According to one of the 72-year-old man's United Kingdom doctors, who wrote about the case in BMJ Case Reports on Monday, his trouble began soon after a successful and seemingly well-done surgery that removed a benign lump from inside his chest.
6 days after the operation, the man went to the hospital's emergency room complaining of blood in his mouth along with difficulties breathing and swallowing, making him unable to eat solid food.
Doctors at the Great Yarmouth hospital believed it was a respiratory infection and side effects from having a tube in his throat during surgery, and prescribed antibiotics and steroids. Doctors say their elderly patient endured a nightmarish week of his throat bleeding out and weeks more of surgeries and hospital care, all because surgeons had forgotten to remove his dentures - dentures that then became lodged in his throat.
But when emergency room doctors examined the back of the man's throat, they found nothing unusual. He was hospitalised, though doctors still mistakenly assumed he had developed severe pneumonia, possibly caused by having inhaled food, stomach acid, or saliva into his lungs.
"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", the report adds.
An X-ray shows dentures in a senior's throat.
Eventually a diagnostic procedure identified a semicircular object lying across his vocal cords, which had caused internal blistering and swelling.
The man turned up to the emergency department six days after his initial abdominal surgery.
Ultimately, more surgery was needed to resolve the problem, which was revealed in a case report published by the British Medical Journal on Monday.
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.
The source of the bleeding was eventually discovered to be "a spurting arterial vessel" in the man's throat that had been obscured by tissue that formed over it during the healing process, according to the report.
The medical journal report states that this is not the first time dentures have been inhaled while a patient is under aesthetic. But the chest scans and blood tests he was given led the doctors on staff to first suspect infection.