International Journal of Pediatric Otorhinolaryngology 76 (2012) 757–760

Case report

Tongue entrapment in aluminum water bottle: Discussion of removal and airwaymanagement

Gopi Shah a,*, Joseph Sciarrino a, Patrick Barth b, Steve Cook b, Robert O’Reilly a

a Thomas Jefferson University, Philadelphia, PA, United Statesb Alfred I. duPont Hospital for Children, Wilmington, DE, United States

A R T I C L E I N F O

Article history:

Received 23 September 2011

Received in revised form 9 February 2012

Accepted 11 February 2012

Available online 21 March 2012

Keywords:

Tongue entrapment

Tongue edema

Foreign body

Airway management

Fiberoptic intubation

Pediatric

A B S T R A C T

Tongue entrapment in a bottle neck is rare, with few cases reported in the literature. Reported here is the

case of a child who presented to the Emergency Department with her tongue entrapped in an aluminum

bottle. This case is unique in that the patient had a delayed presentation resulting in significant tongue

edema, requiring advanced methods for removal and airway management. These include sedated

mechanical removal of the strangulating object and transnasal fiberoptic intubation. We review

published cases and the options for removal of an entrapped tongue from a bottle neck, and we discuss

the importance of airway management.

� 2012 Elsevier Ireland Ltd. All rights reserved.

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International Journal of Pediatric Otorhinolaryngology

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1. Background

Tongue entrapment in a container is an infrequently reportedoccurrence in the literature [1–6]. Such cases can prove to bechallenging for Emergency Medicine, Anesthesiology, and Otolar-yngology physicians, often requiring innovative techniques toremove the container while protecting the patient from injury orairway compromise.

The tongue, like any appendage, is at risk for entrapment incontainers with narrowed openings. Both vacuum and constrictiveforces can lead to entrapment and even strangulation. This resultsin pain, venous congestion, edema, and ecchymosis. Delayedpresentation and previous unsuccessful attempts to free thetongue complicate matters due to potential for worsening edema,ischemia, and injury to the tongue.

Treatment revolves around basic principles such as ensuringairway protection, minimizing trauma to the patient during theprocedure, and appropriate sedation and patient comfort. Howev-er, novel techniques must be used to employ these principles for asatisfactory outcome. Reported here is the case of tongueentrapment in anr aluminum water bottle in a pediatric patientand a review of the cases and techniques previously described inthe literature.

* Corresponding author at: Department of Otolaryngology, 925 Chestnut St, 6th

Floor Philadelphia, PA 19106, United States. Tel.: +1 318 572 8850.

E-mail address: gopibshah@gmail.com (G. Shah).

0165-5876/$ – see front matter � 2012 Elsevier Ireland Ltd. All rights reserved.

doi:10.1016/j.ijporl.2012.02.038

2. Case presentation

The patient is a 6-year-old female with no past medical historywho presented to our Emergency Department (ED) with the chiefcomplaint of ‘‘bottle stuck on tongue’’. Her tongue becameentrapped in the neck of a 20 oz. aluminum water bottle duringlunch at school (see Fig. 1). She initially presented to an outsidehospital ED. An attempt was made to break the suction around thetongue by sliding a red rubber catheter along the side of the bottle.The catheter was successfully threaded through a small openingbetween the tongue and the rim of the bottle, but the bottle wasnot able to be removed. The bottom of the bottle was cut off with aring cutter to visualize the tongue. She was then transferred to ourED by helicopter for further care. During the transport, the patientwas breathing comfortably on 2 l nasal canula, with an oxygensaturation of 100%. She was given Zofran for nausea.

The patient arrived to our ED approximately 4 h after theincident. She was extremely cooperative and was complaining oftongue pain which she rated as 6 out of 10 on the pain scale. Shesaid she was breathing comfortably through her nose. She deniedtightness in her throat and reported being able to swallow hersaliva without difficulty although suction was available at bedside.On exam, the patient was a well-nourished, healthy 6-year-oldfemale in no acute distress. She was on room air with an oxygensaturation of 99% and had a respiratory rate of 15. All other vitalssigns were within normal limits. She had no stridor and no stertor.She was unable to speak but responded to questions with a headshake or nod. The anterior 1/3 to 1/2 of the tongue was entrapped

Fig. 1. Bottle identical to the one causing tongue entrapment in this case.

Fig. 3. Removal of aluminum body of the bottle.

