Tips and tricks

Editor, A 7-year-old previously healthy boy weighing 24 kg presented to our hospital's emergency department with a 1-h history of entrapment of his tongue in a glass bottle (Fig. 1). Prior to admission, his parents had unsuccessfully attempted to release the tongue with the use of pulling and twisting manipulations of the bottle; similar interventions on admission by the attending paediatric surgeon also were ineffective. Paediatric anaesthesia was consulted.Fig. 1: Seven-year-old boy with his tongue firmly entrapped in the bottle.Written informed consent by the child's parents was obtained for publication of the case and the photographs. On examination, the boy was in mild distress and showed drooling but had a patent airway and no apparent dyspnoea. Under light intravenous sedation with midazolam (0.04 mg kg−1) and esketamine (0.4 mg kg−1), a thin 70-mm plastic button cannula (Interlock Medizintechnik GmbH, Lensahn, Germany) was carefully advanced between the tongue and the bottle neck, with the intent to release a presumed vacuum inside the bottle. This had no effect. Subsequently, the button cannula was connected to a combination of intravenous extension tubing, a three-way stopcock and a 20-ml syringe (Fig. 2). Air was then injected into the bottle, and after insufflation with 60 ml, the oedematous and lividly discoloured tongue squeezed out of the bottle neck – slowly at first and then swiftly. To help reduce the swelling (Fig. 3), prednisolone (5 mg kg−1 intravenously) and ibuprofen (10 mg orally) were given and the boy was admitted to a paediatric surgical ward for a 24-h observation period. On discharge, the swelling had largely dissipated but for about 3 days the anterior aspect of the tongue remained lividly discoloured, with a sharp demarcation (Fig. 4). At follow-up 14 days after the entrapment, the tongue exhibited full recovery.Fig. 2: Positive pressure instillation setup consisting of a 70-mm plastic button cannula, intravenous extension tubing, three-way stopcock and syringe.Fig. 3: The boy's tongue immediately after liberation from the bottle.Fig. 4: The boy's tongue 3.5 h after liberation.Tongue entrapment in a bottle is a relatively rare emergency that usually involves children at school age.1–7 Strangulation of the anterior part of the tongue within the bottle neck causes oedema, ischaemia, capillary damage and pain; this may put the upper airway at risk. Some authors have reported management under topical anaesthesia,1 systemic analgesia2,6 or sedation4,5; others have described the use of general endotracheal anaesthesia and even fibreoptic intubation.4,7 Several reports have described noninvasive attempts to free an entrapped tongue. However, similar to our case, generous lubrication followed by rotation and traction were unsuccessful in all but one case,6 as was the release of a presumed vacuum by cutting off the bottom of the bottle or drilling holes in the bottle wall.3–5 In most cases, the bottles (glass, plastic or metal) were physically cut. All reported children had a severely swollen tongue after liberation from the bottle neck as well as signs of ischaemia and capillary damage. One child had to be fibreoptically intubated because of secondary upper airway obstruction after the bottle was removed, and remained ventilated for 2 days.4 Eventually, all children made full recoveries. We found only one report of a positive pressure technique similar to the one used in our patient.1 Published over 30 years ago, it obviously had largely been forgotten. In the present case, the idea to attempt to inject air into the bottle to produce positive pressure was inspired by the first author's recollection of successfully uncorking a wine bottle as an anaesthetic registrar with the use of a syringe-and-cannula technique on an occasion when no corkscrew was available. In conclusion, the use of positive pressure proved to be a simple, effective and safe technique for releasing a tongue entrapped in a bottle. We would suggest that this method warrants attempting before more invasive procedures under general anaesthesia are considered. Addendum: In the ironically written Comments section of their case report, Mills and Simon cited an article by ‘IM Quickknife’ published in the ‘first and last volume’ of the ‘Journal of Medical Misadventures’ where 50 cases with entrapped tongues purportedly were managed by cutting the tongues off, leaving ‘49 of the children and all of the parents’ ‘speechless by the procedure’.1 Of note, this article has been cited again by other authors.6 Acknowledgements relating to this article Assistance with the letter: Stephan K.W. Schwarz, UBC Vancouver, Canada. Financial support and sponsorship: none. Conflicts of interest: none.

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