|Year : 2022 | Volume
| Issue : 3 | Page : 273-275
Ten years of impaction of a denture in oesophagus with acquired bronchoesophageal fistula
Rajesh Sharma1, Brij Sharma1, Deepika Bodh2, Vishal Bodh1
1 Department of Gastroenterology, IGMC, Shimla, Himachal Pradesh, India
2 Consultant Orthodontist, Indira Dental Clinic, Sanjauli, Shimla, Himachal Pradesh, India
|Date of Submission||03-May-2021|
|Date of Decision||05-Jun-2021|
|Date of Acceptance||04-Aug-2021|
|Date of Web Publication||24-Nov-2021|
Dr. Vishal Bodh
Department of Gastroenterology, IGMC, Shimla, Himachal Pradesh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Sharma R, Sharma B, Bodh D, Bodh V. Ten years of impaction of a denture in oesophagus with acquired bronchoesophageal fistula. J Med Evid 2022;3:273-5
|How to cite this URL:|
Sharma R, Sharma B, Bodh D, Bodh V. Ten years of impaction of a denture in oesophagus with acquired bronchoesophageal fistula. J Med Evid [serial online] 2022 [cited 2023 Feb 1];3:273-5. Available from: http://www.journaljme.org/text.asp?2022/3/3/273/331160
| Introduction|| |
Accidental ingestion of a foreign body is common in both children and adults. In adults, dentures are commonly ingested foreign bodies. Factors responsible for the dislodgement of dentures and subsequent impaction are poor fit of the denture, prolonged usage and dentures induced gradual loss of sensation of the oral cavity and laryngopharynx. The majority of the patients with acute ingestions presents within a span of 48 h with complaints of dysphagia and odynophagia. A prolonged impaction of the dentures in the oesophagus can cause peri-oesophagitis, necrosis and perforation of the wall or a fistula formation. After 24 h, the rate of complication from impacted foreign body is 3.2% which becomes as high as 23.5% after 48 h. We report the case of a 30-year-old male with accidental ingestion of denture 10 years back, leading to bronchoesophageal fistula (BEF) and was managed surgically.
| Case Report|| |
A 30-year-old male, visited our outpatient clinic with complains of difficulty in swallowing and retrosternal pain for the past 10 year and coughing during swallowing for the past 2 months. He mainly had difficulty in swallowing solid food but was able to swallow liquid or semisolid diet. History of weight loss was present but no history of loss of appetite. The complaints had started after accidental ingestion of upper removable partial denture of a single tooth (central incisor), for which he was investigated at local hospital with laryngoscopy and X-ray of neck and chest. As the reports were normal, he was told that the denture might have progressed into the stomach and will pass out with stool. As he continued to have persistent complaints, so he was referred to a tertiary care centre. He was evaluated at the tertiary care centre in the otolaryngology department after about 18 months of initial presentation. His laryngoscopy and nasal endoscopy were normal. His contrast-enhanced computed tomography (CECT) of neck and chest was performed and was reported as normal with no evidence of foreign body or any filling defect in oesophagus. He continued to have intermittent retrosternal discomfort and difficulty swallowing.
His symptoms got aggravated in the past 2 months and he started having cough during swallowing. Upper gastrointestinal endoscopy at our centre revealed an impacted denture at 23 cm from incisors with nodular, oedematous and hyperaemic surrounding mucosae producing a stricturing effect at that site [Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d. At 20 cm from incisor, a large fistulous opening was seen that was leading in to bronchus. Proximal location of the fistula from the present site of denture impaction may be due to the further slippage of the denture from the initial site of impaction after formation of fistulous opening. Biopsy taken from stricture site and showed no evidence of malignancy on histopathology. A CECT thorax was done that showed dilated oesophagus with wall thickening and BEF between right posterolateral oesophageal wall and segmental bronchus of apical segment of right upper lobe [Figure 2]a and [Figure 2]b. No definite foreign body was seen in CECT. As the denture was impossible to remove endoscopically, the case was referred to the cardiothoracic and vascular surgery department of higher institute. Patient underwent oesophageal bypass with gastric conduit through retrosternal route with cervical esophagogastric anastomosis with remanant Roux-En-Y oesophagojejunostomy with feeding jejunostomy.
