Delayed diagnosis of tooth aspiration in three multiple trauma patients with mechanical ventilation

A 23-year-old man was severely injured in a car accident and had multiple trauma, with an injury severity score (ISS) of 50 and a head abbreviated injury score (AIS) of 5. Three days later he was transferred to our hospital and chest CT showed a tooth-like foreign body in the right bronchial tree, which was confirmed to be a bicuspid ( according to the Palmer notation method) by flexible bronchoscopy. As the tooth was psilate and firmly embedded, many attempts with either flexible or rigid bronchoscopy could not extract it. The patient died of sepsis 70 days after the accident.A 26-year-old man was presented to a local hospital with multiple trauma (ISS 54, head AIS 5) following a motorcycle accident. On the next day when he was transferred to our hospital, a chest film and fibreoptic bronchoscopy confirmed a lateral incisor () in the left lobe. We failed to extract the tooth, but fortunately it was expectorated via the tracheotomy tube following a vigorous cough on day 12.A 25-year-old man was presented with multiple trauma (ISS 41, head AIS 4) after a motorcycle accident. He was transferred to our hospital 9 hours later. Chest CT and flexible bronchoscopy confirmed a central incisor () in the right bronchial tree. It was extracted by flexible bronchoscopy on day 8 (Figure 1).Early diagnosis of tooth aspiration in coma patients is difficult because aspiration is rarely considered in the absence of an acute clinical presentation. Thus, an endobronchial tooth can remain undetected for a long time and result in serious complications [1]. In all three cases reported here, tooth aspiration was missed by the local hospitals. Doctors should suspect that any tooth that has been avulsed and not found as possibly aspirated in trauma patients, especially for those in a coma status. The medical history, clinical signs and radiological findings should be carefully checked. CT is more accurate than chest radiography in detecting endobronchial foreign bodies. When negative chest