|Year : 2022 | Volume
| Issue : 4 | Page : 204-207
An Unusual Case of Tongue Entrapment in a Plastic Water Bottle
Shafaat Ahmad, Prakhar Goel, Ravi Meher, Vikram Wadhwa
Department of ENT and Head and Neck Surgery, Lok Nayak Hospital and Associated Maulana Azad Medical College and G. B. Pant Hospital, New Delhi, India
|Date of Submission||05-Aug-2022|
|Date of Decision||28-Oct-2022|
|Date of Acceptance||28-Oct-2022|
|Date of Web Publication||29-Nov-2022|
Dr. Prakhar Goel
Department of ENT and Head and Neck Surgery, B. L. Taneja Block, Lok Nayak Hospital and Associated Maulana Azad Medical College and G. B. Pant Hospital, New Delhi - 110 002
Source of Support: None, Conflict of Interest: None
Background: Foreign bodies inside the oral cavity are commonly encountered among children. One peculiar occurrence is when the tongue gets entrapped in foreign bodies such as bottles. This happens as children often insert their tongues into the bottle and apply oral suction to ingest the last few drops from the bottle. There is a paucity of data in Indian literature and no recommended guidelines for the management of such cases. Clinical Description: The patient, a 12-year-old boy had a history of inability to remove a plastic water bottle sipper from around the tongue while swallowing water quickly. He was initially asymptomatic and then he started developing progressive pain and swelling on the anterior part of the tongue. On examination, the plastic sipper was constricting the tongue circumferentially and the patient felt a sharp pain on maneuvering the bottle. Minimal discoloration of the anterior part of the tongue had set in 1 h after the presentation. Management: Lubrication with 2% lignocaine jelly and ice packs circumferentially followed by attempts of gentle traction and manipulation to remove the foreign body were unsuccessful. Consequently, the patient was shifted to the emergency operation theater where the patient was sedated with intravenous (IV) ketamine and midazolam after securing a nasopharyngeal airway with 100% preoxygenation. An orthopedic bone cutter was used, and a radial cut was given on the impacted end of the bottle, and the constricted part was removed as pressure on the tongue was released, followed by 100% oxygenation with bag and mask ventilation. Conclusion: Immediate intervention in cases of the entrapped tongue can prevent grave consequences such as airway compromise and tongue ischemia and necrosis. Mechanical removal can be done safely using heavy scissors or orthopedic bone under IV sedation after securing the airway in collaboration with the anesthesia team.
Keywords: Deep sedation, foreign bodies, mouth, surgical instruments
|How to cite this article:|
Ahmad S, Goel P, Meher R, Wadhwa V. An Unusual Case of Tongue Entrapment in a Plastic Water Bottle. Indian Pediatr Case Rep 2022;2:204-7
|How to cite this URL:|
Ahmad S, Goel P, Meher R, Wadhwa V. An Unusual Case of Tongue Entrapment in a Plastic Water Bottle. Indian Pediatr Case Rep [serial online] 2022 [cited 2023 Feb 3];2:204-7. Available from: http://www.ipcares.org/text.asp?2022/2/4/204/362243
Foreign bodies inside the oral cavity are commonly encountered among the pediatric population. One peculiar occurrence is when young children present to the emergency department with tongue entrapment in foreign bodies, especially water bottles, glass, aluminum, metal, plastic, and codd-necks (with marbles within). This happens when children insert their tongues into the bottle and apply oral suction to ingest the last few drops from the bottle. There are no recommended guidelines on the management of these cases. Crucial factors to consider include the duration of entrapment, amount of edema and congestion of the tongue, general condition of the patient, potential risk of airway compromise, and availability of resources. A variety of novel, innovative techniques are usually attempted. These start with gentle traction, traction with lubrication, and positive pressure technique, and may escalate to the use of dental drills, orthopedic wire cutters, surgical scissors, and the Gigli saw wire to remove the constricting foreign body.
We present this particular patient to create awareness of this underreported emergency and highlight the challenges we faced due to delayed presentation, administration of anesthesia, and planning surgical intervention.
| Clinical Description|| |
A 9-year-old boy presented to the ENT emergency with the inability to remove a plastic water bottle sipper that had got stuck around his tongue. The patient had a history of drinking water from a plastic water bottle approximately 4 h before the presentation. While swallowing water quickly, the patient felt his tongue being pulled inside and was unable to withdraw it on pulling back or applying pressure. Initially, he was asymptomatic, then he started developing pain and perceived that the anterior part of his tongue appeared to be progressively swelling up. There was no history of any bleeding into the oral cavity or discoloration of the tongue.
The child was very anxious and apprehensive on the presentation and the parents though worried, remained calm, and cooperative. There was no history of any similar events in the past. The developmental history was normal without any behavioral issues, pica, or atypical repetitive oral habits. He was an average student studying in class six.
The child was made to comfortably lie on the table in the examination room. His temperature was 37°C, pulse rate –85 beats per min, capillary filling time –<3 s, blood pressure –110/65 mm Hg (50th percentile, Indian Academy of Pediatrics Growth Charts), and respiratory rate –18 breaths per min with the saturation of peripheral oxygen (SpO2) of 99% in room air. His body mass index was 19.3 kg/m2 (71st percentile, Indian Academy of Pediatrics Charts). There was no pallor, cyanosis, or facial congestion. On examination of the oral cavity, a black water bottle sipper was seen constricting the tongue circumferentially. The protruding anterior part of the tongue was congested and edematous. There were no abrasions, lacerations, or any active bleeding [Figure 1]. The rest of the general physical examination was within normal limits, and the systemic examination was not contributory.
