Whole fish an unusual foreign body in the tongue of a child.

Sir,

Foreign body ingestion in children is quite common in 6 months to 6 years.[1] However, the whole fish impact in a tongue is very unusual in children.[2] Here we are reporting a successful management of one such case in a child.

An 18-month-old male child, weighing 10 kg was admitted to the hospital for emergency removal of live fish from the mouth after 2 h of ingestion. The child belongs to the fisher man's family. When siblings were taking care of the child in the evening, suddenly the mother noticed an object in the mouth of the child. Trying to remove the fish failed at home. Immediately, they consulted an Otolaryngologist and the child was shifted to the hospital. On examination, the child was restless, Respiratory Rate 20/min, Pulse Rate 110/min. The mouth was open. Half of the body and tail of the fish were visible in the oral cavity [Figure 1]. There was no stridor. The dribbling of blood tinged saliva present. Since the child was in agony, he was shifted to the operation theatre immediately.

Figure 1

Diagrammatic representation of the impacted fish in tongue

Consent was taken, intravenous line secured. The child was fed milk 3 h before the operation. Fiber-optic bronchoscope and emergency surgical airway gadgets were kept ready; preoxygenation was done by holding a face mask just above the face with 4 l of O2. The child was sedated with Inj midazolam 0.03 mg/kg, Inj atropine 0.02 mg/kg, Inj ketamine 1 mg/kg intravenously. In the head, low-position and continuous suction extraction of fish was done for 10 min using Magill's forceps. The fish measured 5 cm in size. It was difficult to extract because of fins, and the scales were deeply embedded to the tongue. Check laryngoscopy was done to confirm hemostasis. Vocal cords were normal. The child was fully awake in 30 min and was advised oral antibiotics and analgesics, and was discharged from the hospital after 24 h.

Foreign body ingestion, aspiration and impacting are commonly reported in following sites, in upper-airway, lower-airway and oesophagus, but their type, size and presentation are unimaginable. On the other hand, foreign body ingestion and impact in the oropharynx are rarely reported since they are easily seen and removed by a finger swap method or by using Magill's forceps.[345] Whole fish impact in the tongue is very uncommon presentation in children. However, it is possible in adults of fisherman family due to the habit of keeping it in between the teeth while fishing, and in older children of same family putting it in the mouth of younger children while playing. It can happen in children since they always have the habit of touching and trying to put, round and shiny objects into the mouth. Hence, accidental ingestion of whole fish in any age is a life-threatening emergency.[5]

The effect of the foreign body in the oropharynx is very different; they can cause no effect or hazardous effects.[4] If the size of the fish is big, it can cause suffocation, choking, death before reaching the hospital. If the size of the fish is small and fins and scales of fish are firmly attached in the oropharynx causing no immediate effect but demands hospital management. Dislodgment during difficult removal can cause complete airway obstruction and requires urgent securing of the airway by surgical methods.[5]

We faced difficulty in holding the face mask, performing laryngoscopy for securing the airway. Aggarwal et al.[2] reported success in removal of impact fish from the hypopharynx of the infant of the fisherman's family under general anesthesia. Subramanian et al.[5] made an attempt to remove impacted fish by Magill's forceps from diminished sensory perception of the pharynx of an elderly patient without anesthesia. They concluded that it is easy to remove fish if it enters with tail first in the mouth and difficult to remove due to presence of fins and the slippery nature of the fish and safe method to remove marine foreign bodies are by using Magill's forceps or sponge stick forceps. Since our case reached the hospital in short-time, with fewer signs and symptoms of airway obstruction, we could successfully remove the whole fish from the tongue by using Magill's forceps under total intravenous anesthesia, without endotracheal intubation.

This case report highlights that whole fish impact in the tongue is accidental and extremely rare in children. Many times they reach the hospital for emergency help as they fail to remove at home. Though it looks very simple it is difficult to remove because of the scaly surface of the fish. Though there are advances in anesthetic management and airway instrumentation, sometimes the procedure of removal of the fish is near fatal. Hence it demands elective procedure before acute decompensation with meticulous care by an expert hand in the hospital setup.