Unusual Complications of a Dental Prosthesis Esophageal Foreign Body: About a Case

Foreign bodies of the esophagus are part of the traumatic emergencies in ENT. They are most often encountered in children, whereas in adults they occur in a particular context and are rarely overlooked.

This was a 48-year-old patient from a neighboring country referred by a colleague for a history of neglected laryngeal contusion with infectious cervical fistula evolving for 2 years. Further questioning revealed a notion of accidental ingestion of dentures. The first endoscopy was of capital interest in especially in the diagnosis and management of this long-retained foreign body. The extraction under general anesthesia was done by a combined endoscopic and external approach. The postoperative course was marked by superinfection and swallowing disorders.

Cervical suppurations secondary to esophageal foreign bodies are rare, especially in adults. Clinicians should consider this possibility in the face of any chronic cervical suppuration that resists treatment.

A dental prosthesis is the replacement of one or more lost teeth with plastic or porcelain teeth, either using an acrylic base or metal clasps for retention to secure them to adjacent teeth [1]. Accidental ingestion of prostheses is an emergency that can immediately jeopardize functional prognosis. Its management requires urgent intervention and rapid treatment [1]. In the event of failure of esophagoscopic extraction, external surgical removal (cervicotomy) must be performed [1].

The significance of this case report lies in the specific clinical presentation characterized by a diagnostic error, the vulnerable type of foreign body, the occurrence of a complication such as perforation followed by cervical fistula, and the extraction difficulties which justified a combined surgical approach.

This was a 48-year-old patient with no particular medical history, originally from Guinea Conakry, working as a lumberjack, who reported suffering a cervical contusion from direct trauma from a tree branch in 2018. He had initially received medical treatment for laryngeal trauma. The subsequent course was complicated by the development of mechanical dysphagia with dysphonia followed by the progressive development of a draining left laterocervical fistula (Figure 1).

A CT scan showed a pattern of left cricoarytenoid subluxation with asymmetry in the width of the bands. Given this clinical presentation, an ENT colleague referred him to us for better management.

The clinical examination at admission found a fairly good general condition, a productive left latero-basic-cervical fistula. The examination of the oral cavity found multiple edentulism. The nasofibroscopy revealed hypomobility of the left hemi-larynx.

Rereading the initial CT scan revealed endolaryngeal hypodensity resembling a gas bubble and retrolaryngeal hyperdense structure resembling bone associated with pharyngeal thickening with left posterior endolaryngeal inflammation (Figure 2).

Given these radiological doubts and the cervical fistula, the diagnosis of neglected cervical trauma with pharyngocutaneous fistula was suggested and rigid tube endoscopy was indicated.

After the endoscopic discovery of solid food debris hiding a foreign body located approximately 18 centimeters from the upper dental arch, further questioning revealed the notion of accidental ingestion of a dental prosthesis at the time of the work accident in Guinea. Thus, an esophago-gastro-duodenal transit (OGDT) and a computed tomography (CT) scan were requested. The OGDT was compatible with a traumatic lesion of the hypopharynx with fistulization and left paracervical abscess (Figure 3).

While the CT showed a V-shaped esophageal foreign body (Figure 4) with very likely a circumscribed old abscess collection and development of fibrosis around it. The presence of an esophageal fistula without tracheal involvement.

An endoscopy was indicated for the extraction of a pharyngoesophageal body, such as a dental prosthesis.

Given the entrapment of the foreign body, making endoscopic extraction infeasible, the intraoperative decision to use a combined cervical approach was made.

The left cervicotomy incision was made along the anterior edge of the sternocleidomastoid muscle followed by an isthmotomy after retracting the soft tissue layers allowing access to the laryngeal region and preservation of the left recurrent laryngeal nerve. The approach to the cervical esophagus under endoscopic guidance, the cervical esophagus was approached at the foreign body site (Figure 5).

It allowed the extraction of a bulky prosthesis with sharp edges (Figure 6).

The esophagotomy was achieved using double-layer extramucosal closure with 3-0 absorbable sutures followed by repair of the inferior pharyngeal constrictor muscle.

A nasogastric tube was placed for feeding. The patient was then given antibiotics (amoxicillin clavulanate) and analgesics.

