Dental aspiration in a pediatric patient: a case report

Abstract

Foreign body aspiration is relatively common in children, especially in children younger than 3 years, and it is associated with a high incidence and mortality rate. Because of impairments in swallowing, speech, and vision, more caution regarding foreign body aspiration is required in children with abnormal nervous system development. This report describes a clinically rare case involving a 6-year-old patient with delayed brain development and epilepsy who was found to have a tooth in the bronchus of the left lung through fiberoptic bronchoscopy. The tooth was successfully removed by an extraction procedure. A follow-up examination showed that the patient had a sequela of left lower lobe atelectasis. This case indicates that greater caution is necessary regarding foreign body aspiration, including dental aspiration, in patients with abnormal development of the nervous system.

Introduction

Tracheobronchial foreign body aspiration is a common cause of respiratory distress in children aged 1 to 4 years, and boys are affected more often than girls.^1,2 Children are considered to be at risk for tracheobronchial foreign body aspiration because of their age-specific curiosity, oral stage of development, and lack of molars. Bronchoscopy results in our hospital have shown that the most commonly aspirated foreign bodies are nuts, among which peanuts are predominant. Foods such as vegetables, fruits, bones, and broad beans are also relatively commonly aspirated because they are among the main food sources for children in China. Pen caps are common foreign bodies in school-age children because they can be accidentally aspirated when children play with their peers. More caution is required when encountering pediatric patients with abnormal nervous system development because of their potential impairments in swallowing, speech, and vision. In this report, we describe a 6-year-old patient with delayed brain development and epilepsy who was found to have a tooth in the bronchus of the left lung through fiberoptic bronchoscopy. The tooth was successfully removed. However, a follow-up examination showed that the patient had a sequela of left lower lobe atelectasis. To our knowledge, most patients with dental aspiration have a medical history of maxillofacial trauma or oral surgery. Dental aspiration of unknown cause is very rare.

Case report

A 6-year-old boy was admitted to our hospital with an 8-day history of fever and 5-day history of coughing. Prior to admission, the patient had been administered azithromycin for 6 days with no improvement. His parents indicated that the child had no history of foreign body aspiration or choking. At the age of 4 months, the patient had been diagnosed with pachygyria and epilepsy and was treated with nitrazepam, levetiracetam, and oxcarbazepine to suppress the epilepsy, which was under control at the time of admission to our hospital. Physical examination upon admission revealed a body temperature of 36.3°C, pulse of 122 beats/minute, respiratory rate of 30 breaths/minute, and blood pressure of 104/59 mmHg. The patient did not exhibit the three-concave sign and did not show head bobbing while breathing. A decreased lung volume was detected on the left side, with no moist or dry rales. The patient showed muscular hypotonia in both lower limbs. Preliminary laboratory examinations showed a white blood cell count of 13.53 × 10⁹ cells/L and a high-sensitivity C-reactive protein level of 158 mg/L. Chest computed tomography (CT) showed an unusual high-density lesion in the left lower lobe bronchus that was indicative of a foreign body. Inflammation and partial bronchiectasis were present in the left lower lobe (Figure 1(a)).

Figure 1.

(a) Chest computed tomography + airway reconstruction showed abnormal high-density lesion or foreign body in the bronchus of the left lower lobe (black arrow). (b) Fiberoptic bronchoscopy showed a foreign body in the left lung with granulation tissue formation (black arrow). (c) Extracted tooth (black arrow). (d) One-week follow-up fiberoptic bronchoscopy showed narrow opening of the left lower lobe (black arrow). (e) One-month follow-up fiberoptic bronchoscopy showed narrow opening of the left lower lobe (black arrow) and (f) Five-year follow-up fiberoptic bronchoscopy showed narrow opening of the left lower lobe (black arrow)

Upon admission, the patient was treated with meropenem by injection for 1 week as anti-infective therapy. He was also treated with oral nitrazepam, levetiracetam, and oxcarbazepine to suppress the epilepsy. After 6 days of treatment, the patient’s symptoms of fever and cough had not improved. Therefore, after obtaining consent from the patient’s family, fiberoptic bronchoscopy was performed, revealing a foreign body in the left lung along with granulation tissue formation (Figure 1(b)). The patient underwent a foreign body extraction procedure, and a tooth surrounded by granulation tissue was successfully extracted from the left lung (Figure 1(c)). Following the extraction procedure, the patient’s fever, coughing, and shortness of breath resolved. His blood parameters were normal. He was discharged upon improvement, and no adverse or unanticipated events occurred. The patient and his family were satisfied with the treatment.

One-week follow-up fiberoptic bronchoscopy revealed a narrow opening in the left lower lobe (Figure 1(d)), and chest CT showed a left lung infection that was improved compared with before treatment and a slightly narrower bronchus in the left lower lobe. One-month follow-up fiberoptic bronchoscopy showed a narrow opening in the left lower lobe (Figure 1(e)). The 5-year follow-up was conducted in June 2023, during which fiberoptic bronchoscopy showed that the bronchus in the left lower lobe remained slightly narrow (Figure 1(f)).

