified retrieval technique can be an alternative approach when the standard retrieval technique fails in retrieving large FB, or it can be used in any clinical setting when there is no availability of big working channel scopes. A clear clinical FB retrieval plan, skilled team, familiar settings, and utilizing appropriate equipment play a significant role in the successful retrieval of large FB from artificial airways. However, misguided endoscopic RTAJ grasping forceps may injure the bronchial walls. Using RTAJ in retrieving smaller FB may relocate FB into the segmental bronchus, making it difficult to retrieve. Therefore, expertise is required to use the endoscopic RTAJ grasping forceps.
The rigid bronchoscopy remains the first choice for the treatment of FB aspiration. However, FFOB may also be used as they have numerous advantages over rigid scopes in specific circumstances.
We would like to acknowledge Ali Mushabab, Dr Ibrahim Mushabab, Dr Bahas, RT Ali Mushabab, RT Anthony.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
1. Hefny AF, El-Ashaal Y, Ali YB, Abu-Zidan FM. Aspiration of an incisor tooth in a polytrauma patient. Medical image. N Z Med J 2009;122:73-4.
2. Sakellaridis T, Koulaxouzidis G, Panagiotou I, Kigka C, Papamichalis G, Antypas G. Aspiration of fixed dental prosthesis following maxillofacial trauma. Emerg Med J 2008;25:143.
3. Allison MJ, Pezzia A, Gerszten E, Giffler RF, Mendoza D. Aspiration pneumonia due to teeth-950 AD and 1973 AD. South Med J 1974;67:479-83.
4. Casalini AG, Majori M, Anghinolfi M, Burlone E, D'Ippolito R, Toschi M, et al. Foreign body aspiration in adults and in children: Advantages and consequences of a dedicated protocol in our 30-year experience. J Bronchology Interv Pulmonol 2013;20:313-21.
5. Nadjem H, Pollak S, Windisch W, Perdekamp MG, Thierauf A. Tooth aspiration: Its relevance in medico-legal autopsies. Forensic Sci Int 2010;200:e25-9.
6. Rafanan AL, Mehta AC. Adult airway foreign body removal. What's new? Clin Chest Med 2001;22:319-30.
8. Xiao WL, Zhang DZ, Wang YH. Aspiration of two permanent teeth during maxillofacial injuries. J Craniofac Surg 2009;20:558-60.
9. Adjeso T, Damah MC, Murphy JP, Kojo Anyomih TT. Foreign body aspiration in Northern Ghana: A review of pediatric patients. Hindawi Int J Otolaryngol 2017; 1478795.
10. Hewlett1 JC, Rickman OB, Lentz1 RJ, Prakash UB, Maldonado F. Foreign body aspiration in adult airways. Therapeutic approach. J Thorac Dis 2017;9:3398-409.
11. Madan K, Aggarwal AN, Bhagat H, Singh N. Acute respiratory failure following traumatic tooth aspiration. BMJ Case Rep 2013;:bcr2012008393. doi: 10.1136/bcr-2012-008393.
12. 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.
13. Othman MN, Kumarasamy S, Ambu VK, See GB. Foreign body in bronchus: A rare method of removal. RMJ 2013;38:204-5.
14. Kim KC. Extraction of endobronchial tooth by flexible bronchoscopy using fishnet basket in patients of intensive care unit with artificial airway. Korean J Crit Care Med 2014 29:38-42.
15. Dong YC, Zhou GW, Bai C, Huang HD, Sun QY, Huang Y, et al. Removal of tracheobronchial foreign bodies in adults using a flexible bronchoscope: Experience with 200 cases in China. Intern Med 2012;51:2515-9.
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