The postoperative course was complicated by an infection characterized by salivary leakage from the surgical site on day 1. A swab followed by a bacteriological study with antibiogram isolated a strain of Enterobacter cloacae sensitive to ciprofloxacin, and antibiotic therapy was adjusted. The patient was discharged on postoperative day 10, with good clinical progress

Removal of the nasogastric tube was performed on postoperative day 45 with an OGDT showed contrast aspiration into bronchial tree without extravasation of the contrast agent. This was confirmed to be a pharyngeal-phase swallowing disorder. The control nasofibroscopy demonstrated hypomobility of the left hemilarynx.

Foreign body ingestion is a common problem, particularly among young children and patients with conditions that limit cognition and communication, such as stroke and mental retardation [2,3].

Among upper aerodigestive tract foreign bodies, esophageal foreign bodies account for approximately 60% of cases [4], twice as common as bronchial foreign bodies, particularly in children [5].

Foreign body ingestion primarily affects children under 6 years of age, accounting for 76% of 663 cases, and adults over 50 years of age [6]. In adults, the peak incidence is in the 70th year of age, and the authors emphasize the beneficial role of dentures due to the reduced oral sensation due to palatal coverage by dentures [7].

Doumbia, et al. in Mali had found that foreign bodies in adults accounted for 37% of all foreign bodies in the esophagus over a 2-year study period [8].

A literature review shows that Deguenonvo, et al. identified, in a 6-year retrospective study in Senegal, 332 patients complaining of accidental ingestion of foreign bodies, 14 cases (3%) of denture ingestion. Foreign bodies are usually impacted at the first anatomical constriction (70%), which is located at the thoracal entrance at the level of the cricopharyngeal muscle [9,10].

Apart from underlying psychiatric disorders in adults, diagnosis is generally easy to obtain if the patient is able to provide a reliable history and is based on questioning. Patients present for actual or suspected ingestion within the first 24 hours in 70% of cases.

When the concept of ingestion is unknown, this delay can be several months [11,12] or even several years [13]. There is a correlation between the severity of local complications of ingested foreign bodies and the time elapsed between ingestion and admission [14].

The diagnostic error noted in our observation could be explained by the fact that cervical trauma, initially the circumstances of the occurrence of the ingestion accident, had occupied the forefront of the picture. However, suspicious images were already present on the CT scan.

Sharp foreign bodies are more aggressive and both immediate and delayed perforations have been documented [14]. Perforations are most often proximal, occurring in less than 1% of cases when it involves an intraesophageal foreign body and in 15% to 30% of cases when the foreign body has crossed the stomach. Bone ridges, dentures or bone splinters pose an added risk of infection and can cause mediastinitis, cellulitis, or a paraesophageal abscess. Any suspicion of an esophageal foreign body is a formal indication for esophagoscopy even if physical and radiological examinations are negative [14]. Prompt surgical intervention is required in case of failure of the endoscopic attempt or any complication untreatable with endoscopy [15].

One of the complications of foreign body ingestion is the non-extractable foreign body. It is either immediately removed or after one or more attempts at endoscopic extraction. Surgical intervention is then required for removal. Deguenonvo, et al. reported a case of extraction by esophagotomy after several attempts by endoscopic approach [1]. In our observation, we had chosen a combined endoscopic and external approach, thus allowing easy identification of the entrapped foreign body.

Surgical exploration allows the search for the ingested foreign body and to specify its nature and location. It also allows for a precise lesion assessment to search for local complications such as perforation, vascular and neural injuries. At the level of the cervical esophagus, esophagotomy by left cervicotomy followed by suturing of the esophagus with the insertion of a nasogastric feeding tube is preferable. However, a right cervicotomy has been described in a case of perforation of the esophagus in the posterior part of its upper third [12].

The average length of hospital stay varies depending on the chosen therapeutic modality. It does not exceed 2 days for endoscopy while it can reach 4 days for monitoring or even 6 days when the treatment is surgical. We deduce that endoscopic extraction of foreign bodies allows to shorten the length of hospital stay, which gives this therapeutic method an additional advantage. Deguenonvo, et al. described a case of postoperative recurrent paralysis which is not the case in our patient whose recurrent laryngeal nerve paralysis was pre-existing.

Accidental ingestion of prostheses is an emergency that can immediately jeopardize functional prognosis. Its management requires urgent and timely treatment. Thorough patient history-taking to identify the ingestion accident can help make the diagnosis. Surgical neck exploration is the preferred method for the extraction of entrapped foreign bodies.

Informed consent: Informed written consent was obtained from the patient for publication.

