An unusual extraction; retrieval of a swallowed crown by appendicectomy

A case report of a patient who swallowed a crown and three weeks later presented with abdominal pain and fever. At operation his crown was found to be causing appendicitis. Foreign bodies have previously been reported as causing appendicitis but never a crown. It's discussed the appropriateness of abdominal radiology in the management of such foreign bodies.

INTRODUCTION
Acute appendicitis remains the most common emergency surgical presentation requiring operative intervention. Foreign bodies within the resected appendix are uncommon; the most recent review of medical literature found 256 reported cases in the last 100 years and estimated the incidence at 1 in 20,000 appendicectomies. It would appear that gravity has prevented them travelling up the ascending colon and they may eventually become impacted within the lumen of the appendix. The most common foreign bodies are pins, lead shot, seeds and bones. There are no reported incidences of an accidentally swallowed crown causing appendicitis. This case was reported where this occurred.

CASE REPORT
A 41-year-old, previously healthy man attended accident and emergency with a history of right iliac fossa pain for the last two days, with pyrexia and ‘feeling hot and sweaty’. He had swallowed a porcelain post crown, three weeks previously while eating, and did not think that it had passed. On examination he was pyrexial and had signs of localised peritonism in the right iliac fossa. His white cell count was moderately elevated. Plain abdominal radiology was requested and the crown was visible (Fig. 1). The likely diagnosis was thought to be appendicitis but a perforation secondary to the crown was considered. He was taken to theatre soon afterwards, the appendix was removed and a foreign body was felt within the lumen. The pathologist opened this specimen and a photograph was taken which showed the crown within the inflamed lumen (Fig. 2). The patient went home 48 hours later after an uneventful recovery.

Fig1.jpg
Fig2.jpg

DISCUSSION
In general dental practice a swallowed foreign body is the second most common medical emergency not associated with general anaesthetic and 1.5-2.0 episodes will occur in a 40 year working life. Inhaled foreign bodies occur less frequently (0.06 episodes per 40 years), however, these figures emphasise the importance of airway protection during dental treatment.
A patient that has swallowed a crown would not be expected to require any intervention. The complication we would perhaps see would be a small bowel the highest likelihood of causing perforation or appendicitis. Ingested foreign bodies that get through the oesophagus will pass in the stool in 99% of cases so this aggressive radiological assessment is probably not warranted. It's recommended that follow up after initial radiology is only required in symptomatic patients.

Source : BRITISH DENTAL JOURNAL VOLUME 202 NO.3 FEB 10 2007

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