Tongue trapped in lid

Sir, a non-verbal, 28-year-old gentleman with autism and severe learning difficulties presented at the Ipswich accident and emergency department (ED), with his tongue trapped in the lumen of the lid of a re-usable plastic drinking bottle. The patient attended with two carers. They had attempted to remove the bottle by unscrewing it from the lid. The patient's medical history revealed he was taking Carbamazepine and Diazepam. By the time he arrived the tongue had been trapped for approximately four hours. He was clearly in a significant amount of pain and was showing signs of distress. The anterior third of the tongue was severely engorged. It was firm to touch and showed signs of necrosis (Fig. 1). It was impossible to remove the bottle lid manually.

Fig. 1

The engorged tongue trapped in a drinking bottle lid

In order to prevent potential loss of the anterior third of the tongue, the lid needed to be removed urgently. Due to the patient's poor compliance, this could only be performed under a general anaesthetic. Access to the airway was restricted because of the large foreign body and this made bag mask ventilation and oral endotracheal intubation challenging. Therefore, preparation was made to perform a tracheostomy. Fortunately, the anaesthetic team were able to secure a nasotracheal airway, via an awake fibre optic intubation, with the assistance of ketamine.

Initial attempts to remove the bottle lid with orthopaedic wire cutters were unsuccessful due to the density of the plastic. The lid of the bottle was drilled through with a fissure bur attached to a surgical dental drill (Fig. 2). A Howarth's periosteal elevator was placed between the tongue and the bore of the lumen throughout to protect the tongue. On removal of the lid, the swelling from the anterior aspect spread posteriorly to the oropharynx. The patient was given two doses of Dexamethasone IV, peri-operatively and six hours later. Due to airway concerns, the patient was kept intubated in ITU for 12 hours. After this time, the swelling had reduced significantly so the patient could be safely extubated. He was discharged home the same day and had no subsequent complications.

Fig. 2

The lid of the bottle after it had been drilled through with a fissure bur attached to a surgical dental drill

Tongue entrapment within a lumen of a bottle is caused when a vacuum is created because the tongue remains in the lumen for too long. The vacuum is formed because the patient places their tongue inside and starts to 'play with' the inside of the bottle, sucking the air out. Once the vacuum has formed, the tongue can then become oedematous and the lid will subsequently strangulate the tongue. If the lid is not removed quickly, venous return is impaired leading to further oedema and, on rare occasions, ischaemia or necrosis.

There are other cases in the literature concerning mostly children and alternative methods for removal have been described. Most of the previous cases involved metal or glass bottles. The authors would like to draw attention to this case as incidents are likely to increase as more plastic reusable bottles are used.