1. Deguenonvo REA, Diouf-Ba MS, Touré S, Ndiaye C, Ndiaye M, Diom ES, Sylla IAS, et al. Accidental ingestion of dental prosthesis: a propos of 14 cases. Dent Health Curr Res. 2016;2(1):2-4. Available from: https://www.scitechnol.com/peer-review/accidental-ingestion-of-dental-prosthesis-a-propos-of-14-cases-60sQ.php?article_id=4632
2. Athanassiadi K, Gerazounis M, Metaxas E, Kalantzi N. Management of esophageal foreign bodies: a retrospective review of 400 cases. Eur J Cardiothorac Surg. 2002;21(4):653-6. Available from: https://doi.org/10.1016/s1010-7940(02)00032-5
3. Hachimi-Idrissi S, Corne L, Vandenplas Y. Management of ingested foreign bodies in childhood: our experience and review of the literature. Eur J Emerg Med. 1998;5(3):319-23. Available from: https://pubmed.ncbi.nlm.nih.gov/9827834/
4. Reilly J, Thompson J, MacArthur C, Pransky S, Beste D, Smith M, et al. Pediatric aerodigestive foreign body injuries are complications related to timeliness of diagnosis. Laryngoscope. 1997;107(1):17-20. Available from: https://doi.org/10.1097/00005537-199701000-00006
5. Lemberg PS, Darrozo DH, Holinger LD. Aerodigestive tract foreign bodies in the older child and adolescent. Ann Otol Rhinol Laryngol. 1996;105(4):267-71. Available from: https://doi.org/10.1177/000348949610500404
6. Panieri E, Bass DH. The management of ingested foreign bodies in children: a review of 663 cases. Eur J Emerg Med. 1995;2(2):83-7. Available from: https://journals.lww.com/euro-emergencymed/abstract/1995/06000/the_management_of_ingested_foreign_bodies_in.5.aspx
7. Brossard E, Perko D. Foreign bodies of the esophagus. Méd Hyg. 1986;44:2305-9. Available from: https://doi.org/10.1007/BF02968562
8. Doumbia-Singare K, Timbo SK, Keita M, Togola-Konipo F, Guindo B, Soumaoro S, Ag Mohamed A. Esophageal foreign bodies in adults: about 26 cases. Mali Med. 2011;26(3):1-4. Available from: https://www.scirp.org/reference/referencespapers?referenceid=3042092
9. Türkyilmaz A, Aydin Y, Yilmaz O, Aslan S, Eroğlu A, Karaoğlanoğlu N, et al. Esophageal foreign bodies: analysis of 188 cases. Ulus Travma Acil Cerrahi Derg. 2009;15(3):222-7. Available from: https://pubmed.ncbi.nlm.nih.gov/19562542/
10. Blair SR, Graeber GM, Cruzzaval JL, Gustafson RA, Hill RC, Warden HE, Murray GF. Current management of esophageal impactions. Chest. 1993;104(4):1205-9. Available from: https://doi.org/10.1378/chest.104.4.1205
11. Haegen TW, Wojtczak HA, Tomita SS. Chronic inspiratory stridor secondary to a retained penetrating radiolucent esophageal foreign body. J Pediatr Surg. 2003;38(2):6. Available from: https://doi.org/10.1053/jpsu.2003.50066
12. Hrabar D, Duvnjak M, Lerotic I, Tomasic V, Supanc V, Bilic B. Gastric foreign body. Gastrointest Endosc. 2006;63(3):498-9. Available from: https://doi.org/10.1016/j.gie.2005.06.068
13. Iseh KR, Oyedepo OB, Aliyu D. Pharyngo-oesophageal foreign bodies: implications for health care services in Nigeria. Ann Afr Med. 2006;5(1):52-5. Available from: https://www.bioline.org.br/pdf?am06012
14. Ngeow WC. Ingested denture. Br Dent J. 2001;191(8):418. Available from: https://doi.org/10.1038/sj.bdj.4801199a
15. Tihan D, Trabulus D, Altunkaya A, Karaca S, Cihan A, Alifi H. Esophageal perforation due to inadvertent swallowing of a dental prosthesis. Turk J Gastroenterol. 2011;22(5):529-33. Available from: https://turkjgastroenterol.org/en/esophageal-perforation-due-to-inadvertent-swallowing-of-a-dental-prosthesis-134127