The study was conducted in accordance with the principles of the Declaration of Helsinki and was approved by the Ethics Committee of Children’s Hospital, Zhejiang University School of Medicine (2023-IRB-0198-P-01). Because we de-identified all patient details, the need for written informed patient consent for publication of the case report was waived. This case report followed the CARE guidelines. ³

Discussion

Aspiration describes the abnormal entrance of gas, exogenous particles, or endogenous secretions into the airway below the glottis. Normally, food and foreign bodies do not easily enter the lower respiratory tract because of laryngeal protective reflexes and swallowing synergy. The aspiration of a small amount of fluid can also be resolved by coughing. ⁴ Patients with epilepsy are more prone to aspiration because of impaired cognition and convulsions, untimely discharge of oral secretions, suppression of swallowing and coughing reflexes by sedatives, and impaired laryngeal function. ⁵ Additionally, patients with abnormal nervous system development usually have impaired vision and speech, and they are often unable to provide accurate subjective information. Therefore, even in the absence of a history of foreign object aspiration, caution is needed when encountering children with abnormal nervous system development because of the possibility of a foreign body or even dental aspiration. If chest imaging indicates the possibility of a foreign body in the bronchus, fiberoptic bronchoscopy should be performed as soon as possible. Early extraction of foreign bodies helps to ensure airway safety and prevent pulmonary complications. We have herein reported a case of dental aspiration in a patient with delayed brain development and epilepsy. This case indicates that clinicians should be cautious of foreign body aspiration, including dental aspiration, in pediatric patients with abnormal nervous system development that impairs their vision and speech. It highlights the need for thorough examinations, such as chest CT, in such patients with fever and coughing that cannot be effectively suppressed with long-term anti-infective treatments. This is the case even if parents deny a history of foreign body aspiration and choking.

Few cases of dental aspiration have been reported to date, and the incidence rate is approximately 0.4%. Some of these cases occurred after traumatic events such as maxillofacial trauma, ⁶ oral surgery under general anesthesia, ⁷ adenotonsillectomy, ⁸ tooth extraction, ⁹ and endotracheal intubation.^10,11 Although dental aspiration often occurs after maxillofacial trauma or oral surgery, it can also occur in other situations. We have herein reported a case of dental aspiration in a pediatric patient with delayed brain development and epilepsy, suggesting that the possibility of dental aspiration should be considered as a differential diagnosis for these patients. Be'er et al. ¹² reported a case of severe neurological damage in an 8-year-old child with dental aspiration, whereas the patient in our case was 6 years old (within the physiological exfoliation period). Compared with the above case, the follow-up time in our case was longer and the treatment and examination data were more complete. Importantly, our case suggests that parents and doctors should be vigilant for the risk of dental aspiration in children with neurological diseases during this period, and routine dental check-ups are recommended for such patients. If loose milk teeth are present, they should be promptly treated.

Dental aspiration may cause airway obstruction and, in severe cases, death due to asphyxia and cardiac arrest. Dental aspiration accounts for approximately 0.4% of all cases of foreign body aspiration; it is very rare. Clinically, the triad of coughing, respiratory distress, and wheezing is highly indicative of a foreign body in the airway. The breath sounds on one side may be decreased, and local wheezing is usually present in the region of the foreign body. Other possible clinical symptoms include asphyxia, dysphagia, dysphonia, and pneumonia. ¹³ The symptoms and physical signs of a delayed diagnosis also include cyanosis, dyspnea, fatigue, fever, continuous pneumonia, hypertension, and unexplained tachycardia. ¹⁴ Hoarseness and tachycardia may also appear as early symptoms. Dental aspiration can be detected easily because teeth are radiopaque. Therefore, individuals with suspected foreign object aspiration should undergo a chest X-ray examination or CT scan as early as possible. Long-term presence of a tooth in the peripheral bronchus may lead to changes in the local tissue, such as edema, pressure necrosis, an inflammatory response, and increased vulnerability of the bronchial wall. Therefore, the tooth should be extracted as soon as possible. Rigid bronchoscopy is a common choice for removal of tracheobronchial foreign bodies. However, the structural design of flexible bronchoscopes allows for more flexible contact with the foreign body than does rigid bronchoscopy, making intervention easier. It can also be performed under local anesthesia and mild sedation. Therefore, foreign bodies are increasingly being removed using fiberoptic bronchoscopes. ¹¹ Foreign bodies can be extracted from most patients within two attempts using a fibrobronchoscope, and the success rate is as high as 81%. ¹⁵ Because the location of the aspirated tooth in our patient was very deep, a fibrobronchoscope was used, and the tooth was successfully extracted through cannulation with the fibrobronchoscope.

The complications of a foreign body in the respiratory tract include persistent coughing, recurrent pneumonia, atelectasis, emphysema, laryngeal edema, laryngeal trauma, anoxic encephalopathy, and airway complications such as pneumothorax, hydropneumothorax, mediastinal emphysema, subcutaneous emphysema, pleural thickening, bronchiectasia, and bronchoconstriction. ¹⁶ The aspiration of a foreign body such as a tooth may lead to airway obstruction, aspiration pneumonia, lung collapse, lung abscess, bronchiectasis, bronchopleural leakage, and obstructive pneumonia. ¹⁷ Follow-up examinations in the current study revealed narrowing of the left lower lobe. This may have been due to the untimely diagnosis and treatment because the patient had delayed brain development and could not express his clinical condition, and his parents were not aware of the dental aspiration. Long-term physical and chemical damage by the tooth and the microbial invasion from the tooth led to a continuous inflammatory response, which resulted in granulation tissue and fibrous scar tissue formation, furthering the bronchoconstriction. ¹⁸ If the constriction is persistent and affects the patient’s breathing, the patient should undergo treatments such as opening of the airway with a bronchoscope electric knife or laser combined with balloon dilation. Quick diagnosis and treatment are critical. Untimely treatment may lead to severe consequences. ¹⁹ Although bronchoconstriction was persistent in the follow-up examinations, it did not significantly impact breathing; therefore, the patient did not undergo an intervention.

Conclusion

We have herein reported a rare case of dental aspiration in a pediatric patient with delayed brain development and epilepsy that led to narrowing of the bronchus. This case highlights the need for greater caution regarding foreign body aspiration, including dental aspiration, in patients with abnormal development of the nervous system. Early diagnosis and treatment may help to ensure airway safety and prevent pulmonary complications.