Cervical esophagotomy for an impacted denture: a case report.

Abstract

We present the case of a 46-year-old woman with an impacted denture and an impending esophageal perforation. Her family physician initially missed the diagnosis but during a subsequent visit reviewed her x-ray and was able to see the shadow of the denture's wire attachment in her esophagus. The patient was then referred to a tertiary care hospital, where esophagoscopy confirmed the location of the denture, but the surgeon there was unable to remove it. Eighteen days after she had swallowed her denture, she was referred to our hospital. Attempts at removal via rigid esophagoscopy were unsuccessful, but the denture was successfully removed via a cervical esophagotomy. A Gastrograffin swallow performed 1 week postsurgically showed no extravasation of the contrast medium, and subsequent follow-ups were unremarkable. We conclude that cervical esophagotomy is a safe method for removing foreign bodies impacted in the cervical esophagus when they cannot be removed endoscopically.

Introduction

Impaction of dentures in the esophagus is a distressing experience for a patient and can lead to serious consequences, such as esophageal perforation. Patients with an impacted denture often present with a history of accidental swallowing, frequently during trauma, seizures, or sleep or in association with some degree of psychological dysfunction. (1-3) The common signs and symptoms of an impacted denture are odynophagia, dysphagia, or simply pain and tenderness in the neck or chest. (4-6) Impacted dentures, mostly broken or partial dentures, accounted for 11.5% of foreign bodies in the esophagus in a case series by Abdullah et al. (1)

Case report

A 46-year-old woman presented to our hospital with complaints of persistent odynophagia and intermittent pain in the neck and shoulders ever since she had swallowed her denture while drinking water 18 days earlier. She had visited a family physician, who ordered a plain radiograph of the neck. The physician could not see the denture on the neck x-ray and told her that the denture had probably passed farther into her alimentary canal.

Because her symptoms persisted, the patient returned to her physician, who restudied the radiograph. This time the physician was able to see the shadow of a metallic wire in the x-ray at the C8-T1 level (figure 1).

The patient was then referred to a tertiary care hospital. Esophagoscopy performed there revealed that the denture was lodged in the esophagus, but the surgeon could not remove it. It appeared to be deeply impacted in the esophageal wall. The patient was therefore referred to our hospital.

We performed a rigid endoscopy. The impacted denture was identified 22 cm from the patient's incisors. Multiple attempts to dislodge it failed; therefore, we enlisted a thoracic surgeon's help with its removal.

A vertical incision was made along the anterior border of the sternocleidomastoid muscle on the left side. The middle thyroid vein was ligated and the recurrent laryngeal nerve identified and preserved. The esophagus was found to be severely inflamed and already perforated. The denture, including its attachment, was visualized at a level just below the clavicle near the brachiocephalic vein.

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The cervical esophagus was separated from the surrounding structures (figure 2). An incision was made at the perforation site to facilitate removal of the denture (figure 3). The edges of the perforation were freshened, and the 3-cm longitudinal opening thus created was closed by primary repair; a drain was left in the patient's neck.

A Gastrograffin swallow performed a week later showed no extravasation of the contrast medium. Subsequent follow-ups were unremarkable.

Discussion

Impacted dentures may lead to fistula formation or esophageal perforation, (3,6) a serious complication. Beyond 24 hours after ingestion, the rate of complications multiplies several-fold, from 3.2% at 24 hours to as high as 23.5% after 48 hours. (3,7)

Diagnosis and treatment are often delayed because of the radiolucent nature of modern dentures (8,9) and the inability of the attending physician to appreciate subtle signs seen on a neck x-ray. (3,10) Even though x-rays remain useful (5) and are the most commonly performed initial investigation, their results need to be viewed with caution. One study showed that lateral radiographs of the neck changed the management approach in only 1.4% of cases. (11) In the series by Abdullah et al, only 33% of the dental prostheses impacted in the esophagus could be visualized on a lateral neck radiograph. (1) Those that could be visualized were only seen because they had metal wires attached to them, but since denture wires are so small, their shadows can be extremely difficult to see. Therefore, a high index of clinical suspicion needs to be maintained and esophagoscopy performed if a patient's clinical history suggests denture ingestion and impaction. (7)

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In a study by Weber et al, rigid endoscopy was found to be a safe procedure. (12) However, others suggest a higher risk of perforation with attempted endoscopic removal. (6) If a denture is found via rigid esophagoscopy to be deeply embedded in the wall of the esophagus, then esophagotomy is the best option for removing the dental prosthesis. (4,5,12) This surgery may be performed through a cervical or thoracic approach, depending on the level of impaction.

We conclude that cervical esophagotomy is a safe procedure for the removal of foreign bodies impacted in the cervical esophagus that are not amenable to endoscopic removal.

References

(1.) Abdullah BJ, Teong LK, Mahadevan J, Jalaludin A. Dental prosthesis ingested and impacted in the esophagus and orolaryngopharynx. J Otolaryngol 1998;27(4):190-4.

(2.) Nashef SA, Klein C, Martigne C, et al. Foreign body perforation of the normal oesophagus. Eur J Cardiothorac Surg 1992;6(10):565-7.

(3.) Firth AL, Moor J, Goodyear PW, Strachan DR. Dentures may be radiolucent. Emerg Med J 2003;20:562-63.

(4.) Nijhawan S, Shimpi L, Mathur A, et al. Management of ingested foreign bodies in upper gastrointestinal tract: Report on 170 patients. Indian J Gastroenterol 2003;22(2):46-8.

(5.) Khan MA, Hameed A, Choudhry AJ. Management of foreign bodies in the esophagus. J Coll Physicians Surg Pak 2004;14(4):218-20.

(6.) Nwaorgu OG, Onakoya PA, Sogebi OA, et al. Esophageal impacted dentures. J Natl Med Assoc 2004;96(10):1350-3.

(7.) Sittitrai P, Pattarasakulchai T, Tapatiwong H. Esophageal foreign bodies. J Med Assoc Thai 2000;83(12):1514-18.

(8.) Newton JP, Abel RW, Lloyd CH, et al. The use of computed tomography in the detection of radiolucent denture based material in the chest. J Oral Rehabil 1987;14:193-202.

(9.) Knowles JE. Inhalation of dental plates--a hazard of radiolucent materials. J Laryngol Otol 1991;105:681-2.

(10.) Ekanem VJ, Obuekwe ON, Unuigbe A. Death from ingestion of removable partial denture: A case report. Niger Postgrad Med J 2005;12(1):65-6.

(11.) Jones NS, Lanningan FJ, Salaama NY. Foreign bodies in the throat: A prospective study of 388 cases. J Laryngol Otol 1991;105:104-8.

(12.) Weber R, Jaspersen D, Draf W. Foreign bodies of the esophagus and upper gastrointestinal tract in childhood. Laryngorhinootologie 1993;72(9):455-8.

Sardar Zakariya Imam, MD; Mubasher Ikram, FCPS; Saulat Fatimi, MD; Moghira Iqbal, FCPS

From the Department of Otolaryngology and Head and Neck Surgery (Dr. Imam, Dr. Ikram, and Dr. Iqbal) and the Department of Cardiothoracic Surgery (Dr. Fatimi), Aga Khan University Hospital, Karachi, Pakistan.

Corresponding author: Moghira Iqbal, Department of Otolaryngology and Head and Neck Surgery, Aga Khan University Hospital, Stadium Rd., Karachi, Pakistan. Fax: [phone]; e-mail: [e-mail]