G. Shah et al. / International Journal of Pediatric Otorhinolaryngology 76 (2012) 757–760758

inside the aluminum bottle. The tongue was cool, pale and wasapproximately 4 cm � 5 cm in size due to significant edema (seeFig. 2). She had a very small amount of blood at the inferior aspectof the tongue. She was able to open her mouth so that the softpalate, uvula, and small amount of posterior pharynx could be

visualized, and these were within normal limits. The base of tongue

Fig. 2. Initial patient presentation in the emergency department. The bottom of the

bottle had been removed at an outside hospital, revealing the edematous and

ecchymotic tongue.

and floor of mouth were soft and appeared spared. The patient wasimmediately taken to the operating room (OR) for removal of the

aluminum bottle as well as airway monitoring and protection.In the OR, the patient was lightly sedated; she could breathe on

her own and indicate if she was in pain. Two percent topicallidocaine was applied to the proximal and distal portion of herentrapped tongue. The lateral side of the bottle was cut in length-wise fashion with wire cutters and scissors (see Fig. 3). Small piecesof aluminum were removed with a hemostat as necessary toadvance the cutting instruments. A tongue blade was used toretract the tongue away from the bottle as cuts were made toprevent injury. Once the cuts were made to the neck and rim, thealuminum bottle was removed. However, a thick, threaded, brass‘‘O’’ ring remained intact at the rim, strangulating the tongue (seeFig. 4). Use of heavy orthopedic pin cutters was required to cut the ring

on each side of the tongue in order to remove it in two pieces (seeFig. 5). The tongue was spared. There were no injuries to the lateralor dorsal aspects of the tongue. The ventral tongue and floor ofmouth had some areas of superficial maceration from the brassring. At this point, the anterior tongue was 5 cm in size fromedema. The patient was unable to place her tongue inside hermouth, and she was not tolerating her secretions well. Uponopening her mouth, less of the soft palate and posterior tongue

Fig. 4. Brass ring strangulating tongue after removal of the body of the bottle.

Fig. 5. Bottle and brass ring after removal.

Fig. 6. Floor of mouth and ventral tongue on post-operative day 3.

G. Shah et al. / International Journal of Pediatric Otorhinolaryngology 76 (2012) 757–760 759

were visualized than prior to removal of the bottle. The floor ofmouth had increased fullness. A decision was made by theotolaryngology and anesthesia team to proceed with a nasotra-cheal intubation to secure the child’s airway due to the unknownpossible progression of airway edema. The nares were sprayedwith Afrin and lidocaine jelly was placed on a 5.0 endotrachealtube (ET tube). The child was nebulized with 1% lidocaine andnasopharyngoscope was passed through the right nare with the ETtube to above the larynx. Another 3 ml of 1% lidocaine was sprayedonto the vocal cords and the 5.0 ET tube was passed over the scopeand secured into the airway.

The patient was transported to the pediatric intensive care ingood condition. She was treated with IV steroids and maintained

Fig. 7. Dorsal tongue on post-operative day 3.

head of bed to 508. Her tongue edema was decreased by 30% Post-op day (POD) 1 and on POD2 she was extubated without difficulty.Her tongue sized returned to normal and was pink and warm. Shewas tolerating a regular diet and was discharged home in goodcondition on POD 3 (see Figs. 6 and 7).

3. Discussion

Children frequently drink from bottles, which are rigidcontainers that will sustain negative pressures. A few cases oftongue entrapment have been reported in the literature. They varyin the kinds of bottles (glass or aluminum), the time betweenpresentation to the ED and the initial incident, the methods used toremove the bottle, and management of the airway.

Mills and Simon [1] first described a case of tongue entrapmentin a glass bottle for 1 hour, which was successfully treated with apositive-pressure technique. A 14-guaze catheter was advancedbetween the neck of the bottle and the tongue. A 6-ml syringe wasthen used to pump 240 ml into the bottle to reverse the negativepressure, causing the tongue to retract from the bottle spontane-ously.

If the seal is not able to be broken, the decision may bemade to break the bottle. Goldman [2] reported a case of a 7-year-old boy who was brought to the ED because of entrapmentof his tongue inside a glass bottle. Initially the ED physicianattempted to remove the bottle by breaking off the base torelieve any remaining vacuum. Once the base of the bottle wasremoved ice, soap, lubricants, and manual pressure were applieddirectly to the tongue without success. In this case, the decisionwas made to break the bottle. A heavy cloth tape was wrappedaround the neck of the bottle. A double-action rongeur was usedto break the glass bottle from the bottom up to the neck. Thebottleneck itself required a mallet to break. The large glassfragments of the bottleneck adhered to the tape and the smallerfragments were immediately irrigated off the tongue withsaline.

There was no subsequent tongue laceration or problem withretained glass in the oral cavity.

Guha and Catz [3] report a case of a 10-year-old girl whopresented to their ED with her tongue tightly entrapped inside aglass bottle (9 oz, Yoohoo brand of chocolate drink). In this case,after repeated attempts at mechanically reducing the tongue out ofthe bottle, a professional glazier was contacted, who was able toremove the bottle in the operating room with a steel glass cutter. Inthis case, the child suffered from lingual ischemia for which ahematoma was drained which allowed for rapid improvement.Prompt treatment of tissue strangulation by a foreign body isessential to avoiding necrosis.

