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Three Part Question

In [patients who might have aspirated a tooth] is [a chest X-ray] indicated to [diagnose and locate the tooth]?

Clinical Scenario

A 40 year old man attends the emergency department having sustained facial injuries following an alledged assault. Examination of the oropharynx reveals a missing tooth. The patient has no clear memory of what happened to his tooth. You wonder whether a chest x-ray would aid diagnosis.

Search Strategy

("tooth"[MeSH Terms] OR "tooth"[All Fields]) AND ("injuries"[Subheading] OR "injuries"[All Fields] OR "trauma"[All Fields] OR "wounds and injuries"[MeSH Terms] OR ("wounds"[All Fields] AND "injuries"[All Fields]) OR "wounds and injuries"[All Fields]) AND ("inhalation"[MeSH Terms] OR "inhalation"[All Fields]) AND ("radiography"[Subheading] OR "radiography"[All Fields] OR "radiography"[MeSH Terms])
Medline 1966-10/2010 using the Pubmed interface.

Search Outcome

13 studies were identified. One was a systematic review which was relevant.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Pinto A et al. 2006 Italy	31 patients over a 5-year period were referred for observation for clinical suspicion of foreign-body aspiration. Suspected foreign-body aspiration had occurred 2-72 h before hospitalisation.		Positive chest radiographs	21/31 patients (67.7%) [The 21 positive chest radiographs consisted of 7/31 (22.6%) demonstrating presence of a foreign body in the tracheobronchial tree including tooth fragment in three specific cases and 14/21 with radiological evidence of pleuroparenchymal lesions (atelectasis, pneumonia, pulmonary hyperinflation and pneumomediastinum)].	Small numbers. Heterogenous causes of tracheobronchial foreign body aspiration were included.
			Positive bronchoscopy	23/27 patients (85.2%)

Comment(s)

Only one recent study with small numbers and heterogenous foreign bodies was found in the search.

Clinical Bottom Line

Plain chest radiography remains the initial imaging modality for patients with clinically suspected tracheobronchial aspiration of a foreign body. Bronchoscopy and/or multi-slice computed tomography should be considered if there is a high clinical suspicion of foreign body aspiration despite a normal plain film radiograph.

Level of Evidence

Level 3 - Small numbers of small studies or great heterogeneity or very different population.

References

1. Pinto A, Scaglione M, Pinto F, Guidi G, Pepe M, Del Prato B, Grassi R, Romano L. Tracheobronchial aspiration of foreign bodies: current indications for emergency plain chest radiography. Radiol Med. 2006 Jun;111(4):497-506.