Management and outcome
The parents and child were reassured. The part of the bottle not involving the tongue was removed using heavy scissors. The patient experienced sharp pain while maneuvering the bottle for which he was administered intravenous (IV) paracetamol. The stuck end of the bottle was lubricated with 2% lignocaine jelly circumferentially and ice packs were applied on the protruding part and the region of constriction of the tongue to decrease the congestion. We tried to remove the bottle by gentle manipulation but failed due to the pain and discomfort experienced by the patient. Minimal discoloration of the anterior part of the tongue had become apparent by now.
IV dexamethasone (3 mg) was administered to decrease inflammation and edema, and the patient was shifted to the emergency operation theater. High-risk consent was taken by the anesthesia team in view of anticipated difficulties in securing the airway. The patient was secured with a nasopharyngeal airway and preoxygenated with 100% oxygen. Following this, he was sedated with IV ketamine (20 mg), midazolam (1 mg), and fentanyl (30 μg). Oxygenation was continued through the nasopharyngeal airway. The orotracheal intubation in this patient was difficult, so measures for an emergency tracheotomy were kept on standby just in case there was any difficulty in ventilating the patient. However, he continued to maintain SpO2 of 98% through the nasopharyngeal airway, and therefore, a tracheostomy was not required.
An orthopedic bone cutter was used to give a radial cut on the impacted end of the bottle [Figure 2]. The pressure on the tongue was released and the bottle was removed. Postremoval of the foreign body, the patient was observed for 15 min to look for any signs of airway obstruction. There was no obstruction of the airway by the slightly swollen tongue. Now, the tongue could be closely inspected. Apart from the edema, congestion, and mild discoloration of the anterior part of the tongue that had been impacted, there was no evidence of any abrasions, lacerations, or bleeding points [Figure 3]a. The patient was able to protrude his tongue but experienced mild pain while doing so. The discoloration of the tongue gradually subsided by the 2nd postoperative day [Figure 3]b, and the patient was discharged and kept under follow-up. He remained well when seen after 1, 2, and 8 weeks.
|Figure 3: (a) Intraoperative appearance, (b) Postoperative appearance after foreign body removal|
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| Discussion|| |
The lodgment of foreign bodies in children is a common scenario, but reports of tongue entrapment in bottles are relatively uncommon. Children drink from rigid bottles which sustain negative pressures. Sometimes, the tongue gets entrapped within the lumen of the bottle when it remains for a slightly longer period during which a vacuum is created. This causes tongue edema and subsequent strangulation of the tongue. Immediate intervention in cases of the entrapped tongue can prevent grave consequences such as airway compromise and tongue ischemia. If there is a delay in removal beyond 4 h as was seen in a case of tongue trapped in the lid of a plastic drinking bottle, venous congestion can occur and lead to tip necrosis. Staying calm throughout the episode is very important. In this case, the patient was made to lie comfortably and advised to lay still, appropriate analgesia was given both locally and intravenously to alleviate the pain. The parents were counseled of the nature of the condition, the nature of the surgery, and the risks and complications associated with the procedure and in the postoperative period.
There is a paucity of published cases of tongue entrapment in Indian settings. Details of an earlier case are given in [Table 1] and compared with the present case. Similar cases have been reported in scientific literature, in which different approaches have been described. Removal can be safely done under sedation, but with anesthetic backup. The authors have described the use of various sedation and presurgical topical or general anesthesia. Topical anesthesia using 2% lignocaine jelly can be applied at the junction of the tongue and point of constriction, as was done in this case. Once the patient is shifted to the operation theater, the patient can be sedated using IV dissociative anesthetic drugs such as ketamine and short-acting benzodiazepines such as midazolam along with IV analgesics. In most cases, the glass, plastic, or metal bottles had to be physically cut to relieve the entrapped tongue. Mills and Simon successfully managed to release an entrapped tongue by positive pressure technique, in which a feeding tube was advanced between the tongue and the bottleneck into the bottle and 240 ml of air was pumped into the bottle with a 6 ml syringe following which the tongue retracted from the bottle, slowly at first, and then suddenly. In another case, the tongue entrapped in a glass bottle was successfully released using a Rongeur and Mallet. There are reports of the use of heavy instruments such as orthopedic wire cutters, tin snips, ring cutters, and heavy scissors (to release the tongue by cutting the constricting part) and the Gigli saw to release the entrapped tongue by threading the wire between the tongue and the constricting object and using the handles to cut the constricting part radially at that point.,,, The use of a surgical drill to release the organ from plastic bottles has also been described., The risks during the removal of foreign body from the tongue include loss of airway, pulmonary aspiration, and tongue ischemia. The patient should be closely monitored postoperatively as tongue swelling can lead to respiratory distress and an airway emergency. Most children complained of edema, discoloration, and pain postoperatively but eventually made full recovery.
|Table 1: Comparison of management and outcomes of cases of tongue entrapment in foreign bodies|
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To conclude, parents should be made aware of this unusual but dangerous condition related to water bottles. It calls for preemptive parental counseling, in which children can be taught not to attempt to drink the last few drops from the bottle, to drink slowly, and not to suck vigorously at the bottle sipper.
Declaration of patient consent
The authors certify that they have obtained the appropriate consent from the parent. The legal guardian has given his consent for the images and other clinical information to be reported in the journal. The guardian understands that the name and initials will not be published, and due efforts have been made to conceal the same, but anonymity cannot be guaranteed.
We would like to thank Dr. P.K. Rathore, Head of Department, Department of ENT and Head and Neck Surgery, Lok Nayak Hospital and associated Maulana Azad Medical College and G.B Pant Hospital, New Delhi – 110002, India, for his continuous guidance and support.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]