In our case, the bottle was aluminum, and though did not needto be broken, it did have to be cut apart, removing small pieceswithout further injuring the tongue in order to advance to the neckand rim for removal. Bank et al. [4] also reported a case of a 10-year-old female who presented with tongue entrapment in analuminum juice can. In this case, the end and sides of the aluminumcan were cut using medic shears. As in our case, the aluminum rimat the lid remained strangled around the tongue. A heavy metalcutter and an orthopedic wire cutter were used to cut the thickeraluminum rim of the lid. In another case described by Siegel et al.[5], a soft drink can was removed from the tongue using a dentaldrill.

The hardest task is not only removing the bottle itself, butremoving it from a young child who may need to be sedated, inwhich case airway management can be difficult. Since the access tothe airway is restricted, bag mask ventilation, direct laryngoscopy,and oral endotracheal intubation may not be possible with such alarge foreign body. Tongue entrapment can lead to laceration with

G. Shah et al. / International Journal of Pediatric Otorhinolaryngology 76 (2012) 757–760760

significant bleeding increasing the risk of loss of airway patency.Not only must removing the foreign body be planned, but airwaymanagement must be well planned with the anesthesia team,including the possibility of a surgical airway.

The anesthetic method is well-described by Parray et al. [6] intheir removal of a metallic globe from the tongue of a 13-year-oldgirl. As in our case, under monitored anesthesia care, the patientwas sedated so that the foreign body was removed while thepatient continued to breathe spontaneously. Though this patientdid not require intubation, airway rescue options included directlaryngoscopy, and oral endotracheal intubation, nasal fiberopticendotracheal intubation and tracheotomy. In our case, the size ofthe bottle obstructed the oral cavity, and even after removal of theforeign body, the size of the tongue precluded oral intubation. Wewere able to safely secure the child’s airway with nasotrachealfiberoptic intubation. Due to significant edema, our patientrequired nasotracheal intubation for 36 h.

Not all cases require intubation. In the case that Goldman [2]had presented, the tongue was removed from the bottleapproximately 3 h after initial incident. This child did not requireintubation but was admitted overnight for airway observation forresidual tongue swelling. In this case, the tongue swellinggradually improved during the next 24 h without airway obstruc-tion or necrosis. In the case by Bank et al. [4], the aluminum canwas removed from the tongue 1 hour after the insult and the childhad minimal swelling and was discharged home on the same daytolerating fluids.

In the case presented by Guha and Catz [3], the patient wasorally intubated in the operating room prior to removal of thebottle. In fact, the bottle was used to place gentle traction on thetongue to facilitate the intubation. This child was extubated severalhours after removal without incident and discharged the followingday.

The risks during the removal of foreign body from the tongueinclude loss of airway, pulmonary aspiration, tongue swelling, andtongue ischemia. After the procedure, the patient should be closelymonitored as massive tongue swelling postoperatively can lead torespiratory distress and an airway emergency. Foreign bodies ofthe tongue should be diagnosed and retrieved early beforecomplications occur.

4. Conclusion

In this case presentation, we review the options for removal ofan entrapped tongue from a bottle neck and discuss theimportance of airway management. Compared to prior reportedcases, our case is unique in that the patient had a delayedpresentation to our ED leading to significant tongue edemarequiring a sedated mechanical removal of the strangulating objectfollowed by transnasal fiberoptic intubation.

Conflict of interest

None of the authors has a conflict of interest to disclose.

References

[1] J.C. Mills, J.E. Simon, Tongue in cheek? Or in the bottle?, Pediatr. Emerg. Care 4(1988) 119–120.

[2] N.C. Goldman, Bottleneck entrapment of the tongue, Otolaryngol. Head Neck Surg.113 (1995) 508–509.

[3] S.J. Guha, N.D. Catz, Lingual ischemia following tongue entrapment in a glass bottle,J. Emerg. Med. 15 (1997) 637–638.

[4] D.E. Bank, L. Diaz, D.A. Behrman, J. Delaney, S. Bizzocco, Tongue entrapment in analuminum juice can, Pediatr. Emerg. Care 20 (2004) 242–243.

[5] R.L. Siegel, A.M. Speiser, V.M. Bikofsky, Tongue ischemia from a soft-drink can:report of case, J. Am. Dent. Assoc. 121 (1990) 607–608.

[6] T. Parray, M.S. Siddiqui, E. Abraham, J. Apuya, S. Shah, A case of an unusual foreignbody of the tongue, South. Med. J. 103 (2010) 966–967.