Denture Esophageal Impaction Refractory to Endoscopic Removal In a Psychiatric Patient

The Journal of Emergency Medicine, Vol. 18, No. 3, pp. 323–326, 2000 Copyright © 2000 Elsevier Science Inc. Printed in the USA. All rights reserved 0736-4679/00 $–see front matter

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Clincial Communications

DENTURE ESOPHAGEAL IMPACTION REFRACTORY TO ENDOSCOPIC REMOVAL IN A PSYCHIATRIC PATIENT Brendon M. Stiles, MD,* Wayne H. Wilson, MD,† Matthew A. Bridges, MD,‡ Arindam Choudhury, Jorge Rivera-Arias, MD,† Diem B. Nguyen, BA,* and Richard F. Edlich, MD, PhD*

MD,†

*Department of Plastic Surgery, University of Virginia School of Medicine, Charlottesville, Virginia; †Department of Surgery, Salem Virginia Medical Center, Salem, Virginia; ‡Department of Otolaryngology and Head and Neck Surgery, University of Virginia School of Medicine, Charlottesville, Virginia Reprint Address: Richard F. Edlich, MD, PhD Department of Plastic Surgery, University of Virginia School of Medicine, Box 332, Charlottesville, VA 22908

e Abstract—Impaction of dental prostheses is frequently encountered in psychiatric patients. These patients may present an especially challenging problem because the diagnosis may be delayed, resulting in increased morbidity and mortality. Delay in diagnosis in such patients has been attributed to their inability to give a reliable clinical history. In addition, radiolucent dentures cannot be easily detected by radiographic examination. The purpose of this report is to describe a psychiatric patient with an impacted radiopaque dental prosthesis that was refractory to endoscopic intervention. An esophagotomy was needed to successfully remove the foreign body. © 2000 Elsevier Science Inc.

sensitivity predispose elderly patients to food bolus impaction (2). Pediatric patients usually ingest objects accidentally as a result of orolingual curiosity. These foreign bodies are very diverse and include coins, buttons, marbles, crayons, watch batteries, screws, pins, and chicken or fish bones (3). Developmentally disabled patients have been found to ingest panties, sticks, acorns, strings, plastic, bed linens, and other items. Prisoners and psychiatric patients swallow a wide variety of objects, including spoons, razor blades, pins, nails, and even dental prostheses (4). Ingestion of a dental prosthesis can be a challenging diagnostic and therapeutic problem that requires endoscopic removal or even surgery. Many types of dentures have metal clasps that can become imbedded in the esophageal mucosa, increasing the risk of serious complications, including esophageal perforation (5). There are numerous reports of ingestion of dentures leading to increased morbidity, possibly even death (2,5–10). Therefore, in patients presenting with complaints of dysphagia, odynophagia, or airway obstruction, foreign bodies of dental origin should be considered. Psychiatric patients account for a significant number of cases of FBI (11). Up to 50% of adult patients who swallow foreign objects have psychiatric histories (2). These patients have a wide variety of psychiatric diagnoses, including psychosis, dementia, delirium, and de-

e Keywords—foreign body; esophagus; dental prosthesis; psychiatric patient

INTRODUCTION The management of patients with foreign body ingestion (FBI) is a common clinical problem. Reports estimate that 1,500 people die annually in the United States as a result of ingested foreign bodies (1). Six groups of patients appear to be particularly susceptible to swallowing foreign bodies: elderly patients; pediatric patients; and alcoholics, prisoners, the developmentally disabled, and psychiatric patients. Esophageal disease and poor oral

RECEIVED: 31 July 1998; FINAL ACCEPTED: 28 July 1999

SUBMISSION RECEIVED:

9 July 1999; 323

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velopmental disability, as well as organic or chemical impairment. Motivational factors involved in FBI by psychiatric patients have not been clearly elucidated (12). In the emergency department (ED), psychiatric patients presenting with dysphagia, odynophagia, or airway obstruction may pose a diagnostic dilemma. Simple radiologic diagnosis may be difficult because some dental prostheses, particularly complete dentures, are radiolucent. Additionally, many psychiatric patients, for a variety of reasons, are unable to give a reliable history. This report describes the management of a psychiatric patient who presented to the ED with a dental prosthetic device impacted in the esophagus. We describe the diagnostic challenges, treatment, and complications in the case.

