Early recognition of an impacted foreign body in the aerodigestive tract and early diagnosis of related complications are important for the success of treatment approaches [8, 9, 13]. Prolonged impaction in oesophagus leads to a pathological process of oedema, mucosal infection and necrosis [7]. In our case, missed identification of the denture allowed it to erode into the airway and become lodged in a fistulous connection contributing to repeated aspiration, mediastinitis and failure to thrive. This led to the challenges we encountered such as failed endoscopic retrieval and the difficult dissection of fibrotic tissue, which contributed to iatrogenic recurrent laryngeal nerve injury during the first procedure. In anticipation of this difficult surgical field, we could have considered intraoperative nerve monitoring, which may have helped to preserve phonation.

Several factors influence the difficulty with identifying impacted dentures. In our case, the patient provided no clear account of swallowing a denture. Unnoticed ingestion is not uncommon and in a 10-year review of ingested dentures including 85 cases, 18% of patients were unaware of swallowing their denture, with 40% of this subgroup having cognitive impairment [4, 10]. We also know that patients with learning disabilities or mental health disorders may be unable to give an accurate history of the event [5, 7]. However, the patient did not have any documented risk factors for unnoticed denture ingestion other than a personal history of epilepsy. It is possible that the patient may have swallowed their denture during a seizure episode. We recognise the need to hold a high index of clinical suspicion for foreign body ingestion in dental prosthesis wearers who present with persistent dysphagia or recurrent chest infections. Popular acrylic dentures are made from radiolucent plastic material [7, 9] and unless they contain metal attachments it is not easy to directly visualise them on plain radiographs [2, 5, 7]. CT is the primary investigation of choice because it is more sensitive at detecting dentures [7] and may identify complications such as perforation, TOF, abscess formation or mediastinitis [2, 5].

Definitive surgical treatment is certainly required for an impacted foreign body with overt complications such as an acquired, non-malignant TOF [13]. Requirement for open surgery is more likely with a longer duration between ingestion event and diagnosis [4]. There are several approaches to surgical management, which can be broadly categorised into single stage procedures for exploration and repair of the TOF, with or without tracheal resection; or ‘exclusion’ procedures involving primary closure of the tracheal defect and oesophageal diversion, without a later second stage reconstruction [3, 14]. The most important influences on choice of approach are underlying aetiology, site of the fistula and state of the affected tissue [14]. Shen and colleagues reported on a case series of 56 operations in 35 patients at a single institution for non-malignant TOF, recommending the safety of single-stage repair of both airway and oesophageal defects with pedicled tissue flap interposition [3]. However, this series did not include any erosions from a foreign body or dental prosthesis. In our presented case, the defect in the trachea was large with inflamed edges, necessitating resection and anastomosis of healthy tissue.

We could only find one existing case report similar to our own that described a late presentation of TOF secondary to swallowed denture [2]. Samarasam and colleagues reported a challenging surgical field complicated by ‘peri-oesophageal sepsis with local abscess formation’ which informed their operative decision to perform a subtotal oesophagectomy and cervical oesophago-gastric anastomosis. The perioperative period in our own case was associated with several adverse outcomes including bilateral vocal cord palsy, dysfunctional oeosphageal stoma and pulmonary-thoracic oesophageal remnant fistula, managed appropriately. This high morbidity was expected since complication rates are reported as high as 54.3% [3]. The most common specific complications include oesophageal leak (11.4%), recurrent TOF (8.6%), tracheal dehiscence (5.7%), vocal cord paralysis (5.7%) and mortality (5.7%) [3]. It is important to note that reconstruction techniques of the pharyngo-oesophageal junction have only been robustly analysed in contexts that differ from our report, such as cancer resection [15, 16] or corrosive oesophageal strictures [17].

Finally, we emphasise the importance of a collaborative MDT approach in the management of complications arising from denture ingestion and impaction. Successful repair of the TOF and restoration of digestive tract continuity required advanced surgical expertise available at our centre as well as diligent preparation and postoperative rehabilitation. The patient was subject to repeated physiological insults, permanent loss of phonation and negative psychological impact from his procedures and related complications. Regular input from speech and language therapy, dietician, physiotherapy and counselling teams was crucial for overcoming these challenges and reaching a condition that was safe for discharge.

In summary, we have reported on a complex case of an acquired, non-malignant TOF secondary to chronically impacted denture which is rarely described in the literature. It highlights the challenges associated with delayed recognition of an ingested dental prosthesis. We promote the importance of a broad MDT to optimally manage all aspects of work-up, surgical intervention and recovery. A robust restoration of the integrity of the airway takes precedence and may require oesophageal diversion to protect the repair site. We demonstrated a satisfactory outcome using this approach that included primary tracheal resection, tracheal anastomosis and temporary oesophageal diversion with cervical oesophagostomy, followed by a secondary reconstruction of digestive tract continuity with gastric-pull up.