|Figure 1: Endoscopic image of esophagus (a) Endoscopic image large arrow showing esophageal lumen and small arrow showing esophagobronchial fistulous opening with impacted food particle, (b) small arrow showing impacted denture in esophageal lumen and large arrow showing esophagobronchial fistulous opening after removal of food particle, (c) arrowhead showing esophageal lumen and small arrow showing closer view of impacted denture, (d) endoscopic image showing segmental bronchus through fistulous opening|
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|Figure 2: (a) Contrast enhanced computed tomography image of thorax showing a fistulous communication between right posterlateral esophageal wall and segmental bronchus of apical segment of right upper lobe, (b) coronal section contrast enhanced computed tomography image showing dilated esophagus with esophageal wall thickening and mucosal irregularity with esophagobronchial fistula and surrounding consolidation of right upper lobe|
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From the 3rd post-operative day, nutrition was started through a feeding jejunostomy tube. Oesophagography did not reveal any extravasations or stagnation of the contrast agent 1 week after surgery so oral feed was started. After 2 weeks, the feeding jejunostomy tube was taken out and since then, the patient is doing well.
| Discussion|| |
The majority of the cases of oesophageal denture impaction present within 24 h of ingestion as seen in our case but unfortunately, no foreign body was detected. This highlights the fact that X-rays are not suitable to visualise the denture (as dentures are made with radiolucent material polymethyl methacrylate). Although endoscopy has almost 100% accuracy in detecting foreign bodies in oesophagus, the impacted denture was missed at a tertiary care centre, which may be due to the inexperience of the endoscopist or use of the nasal endoscopy. CECT also failed to visualise denture which may be due to radiolucency of the denture and absence of complications of foreign body at that time. Difficulty in localising impacted denture by radiological imaging technique has been reported, especially if there is no wire in it or unless there is complications such as emphysema, mediastinitis, increased pre-vertebral shadow and loss of cervical lordosis. Despite numerous reports of this problem, a radio-opaque denture material alternative has yet to be commercially available possibly due to their increased vulnerability to crack or break. There are case reports with prolonged denture impactions.,, Longer durations of denture entrapment have been linked with increased complications. Some late complications are life threatening such as fistula formation with major vessels and major bronchus, abscess formation or perforation. Due to their rigidity, large size and unyielding edges, impacted dentures are apt to produce lacerations during endoscopic removal. A vigorous attempt at removal of impacted denture is not warranted in the presence of pus, slough or bleeding. As endoscopic removal of old impacted denture is dangerous; surgery is often required for its retrieval. Despite progress in endoscopic methods, non-operative treatment of benign acquired BEF is generally unsatisfactory. The treatment of choice is a surgical repair; however, it is associated with the adverse events such as recurrence of the fistula. Oesophageal bypass surgery using a substernaly interposed gastric conduit may be considered if the standard surgical repair of acquired BEF is not feasible (as in our patient). Denture was impacted for a very long time in present case, leading to chronic BEF, for which primary repair would have been difficult, so oesophageal bypass surgery was performed.
| Conclusion|| |
A prolonged impaction of the dentures in the oesophagus can be life threatening. To prevent accidental ingestion, dentures should be made to fit properly and damaged or malfitting dentures should be discarded. Alternative radio-opaque denture material should be made commercially available to overcome difficulty in localising impacted denture by radiological imaging. In old impacted denture, endoscopic removal is dangerous, and surgery is the modality of choice. Oesophageal bypass surgery using a substernaly interposed gastric conduit may be considered if the standard surgical repair of acquired BEF is not feasible.
Professor T D Yadav, surgeon who performed the successful oesophageal bypass in the index case.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]