What to Do in Subglottic Denture Dislodgement: Anesthesiologist Perspective for Airway Control

Swati Jindal¹ https://orcid.org/0000-0001-6819-5201, Kritika Dwivedi²

^1,2Department of Anaesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India

Corresponding Author: Swati Jindal, Department of Anaesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India, Phone: +91 9646004171, e-mail: swatirohit604@gmail.com

How to cite this article: Jindal S, Dwivedi K. What to Do in Subglottic Denture Dislodgement: Anesthesiologist Perspective for Airway Control. Res and Innov Anesth 2024;9(1):31–32.

Source of support: Nil

Conflict of interest: None

Sir,

A 50-year-old male patient presented in the ear, nose, and throat (ENT) emergency department with a chief complaint of a history of dislodgement of a dental bridge while sleeping at night, along with throat pain and difficulty in breathing for 2 days. His throat pain was continuous and difficulty in breathing was progressive in nature. Patient was brought to operation theater directly from emergency department. In the operating theater, during preoperative assessment, it was noted that the patient was having labored breathing. He was not cyanotic and was able to communicate but with little difficulty. His vital signs were heart rate 86 bpm, blood pressure 128/74 mm Hg, SpO₂ 97%, and respiratory rate 24 breaths per minute. On physical examination, there was noisy breathing suggestive of impending stridor and suprasternal retractions. Patient had got himself treated at a local hospital. Investigations were present with the patient done from another hospital. A 90° endoscopy showed foreign body at level of vocal cords. True vocal cords (TVC) were edematous. Plain X-ray neck radiographs showed the missing dental bridge (Fig. 1D). Contrast-enhanced computed tomography (CECT) neck showed an ill-defined curvilinear hyperdensity at the level of the TVC, along the posterior aspect of the cricopharyngeus, with wall thickening.

Figs 1A to E: Dislodged denture

Intraoperatively, plan was to do awake laryngoscopy using C-MAC videolaryngoscope and, if possible, visualize the foreign body position. A difficult airway cart was kept ready due to the findings of physical examination of the airway and the risk of dislodgment of the impacted foreign body further into the airway, with the risk of complete obstruction and/or perforation of the esophagus being high. A tracheostomy kit was also kept ready with surgeon already scrubbed and ready for emergency tracheostomy in case of failure to intubate. Topicalization of the airway was done using nebulization of 4% lignocaine (4 mL) with 5 mL of normal saline over 20 minutes. Lignocaine jelly was smeared over the base of the tongue, and 10% lignocaine spray was used to anesthetize the base of the vallecula. Preoxygenation via a face mask was done for 5 minutes. Paraoxygenation done with nasal cannula at 15 L/minute O₂. Following awake videolaryngoscope-assisted laryngoscopy, the epiglottis, glottis, and misplaced dentures could be seen behind the vocal cord (Fig. 1C), leaving only a small space for endotracheal tube (ETT) insertion. Intubation using a small uncuffed ETT was tried as surgeon wanted general anesthesia (GA) before proceeding. However, the ETT intubation was abandoned due to high risk of pushing the denture further down in trachea. So, the surgeon performed emergency tracheostomy under local anesthesia. Airway control was achieved following induction with propofol and fentanyl and anesthesia circuit attached to tracheostomy tube. Surgeon removed the denture (Figs 1A and B) with great difficulty as it was impacted in the submucosa (Fig. 1E). Intraoperative phase was uneventful. Patient was shifted to postanesthesia care unit after regaining consciousness and was shifted to the ward on T-piece. Later, on follow-up, the patient was decannulated after 1 month of treatment. Postoperative X-ray and investigations were within normal limits.

In adults, foreign body aspiration is a rare but potentially fatal occurrence. Majority of accidental aspiration cases are seen in children, but many cases can occur in adult patient.¹ Objects that are frequently aspirated include food and fractured denture pieces. Diagnosis of foreign body aspiration can be confirmed with imaging. Different sedation techniques used to remove foreign bodies from the airway include rigid bronchoscopy with jet ventilation, GA with a laryngeal mask airway or ETT, and conscious sedation with spontaneous ventilation.¹ In our case, we had taken the decision to go for C-MAC awake laryngoscopy due to urgency of condition and to know the location of impacted foreign body. Foreign body can lead to dyspnea, choking, and respiratory tract obstruction. The initial treatment of the foreign body involves close teamwork between the ENT surgeons and the anesthetic team.² Aspiration of a dental prosthesis with a fixed bridge can result in significant morbidity because the edge of the prosthesis can injure the lining mucosa in addition to obstructing the airway.³ GA is more frequently required for removal of dentures than for other types of foreign bodies as chances of impaction leading to bleeding and edema are higher. It can also cause soft tissue injury and can be time-consuming due to larger size of denture.² Main reasons for an aspirated tooth or denture include trauma to the face or maxilla, dental treatment procedures, and being under the influence of alcohol. Dementia, stroke, and epilepsy are predisposing factors, but most cases occur in patients in which there is no risk factor.² Our case highlights how impacted foreign body was removed from the airway.

ORCID

Swati Jindal https://orcid.org/0000-0001-6819-5201

REFERENCES

1. Shah S, Howard J, Winston N. Foreign body in the glottis. Cureus 2022;14(04):e24428. DOI: 10.7759/cureus.24428

2. Cunniffe HA. Dentures discovered in larynx 8 days after general anaesthetic. BMJ Case Rep 2019;12(08):e230055. DOI: 10.1136/bcr-2019-230055

3. Hidaka H, Suzuki T, Toyama H, et al. Dislocated dental bridge covering the larynx: usefulness of tracheal tube guides under video-assisted laryngoscopy for induction of general anesthesia, thus avoiding tracheostomy. Head Face Med 2014;10:23. DOI: 10.1186/1746-160X-10-23

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