Experts have warned dentures should be removed before general anaesthetic - after a pensioner's false teeth were found in his throat eight days after surgery.
The 72-year-old man - who has not been named - became seriously ill after his dentures were found lodged in his throat.
He was having the procedure at an unidentified hospital to remove a harmless lump in his abdominal wall.
Six days after the operation the man was forced to return to A&E, complaining of blood in his mouth, swallowing difficulties and pain, which had prevented him from eating solid food, the report said.
The man was prescribed mouthwash, antibiotics and steroids to treat what doctors thought were symptoms of a respiratory infection as a result of having a tube down his throat.
But, two days after doctors sent him home, he returned to A&E with worsening symptoms – unable to swallow any of the medicine - and was admitted with suspected pneumonia.
Doctors then discovered he had a semi-circular object lying across his vocal chords, which had caused internal swelling and blistering.
The report said: 'On explaining this to the patient, he revealed that his dentures had been lost during his general surgery admission eight days earlier and consisted of a metallic roof plate and three front teeth.'
X-rays confirmed the foreign body lodged in his throat were the man's dentures – he was taken for emergency surgery to remove them.
It transpired that the patient inhaled them while under anaesthetic in the initial surgery.
He was discharged after six days in hospital.
But his ordeal was far from over.
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However, a bout of bleeding forced him to return once more six days later, followed by a second visit 10 days after that, and a third six days after being discharged again.
Tests showed he had suffered an internal wound tissue around the site of the blistering which doctors then treated by cauterising it to prevent further bleeding.
The man also required a blood transfusion because he had lost so much blood.
Nine days after he was discharged once more, he returned with further bleeding which required emergency surgery as the source of the bleed was a torn artery in the wound.
According to the report, a check-up a week after the procedure showed the tissue was healing, and six weeks after that the man had not needed further emergency care.
However, its authors state that this is not the first instance of dentures being inhaled while anaesthetic is being administered.
'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, and therefore, many hospitals allow dentures to be removed immediately before intubation, as long as this is clearly documented,' it said.
According to the authors, learning points from the incident include clearly documenting before and after any procedure the presence of any dentures or false teeth, with all members of the surgical team made aware of what is to be done with them.
The report was published in the BMJ Case Reports medical journal.