Introduction

Foreign body ingestion is a common problem ₁ . Most common foreign bodies in pediatric age group are coins ₂,₃ but meat bone, marbles, safety pins, button, batteries and screws are also reported. Adhikari et al study also showed coins and denture as a common foreign body in adults ₄ . Foreign body ingestion is a common occurrence and carries significant morbidity and mortality. Sharp F.B. is frequently associated with serious complications ₄ . If they are not removed at the earliest, they can cause erosion, perforation, abscess or mediastinitis ₃ . Early removal of these F.B. must be considered to reduce the risk of complication ₄ . We report a case of impacted foreign body (artificial denture) in the oesophagus. To the best of our knowledge this is the first case report from Nepal.

Case Report

A 60 years old male presented to ENT outpatient department of TU Teaching Hospital, Kathmandu with the history of gradually progressive dysphagia, odynophagia and pain in the neck after he accidentally ingested artificial denture. There was no history of fever, drooling of saliva, shortness of breath, seizures. On examination, the patient was ill looking. ENT and head and neck examination revealed tenderness over the neck. Indirect laryngoscopy showed pooling of saliva in pyriform sinus. Other examinations were normal. On x-ray soft tissue neck lateral view there was widening of prevertebral space along with a radio opaque shadow of wire of denture at the level of 6 ^th and 7 ^th cervical vertebra.( Fig:1). Other routine investigations were normal.

Figure 1

Figure 1: X-ray STN lateral view- Wire of denture at C, C level

With the provisional diagnosis of foreign body (denture) oesophagus, patient underwent rigid oesophagoscopy under general anesthesia after 24 hours of antibiotics. Per operative finding was artificial denture impacted at 16 cm from upper incisor. The wire of the denture was impacted on lateral wall of oesophagus and denture could not be removed. The patient developed cervical emphysema on first post operative day and was managed conservatively .On the next day the patient underwent oesophagotomy and retrieval of the denture and sternocleidomastoid muscle patching via external approach. Peri operative finding showed a small rent in the cervical oesophagus anteriorly and impacted denture at lower the cervical oesphagus. (Fig: 2 and 3).

Figure 2

Figure 2: Showing oesophageal perforation after rigid oesophagoscopy

Figure 3

Figure 3: Operative photograph showing a denture.

The left sternocledomastoid muscle was mobilized to create a patch over the defect and interrupted suture were given to close it. A Removac drain and nasogastric tube was inserted. The incision was closed in layers and dressing applied. Fig. 4 showed the artificial denture after removal by oesophagotomy.

Figure 4

Figure 4: Artifical denture removed by Oesophagotomy

Post operatively intravenous antibiotics were continued for 10 days and nasogastric feeding am removac drain kept for 13 days. The suture was removed on 7 ^th postoperative days. The patient was discharged on the 14 ^th postoperative day without any problem.

Discussion

Swallowing and aspiration of dental foreign objects is often reported in the literature ₅ . Swallowing is more common than aspiration and usually seen in the elderly ₅ . Careful examination is therefore essential in all cases of foreign body injury irrespective of the age and mode of presentation ₆ . Too often the size and configuration of these objects compound their impaction and removal ₆ . Ingestion usually occurs after trauma, intoxication, loss of consciousness or sleep, so there may not be a definite history of ingestion ₇ . Psychiatric ad mentally handicapped patients run a high risk of denture ingestion ₈ . Following foreign body ingestion, patients usually present with dysphagia (92%) and tenderness of the neck (60%) ₉ . Other symptoms include: inability to swallow oral secretions, throat pain, painful swallowing, hypersalivation, retrosternal fullness and regurgitation of undigested food. Indirect laryngoscopy will reveal pooling of saliva in pyriform sinus. Thus the diagnosis can be made by suggestive history of foreign body ingestion which is also in our patient.

Radiological imaging can determine the exact site of radio opaque foreign body. It is difficult to localize the site of impacted denture by imaging technique if there is no wire in it unless there is complications such as emphysema, mediastinitis, increased pre-vertebral shadow and loss of cervical lordosis. Their radiolucence makes radiological localization almost impossible, and because of their rigidity, large size, irregular and unyielding edges, impacted dentures are apt to produce lacerations during endoscopic removal from gullets rendered friable by impaction ₁₀ .

These foreign bodies' especially sharp objects perforate and cause complication. It includes retropharyngeal abscess, perforation to oesophagus, aorta, pericardium and gastrointestinal tract. Therefore the possibility of being damage of the vital structures along the path of migration should be borne in mind ₆ .

Endoscopic extraction of dentures carries a high risk of perforation ₁₁ . Extraction of an impacted denture via oesophagotomy can be undertaken under direct vision and in an ideal situation with judicious use of the shear forceps ₁₁ . Small perforations of the cervical oesophagus in adult patients produced by foreign body impaction or rigid oesophagoscopy can be managed by observation, restricted oral intake and intravenous antibiotics ₁₂ . In our case, rigid oesophagoscopy was tried but the patient had cervical emphysema on first post operative day due to cervical oesophageal perforation.

Most of the impacted foreign body are located at cervical and upper oesophagus and can be removed by cervical oesophagotmy. Our patient also underwent oesophagotomy and retrieval of foreign body (denture). There are various methods of closing the oesophageal perforation but we close it using sternocleidomastoid muscle flap. Oesophagotomy has got the risk of oesophageal leakage and increases the chance of mortality. In the presence of positive history, prompt management is safe and effective to reduce the significant morbidity and mortality. The safest most effective method of removing impacted dentures in the oesophagus is through an open oesophagotomy.

Conclusion

Impacted denture in the oesophagus which was removed by oesophagotomy is an unusual presentation. To prevent accidental ingestion, dentures should be made to fit properly and damaged or malfitting dentures should be discarded and replaced. Patients should be strongly advised against wearing them in bed.

Correspondence to

Dr. Prakash Adhikari, MBBS, M.S.Resident Department of Otorhino-Laryngology and Head and Neck Surgery, T.U.Teaching Hospital, Kathmandu, Nepal, Tel:+977-1-4414191,Fax:+977-1-4414191.E-mail: prakash_ooz@hotmail.com