Foreign Body Seen on X ray

A 65-year-old male presented with cardiogenic shock. He had an emergency CABG (Coronary artery bypass grafting) which was associated with a very stormy peri-operative period.  His CXR (shown in picture below) was taken upon arrival at the Intensive Care Unit (ICU).

What is the most significant abnormality?

Case Discussion:

The CXR shows an opaque density in the region of the right lower zone.
Each lung field on an erect CXR is divided into three zones.

1. The upper zone is an area which lies above a horizontal line drawn from the medial end of the second rib anteriorly. 
2. The middle zone lies below this and is bordered inferiorly by a line drawn similarly from the fourth rib. 
3. The lower zone lies below this. 

This opaque density is similar in configuration to a tooth which was dislodged during emergency
intubation of this patient.

See the X ray again with the arrow pointing to the opacity

Foreign bodies are not as common in adults compared with children. It can occur silently in patients with decreased conscious level. The typical site is in the right main stem bronchus, as this has a more vertical course than the left.

Bronchoscopic removal is the usual initial treatment of choice.