Sir,

It is with pleasure we read the short letter indicating the use of Magill's Forceps for non anesthesia purposes. It nicely described the approach of dislodging and removing an impacted bolus of meat, in the lower third of esophagus, through the stomach.[₁]

Anesthesiologists use this valuable instrument to help introducing the endotracheal tube into the larynx. On many occasions they used it for other anesthesia and extra-anesthesia purposes; e.g. removal of mucous plugs, solid food particles in case of vomiting on induction, fallen loose tooth in the mouth and impacted bolus of meat. Even Ascaris worm obstructing the airway [₂] even sacred thread (MOULIE) [³] and the list would not end.

The strangest case from my practice was picking up impacted foreign body in 18 months old child who was rushed from emergency room (ER) to operating theatre after unintended episode which lead to positional respiratory distress so the child was positioned himself in the best position to keep his airway open. He was so distressed and lethargic that the examining physician could not manage opening his mouth, since he was closing his jaw tightly. The ER physician suspected foreign body (FB) inhalation. The surgeon was notified to prepare for bronchoscope visualization and examination of the airway and possible tracheotomy. When the patient was arrived in the operating room he was lethargic with dusky color and cold. His pulse was felt and he was still conscious. He was positioned in supine position which lead to complete obstruction of the airway. Then the patient was positioned in the original position he was comfortable in. Inhalation induction with halothane in oxygen was performed and when the patient fell asleep quick laryngoscopy demonstrated the presence of glass bead [Fig.1] impacted in the oropahrynx producing a ball-valve mechanism over the larynx and hiding all the view beyond.

Figure 1

Figure 1: Glass bead was obstructing FB in the oropharynx which endangered the life of reported child presenting by positional respiratory distress. The diameter of glass bead was 20 mm (Photo Mohamad Said Maani Takrouri)

The surgeon saw the object and he tried to pull it out but the bead was not movable due to spastic muscles. The anesthesiologist (Author) suggested trying Magill's forceps and he manipulated the bead gently and removed it from its dangerous place. The airway obstruction was immediately relieved and check bronchoscope did show no inhalation of other FB, neither any pathology. The patient did recover from anesthesia safely and was in normal general condition.

He was put under supervision over few hours and discharged subsequently in good health.

Figure 2

Figure 2: Magill's forceps pediatric (left) and adult sizes (eight) note the long objective arms which make wider opening to hold spherical or thin objects.. These instruments have better ability to grip round object because of serrated holding tips. (Photo Mohamad Said Maani Takrouri)

Conclusion

We may conclude; the moral from these stories is an emphasis on the possible role of observing anesthesiologist to solve problem dire situation.

On the other hand, Magill's forceps is an adjunct to airway management when endotracheal intubation is expected. So the practitioner who faces a situation of FB obstructing the airway in the depth of the oropharynx may ask for either the pediatric or adult size which may prevent the delay in sorting this problem out. The bronchoscope long forceps usually have short objective arms and when manipulation would be tried through the rigid bronchoscope, it may not be easy to control the FB.

Acknowledgement