It was a case that had doctors baffled.
When a 72-year-old patient turned up at A&E coughing blood and complaining he was struggling to breathe, medics ran tests for possible chest infections, pneumonia and even throat cancer.
The problem, an X-ray eventually revealed, was rather more obscure: the man had breathed in his own false teeth and they were lodged in his larynx.
Doctors deduced the patient had inhaled his dentures eight days earlier while under anaesthetic during an unrelated operation to remove a benign lump from his abdomen.
Now, the case - reported from James Paget University Hospital in Great Yarmouth - has prompted a warning to doctors performing operations to take note of whether patients have false teeth, and to keep track of them during all procedures.
“Presence of any dental prosthetics should be clearly documented before and after any procedure, and all members of the theatre team should be aware of the perioperative plan for them,” said Harriet Cunniffe, the author of a report published in the British Medical Journal.
When the patient in this case first arrived at A&E coughing blood, she said, staff did not equate his difficulties to the previous operation.
Instead, they examined the man’s throat, carried out a chest X-ray and blood tests, and eventually sent him on his way with a prescription of antibiotics for a suspected infection.
But when he came back several days later now unable to either swallow or breathe properly, doctors suspected he may have contracted pneumonia from inhaling something foreign. They inserted a flexible tube through the man’s nose, and - to both his and their surprise - found a metallic plate covering his vocal cords.
“On explaining this to the patient, he revealed his dentures had been lost during his general surgery admission eight days earlier and consisted of a metallic roof plate and three front teeth,” the report states.
The false teeth were removed with a pair of forceps - although, by then, they had caused the man to catch pneumonia and had resulted in so much blood being coughed up he needed two blood transfusions.
Although unusual, such loss of dentures is far from unheard of. A 2016 review found 91 such incidents over a 15-year period in 28 countries.