A 72-year-old's false teeth got stuck in his throat during surgery and weren't discovered for eight days, doctors have said.
The man was having surgery to remove a harmless lump in his abdominal wall, but the operating team neglected to take out his dentures before the operation.
He returned to the hospital six days later complaining of blood in his mouth and difficulties breathing and swallowing, which had prevented him from eating solid food.
Ultimately, more surgery was needed to resolve the problem, which was revealed in a case report published by the British Medical Journal on Monday. Lead author Harriet Cunniffe, from James Paget Hospital in eastern England, is calling for surgeons to ensure dentures are removed from patients before an operation.
During the patient's first return to the emergency room, doctors were unable to diagnose the problem and the unnamed man was sent home with a prescription for mouthwash, antibiotics and steroids.
But he returned two days later with worsening symptoms and was admitted to the hospital with suspected aspiration pneumonia -- a severe chest infection.
Eventually a diagnostic procedure identified a semicircular object lying across his vocal cords, which had caused internal blistering and swelling.
The man, who said he had lost his dentures during his initial visit to hospital, was subsequently rushed into surgery to remove the false teeth. He remained in the hospital for another six days.
He returned suffering complications on multiple occasions over the following month, before eventually healing.
The authors of the study wrote: "There are no set national guidelines on how dentures should be managed during anaesthesia, but it is known that leaving dentures in during bag-mask ventilation allows for a better seal during induction (when the anaesthetic is being infused), and therefore many hospitals allow dentures to be removed immediately before intubation (when a tube is inserted into the airway to assist breathing)."
"In addition to reminding us of the risks of leaving dentures in during induction of anaesthesia when the Swiss cheese model of errors aligns, this case also highlights a number of important learning points," they added.
"The first is to always listen to your patient. It has long been known that one gets the majority of the information needed to form a diagnosis based on the patients' history."