Sir, despite many years of experience in oral surgery, occasionally I come across a situation that keeps me on my toes. An apparently routine case may not always be predictable and can take one by surprise. The following case is an example of this and relates how the problem posed was eventually resolved by the combined approach of surgeon and anaesthetist.
A 13-year-old girl was admitted to hospital as a day case patient for surgical removal of a palatally-impacted, unerupted upper right second premolar together with extraction of the upper left second premolar and both lower first premolars under general anaesthesia administered by a consultant anaesthetist.
Following anaesthetic induction she was intubated with a cuffed nasal tube via her right nasal airway and a gauze throat pack was inserted into the inferior region of the oropharynx. In order to optimise surgical access to the palate, the top end of the operating table was dropped to allow for neck extension and in addition the table was adjusted to give some head-down tilt.
Following local anaesthetic infiltration a palatal mucoperiosteal flap was raised to reveal the crown of the upper right second premolar. This tooth was very simply elevated but unfortunately dropped into the oropharynx. Suction of the oropharynx, into which some blood was accumulating, was immediately carried out but the tooth could not be located.
Due to the position of the patient, with her nasopharynx being lower than her oropharynx, it was suspected that the tooth may have passed into the nasopharyngeal region. Careful suction of the accessible region behind the soft palate was carried out but this failed to retrieve the tooth. At this point the palatal flap was sutured in order to achieve haemostasis and optimise visualisation of the pharynx. A laryngoscope was inserted into the oropharynx in order to visualise the throat pack and to confirm that the tooth had not fallen onto its surface. A fibre-optic scope was then passed behind the soft palate in order to locate the position of the tooth in the nasopharynx. The patient's position was then adjusted to use gravitation force. The neck was straightened and the table adjusted for head-up tilt but this did not deliver the tooth into the oropharynx. Further gentle mobilisation of the patient's head together with flushing of water into the left nasal airway similarly failed to dislodge the tooth. The tube was then replaced with a laryngeal mask. Before this was carried out the patient's position was again adjusted to give maximum head-down tilt in order to ensure that the tooth remained in the nasopharynx whilst the tube was changed.
After removal of the nasal tube, placement of a laryngeal mask, replacement of the throat pack and further repositioning of the patient to a head-up tilt, the tooth remained elusive. However, following flushing of the right nasal passage with water, whilst occluding the left nasal airway to achieve maximum flushing pressure, the tooth finally appeared in the oropharynx and was retrieved using Fickling forceps. The tooth was found to have a somewhat shortened root which may have contributed to the ease of its elevation and subsequent loss and also to its ease of passage in a cranial direction in the nasopharynx.
In order to avoid this problem occurring again, when patients are positioned with a head-down tilt I will, in addition to the anaesthetist's pack, be placing a further pack in the accessible oropharynx as a safety net to capture any stray teeth!