CASE REPORT The patient is a 58-year-old male who was admitted to our inpatient Psychiatric Unit with a chronic disorder characterized as dementia, mixed type, with behavioral problems for which he was treated with haloperidol. The patient had complained of worsening dysphagia of 1 month’s duration but gave no history of foreign body ingestion. Physical examination demonstrated no tenderness to palpation and no neck masses suspicious for malignancy. Vital signs were within normal limits. Anteroposterior and lateral chest films showed the presence of what appeared to be dentures in the patient’s upper esophagus (Figure 1). The patient was taken to the operating room and placed under general endotracheal anesthesia for attempted endoscopic removal of the foreign body. Using esophagoscopy, the dentures were visualized approximately 18 cm from the patient’s remaining teeth. They could not be retrieved despite several attempts with both rigid and flexible fiberoptic esophagoscopes. It appeared that multiple prongs on the ends of the dentures had become embedded in the wall of the esophagus, anchoring the foreign body in place. Because of the failure to remove the object endoscopically, the patient was prepped and draped for a surgical exploration through a left neck incision. An incision was made along the anterior border of the sternocleidomastoid muscle and brought down to the midline. The platysma and the omohyoid muscle were divided and the sternocleidomastoid was retracted laterally. The jugular vein and the carotid artery were exposed and also retracted laterally. The recurrent laryngeal nerve was identified and spared. The dental prosthesis was easily palpated in the cervical esophagus. A longitudinal esophagotomy was performed over the area where the foreign body was palpable. The dentures were subse-

Figure 1. Anteroposterior chest film demonstrates radiopaque dental prosthesis (arrow) in the upper esophagus.

quently exposed and removed with some difficulty, even under direct visualization (Figure 2). The esophagotomy was then closed in a single layer of interrupted 3– 0 braided absorbable sutures, followed by reapproximation of the platysma fascia and skin. The postoperative course was uncomplicated. At follow-up 2 weeks later, the

Figure 2. An incision was made through the skin along the anterior border of the left sternocleidomastoid muscle. The jugular vein and carotid artery were exposed and retracted laterally. A longitudinal esophagotomy was performed for removal of the dental prosthesis (arrow).

Denture Esophageal Impaction

patient was doing well without further complaints of dysphagia or pain. During the early postoperative course, he was not fitted for new dentures and was considered to be a candidate for bone fixation of the dental prosthesis.

DISCUSSION One of the major goals in the treatment of FBI is the avoidance of complications associated with entrapped foreign bodies within the esophagus, including mucosal damage, retropharyngeal abscess, and esophageal necrosis, stricture, or perforation. Consequently, early diagnosis with operative removal of the object is critical. Delay in diagnosis can increase the chance of developing rare but preventable complications such as fistula formation or aortic perforation (8,10). There are numerous reports of delayed diagnosis of impacted esophageal dental prostheses, in some cases resulting in serious complications and even death (8,10,13,14). The failure to diagnose impacted esophageal foreign bodies, particularly dental prostheses, may result from unclear patient histories or simply failure of the physician to consider and search for them. A striking example of this was reported by Carson and Schneider, who described a 23-year-old male who complained of a “lump in the throat” that was treated for over a year as a thyroid condition before it was finally discovered by plain radiograph that the patient had simply swallowed his dental prosthesis (9). Diagnosis of foreign body ingestion in the psychiatric patient presents an even greater challenge. The emergency physician must always suspect dental impaction in psychiatric patients with esophageal obstruction. Psychiatric patients are more likely than other patients to swallow foreign objects, either accidentally or intentionally (15). Depending on the type of psychiatric illness, the patient may exhibit altered mental status, affecting the ability to give a reliable history of foreign body ingestion or an adequate description of symptoms, which may prolong the time between foreign body ingestion and diagnosis. A study by Barros et al. found that only 20% of psychiatric patients who ingest foreign bodies are seen within 24 h of ingestion (15). Combined with the greater potential for complication associated with sharp foreign bodies, such as dentures, a delay in diagnosis secondary to psychiatric illness may lead to a significant increase in morbidity. The delay in diagnosis of ingested dental prostheses is evidenced by our patient, who was not diagnosed until more than a month after ingestion. Evaluation of esophageal FBIs should include a careful clinical history detailing the type of foreign body, interval from ingestion to presentation, onset and nature of symptoms, previous digestive symptoms or foreign

