How teeth got stuck in man’s throat for 8 days after surgery without anyone noticing
A 72-year-old man is reported to have had his false teeth stuck in his throat during surgery and were not discovered for eight days.
The man was having a surgery to remove a harmless lump in his abdominal wall, but the operating team neglected to take out his dentures before the operation.
During the patient’s first return to the emergency room, doctors were unable to diagnose the problem and the unnamed man was sent home with a prescription for mouthwash, antibiotics and steroids.
Six days later, the man returned to the hospital complaining of blood in his mouth and difficulties breathing and swallowing which had in turn prevented him from eating solid food.
He was admitted to the hospital with suspected aspiration pneumonia- a severe chest infection but a diagnostic procedure identified a semicircular object lying across his vocal cords, which had caused internal blistering and swelling.
The man, who said he had lost his dentures during his initial visit to hospital, was subsequently rushed into surgery to remove the false teeth.
According to a case report published by the British Medical Journal, there are no set national guidelines on how dentures should be managed during anesthesia.
It is however known that leaving dentures in during bag-mask ventilation allows for a better seal during induction (when the anesthetic is being infused) and therefore many hospitals allow dentures to be removed immediately before intubation (when a tube is inserted into the airway to assist breathing).
Lead author Harriet Cunniffe, from James Paget Hospital in eastern England, is calling for surgeons to ensure dentures are removed from patients before an operation.
“In addition to reminding us of the risks of leaving dentures in during induction of anaesthesia when the Swiss cheese model of errors aligns, this case also highlights a number of important learning points,” said the authors of the study.
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