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An unusual foreign body in the oral cavity: a case report from a patient safety point of view and literature review

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Abstract

Accidental foreign bodies (FBs) in the oral cavity, airway, esophagus and breathing circuit associated with anesthetic procedures are rare but can cause serious and life-threatening complications. We here present a case in which an unusual FB in the oral cavity was found after emergence from general anesthesia. The FB was later identified as a melted cap of a felt-tip pen. We investigated the cleaning process for reusable materials and concluded that the FB was accidentally placed in the inner lumen of the reusable bite block during the cleaning process. We then performed a review of the literature on FBs other than those of dental origin which were entrapped in the oral cavity, pharynx, larynx, trachea, esophagus, and anesthetic breathing circuit due to anesthetic procedures. From our case and 53 cases found in the search, we concluded that 1) use of disposable medical devices is recommended, 2) FBs can easily migrate into the oral cavity and airway during anesthesia, 3) delayed FB recognition may be associated with difficult intubation situations, and 4) more attention should be paid to the possibility of any medical or non-medical device becoming an FB during anesthesia.

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Authors and Affiliations

  1. Department of Anesthesiology and Resuscitology, Shinshu University School of Medicine, Matsumoto, Nagano, Japan

    Mariko Ito, Natsuko Watanabe, Yuko Sawado, Kumiko Ishida, Yuki Yoshiyama, Takashi Ishida, Satoshi Fuseya, Satoshi Tanaka & Mikito Kawamata

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  1. Mariko Ito
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  2. Natsuko Watanabe
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  3. Yuko Sawado
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  4. Kumiko Ishida
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  5. Yuki Yoshiyama
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  6. Takashi Ishida
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  7. Satoshi Fuseya
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  8. Satoshi Tanaka
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  9. Mikito Kawamata
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Contributions

Conceptualization: Mariko Ito. Data curation: Mariko Ito, Natsuko Watanabe, Yuko Sawado. Formal Analysis: Kumiko Ishida. Investigation: Mariko Ito, Yuki Yoshiyama, Satoshi Fuseya. Methodology: Takashi Ishida, Mariko Ito. Supervision: Satoshi Tanaka, Mikito Kawamata. Writing – original draft: Mariko Ito. Writing – review & editing: Mikito Kawamata

Corresponding author

Correspondence to Mariko Ito.

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Written informed consent was obtained from the patient to publish this case report and literature review.

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The authors declare that they have no competing interests.

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Ito, M., Watanabe, N., Sawado, Y. et al. An unusual foreign body in the oral cavity: a case report from a patient safety point of view and literature review. J Anesth 36, 564–571 (2022). https://doi.org/10.1007/s00540-022-03087-y

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