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body entrapments, presence or absence of dentures, and history of alcohol or tobacco use. Patients who ingest foreign bodies that become lodged in the upper esophagus are usually able to localize the site of impaction. In contrast, foreign bodies impacted lower in the esophagus may cause more diffuse symptoms that do not allow patients to identify the site of obstruction as easily. Such symptoms include chest pain or pressure, dysphagia, gagging, vomiting, or a sensation of choking. Odynophagia may be a marker for esophageal injury (11). The initial step in evaluation and confirmation of the presence of an impacted foreign body is a radiologic examination. Radiopaque objects are typically easy to identify. Plain radiographs are usually sufficient and should include both an anteroposterior view and a lateral view for localization of the foreign body. Objects initially thought to be in the esophagus by anteroposterior view may, in fact, be found with use of the lateral view to be in the pulmonary tree. Radiolucent objects such as some dental prostheses, food boluses, chicken and fish bones, plastic items, and toothpicks may require a more extensive radiologic evaluation. These objects often can be diagnosed by barium swallow; however, contrast radiographs should be delayed until completion of an endoscopic examination (15). Some studies report favorable results using computed tomography (CT) scans for diagnosis of radiolucent esophageal foreign bodies (11). However, the charges for CT scans are considerably higher than for plain radiographs or barium swallow. In our patient, the foreign body was easily visualized by plain radiograph because of metal clasps imbedded in the denture material. However, many case reports in the literature describe ingestion or aspiration of radiolucent dental prostheses, often leading to delay in diagnosis and, in some cases, death (16 –20). A survey of dentists in the U.S. by Bloodworth and Render in 1992 revealed that identification and retrieval of dental prostheses are complicated by the radiolucency of the materials used in the manufacture of some devices (18). Complete dentures may contain no metal clasps and are radiolucent unless some type of radiopaque material is incorporated into the denture base. This issue has been addressed repeatedly by dental organizations; however, no standard manufacturing protocol exists (16,18). The difficulty of making a radiologic diagnosis in such cases complicates a suspicion of denture esophageal impaction when evaluating psychiatric patients presenting with possible foreign body ingestion. Once the presence of an esophageal foreign body is either suspected or confirmed, the emergency physician must consider endoscopic evaluation and retrieval within a 24-h period (11). When considered as a separate group, sharp objects impacted in the esophagus generate more morbidity and mortality than other types of objects (21).

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Esophageal foreign bodies are rarely refractory to endoscopic intervention. When this dangerous situation arises clinically, care should be taken to avoid overly aggressive attempts at endoscopic removal. The incidence of instrumental perforation of the esophagus during diagnostic and therapeutic endoscopy has been reported to be 1–9% (22). Potential for iatrogenic perforation is certainly increased by repeated attempts at removal of a sharp foreign body entrapped in the esophagus. Complications related to perforation include paraesophageal abscess, mediastinitis, pericarditis, pneumothorax, pneumomediastinum, tracheoesophageal fistula, and vascular injury (11). To avoid such complications, it is often necessary to surgically remove an impacted esophageal foreign body refractory to endoscopic retrieval, as in our case. Once the foreign body is removed from the psychiatric patient, prevention of repeated ingestion becomes an issue. In most cases reported, the ingestion of dental prostheses occurred secondary to trauma, sleep, eating, decreased mental status, or seizure. In cases where it is felt that the psychiatric patient poses a significant risk for repeat ingestion of dental prostheses, it may be advisable to have the patient fitted with a fixed appliance (5,6). The patient should be advised not to wear or attempt to repair

defective or broken dentures, as this increases the chance of accidental ingestion (18).

CONCLUSION Dental prosthesis impaction is suggested in a psychiatric patient with esophageal obstruction. Evaluation of a patient with suspected dental prosthesis ingestion should include a careful clinical history and a radiologic examination. Some dental prostheses are radiolucent, presenting a diagnostic challenge. Sharp objects, such as dental prostheses, as well as objects that have been impacted within the esophagus for greater than 24 h, require endoscopic intervention to avoid morbid complications, such as mucosal damage and esophageal perforation or stricture. Dental prostheses may have metal clasps or retaining wires that predispose them to impaction in the esophagus when ingested. If the impacted foreign body cannot be removed endoscopically, surgical removal should be undertaken to avoid iatrogenic esophageal trauma or perforation. Preventing the ingestion of dental prostheses involves careful patient selection as well as patient education regarding the potential risks of wearing broken or defective dentures.

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