Tale of a tooth

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Tale of a tooth
Shalini Nair, Bijesh R Nair 1

, Divya E
A young adult with history of road traffic accident suffered a severe head and maxillofacial injury. The Glasgow coma scale was 8/15.He was intubated in view of his low sensorium. After one day, the ventilatory requirements progressively escalated. The FiO 2 was increased from 0.3 to 0.5 for maintaining 100% saturation. Similarly, pressure requirements increased from 12 cm of H 2 O to 20 cm of H 2 O for attaining a tidal volume of 400 ml. A chest X-ray showed a lingular segmental collapse with a tooth within the bronchus. A fibreoptic bronchoscopy was carried out and the tooth was retrieved [ Figure 1]. The ventilator requirements were promptly deescalated and patient was successfully extubated by the next day.
The challenges of maxillofacial injury are usually encountered at intubation. Following an uneventful intubation, suspicion of aspiration of a tooth in comatose patient is difficult because aspiration is rarely considered in the absence of an acute clinical presentation. We too had not observed the tooth in pre-and immediate post-intubation chest X-ray. Only when difficult ventilation prompted a repeat chest X-ray with a segmental collapse, we tried evaluating the cause for collapse and detected the tooth within the bronchus [ Figure 2].
The possibility of such airway and pulmonary complications are twice more common when diagnosed more than 24 hours after aspiration. [1] Extraction of  Correspondence foreign bodies from airway is traditionally done with rigid bronchoscope.However, this was not feasible in our case due to the maxillofacial injury. Use of fibreoptic bronchoscope for the purpose is challenging, as the extraction beyond endotracheal tube may be limited due to size of the foreign body. [2] Kim et al. suggested tracheostomy as an alternative to facilitate secured airway and shorter distance for extracting foreign body associated with maxillofacial trauma. [3] Early suspicion of an aspirated foreign body causing difficult ventilation helped us prevent a catastrophe, and timely intervention averted a morbid procedure as tracheostomy.
We, therefore, reiterate the importance of detailed scrutiny of radiograph in all comatose trauma victims for aspirated foreign bodies that can go a long way in preventing major complications. forearm and hand where she had developed painful skin eruptions 10 weeks back. Considering it as herpes zoster, patient had already been treated with various NSAIDs and neuropathic pain medications by primary physician. Later on, patient was referred to pain clinic where we found her to have -SHN ((Numeric Rating Scale/NRS -9/10) affecting areas mostly supplied by radial nerve (C5-C6-C7 distribution) with allodynia and hyperalgesia in the affected areas. Considering the severity, trend and duration of pain as well as her age, we anticipated least possibility of its natural remission any more. We planned for continuous brachial plexus block through axillary route with catheter placement targeting blockade of painful volley of afferent inputs from sensitized receptors to alleviate the agony as well as to halt the progress of the disease, if possible, towards its development of PHN. With a 22 G insulated needle (Centiplex: B-Braun, Germany) and nerve stimulator (EZSTIM 2, Model 400; Life Tech Company, USA), left-sided axillary brachial plexus block was accomplished under sterile condition. The needle was placed superior to the axillary artery (with an aim to place the catheter posterior to artery predominantly occupied by radial nerve) and needle advancement was adjusted to best stimulator response (metacarpo-phalangeal as well as wrist extension) with < 0.4 mA current. Once