Magill Forceps: Foreign Body Removal Under Direct Vision

Magill forceps are one of those instruments that must not be missing from any emergency equipment – yet in practice, they are surprisingly often used incorrectly. Whether for foreign body aspiration in children, removal of a bolus impaction in the hypopharynx, or as an aid during nasotracheal intubation: correct handling of this curved grasping instrument can be life-saving. At the same time, improper use carries the risk of significant iatrogenic injuries. This article examines the indications, technically correct application, size selection for different age groups, and the most common errors encountered in clinical and prehospital practice.

Historical Background and Design Principle

Magill forceps were developed by the Irish-British anesthesiologist Sir Ivan Whiteside Magill, who is considered one of the pioneers of modern anesthesia. The instrument is characterized by its distinctive double curvature, which provides a decisive advantage: the operator's hand remains outside the line of sight while the forceps tip can be precisely positioned in the hypopharynx or laryngeal inlet.

Design Features

• Double-curved blades: Enable working in the hypopharynx without blocking the direct laryngoscopy line of sight.
• Rounded, serrated jaw tips: Provide a secure grip on the foreign body without excessively traumatizing the surrounding tissue.
• Spring ring or lock: Holds the forceps in the desired position and allows controlled opening and closing with one hand.
• Various sizes: Available from neonatal to adult, adapted to the anatomical proportions.

The principle is simple, but application under stress conditions is demanding: Magill forceps are a precision instrument used under direct vision – typically via laryngoscope.

Indications

Magill forceps are used in several clinical scenarios. The most common indications can be divided into two main groups:

Foreign Body Removal from the Hypopharynx

This is the classic and most common indication. When a foreign body is impacted in the hypopharynx or supraglottic area and obstructs the airway, it can be grasped and extracted under laryngoscopic vision using Magill forceps. Typical scenarios include:

• Bolus impaction in adults: Pieces of meat, large food chunks, dental prostheses
• Foreign body aspiration in children: Toy parts, nuts, coins, button batteries
• Vomitus or blood clots: When suctioning is insufficient and visible obstruction is present
• Tooth fragments or dental prostheses: Following trauma or as a complication during intubation

Important: Magill forceps are only indicated when the foreign body is reachable under direct vision. A foreign body that has already descended deep into the trachea or bronchi is not a target for Magill forceps – rigid or flexible bronchoscopy is the method of choice in such cases.

Nasotracheal Intubation

During nasotracheal intubation, the tube is advanced transnasally and frequently needs to be directed under laryngoscopic vision in the hypopharynx to pass through the laryngeal inlet. The Magill forceps serve to grasp the tube tip and guide it precisely through the glottis. This technique requires practice and good coordination between laryngoscopy and forceps manipulation.

Additional Indications

• Placement of a gastric tube under laryngoscopic vision in cases of difficult passage
• Removal of packing from the nasopharynx
• Positioning of esophageal obturators or specialized airway adjuncts

Size Selection: Adults and Children

Choosing the correct forceps size is critical. Forceps that are too large in a child's hypopharynx cause trauma; forceps that are too small in adults provide insufficient grip and prolong manipulation time – with the risk of hypoxia.

Size Selection Reference Table

Patient Group	Age / Weight	Magill Forceps Size
Neonates	0–3 months / < 5 kg	Neonatal (approx. 15 cm)
Infants	3–12 months / 5–10 kg	Infant size (approx. 17 cm)
Toddlers	1–6 years / 10–20 kg	Pediatric size (approx. 19–20 cm)
School-age children	6–12 years / 20–40 kg	Adolescent size (approx. 21–22 cm)
Adolescents and adults	> 12 years / > 40 kg	Adult size (approx. 24–25 cm)

Practical tip: When in doubt, choose one size smaller. Slightly smaller forceps can be guided more precisely than oversized ones, which restrict the working space in the pharynx and obstruct the view. During initial emergency care, only a limited selection of sizes is often available – it is advisable to regularly check the equipment in your emergency bag or backpack and to stock at least one pediatric and one adult size.

Technique: Step-by-Step Guide

Foreign body removal with Magill forceps under laryngoscopic vision follows a structured approach. Each step should be performed deliberately and in a controlled manner.

Preparation

1. Positioning: Modified Jackson position for adults (head slightly extended, neck flexed using a pillow). For infants and toddlers: neutral head position, with a shoulder roll if needed.
2. Ensure monitoring: Pulse oximetry, ideally capnography, ECG.
3. Prepare suction: Large-bore suction catheter (Yankauer) immediately at hand. Suction must be functional before you use the laryngoscope.
4. Lay out the correct instruments: Magill forceps in the appropriate size, laryngoscope with suitable blade (Macintosh or Miller depending on age and preference).
5. Organize assistance: A second person for suctioning and instrument handling is highly recommended.

Procedure

1. Laryngoscopy: The laryngoscope is inserted with the left hand. The epiglottis is visualized, and the view into the hypopharynx or laryngeal inlet is established.
2. Identification of the foreign body: The foreign body must be clearly visualized. Without clear vision – no forceps maneuver.
3. Insertion of the Magill forceps: The forceps are guided with the right hand, opened, and advanced under direct vision toward the foreign body. The curvature of the forceps points ventrally (toward the larynx).
4. Grasping the foreign body: The forceps tips are positioned around the foreign body and closed firmly but not excessively. With soft foreign bodies (e.g., meat), controlled pressure is critical to avoid tearing.
5. Extraction: The foreign body is extracted in a controlled, arcing motion – following the curvature of the forceps – toward the oral cavity. Keep the laryngoscope in position until the foreign body is safely removed.
6. Post-extraction inspection: Re-inspect the hypopharynx and laryngeal inlet under laryngoscopic vision. Are residual fragments present? Is there mucosal injury? Suction as needed.
7. Oxygenation: After successful removal, immediately ventilate or administer supplemental oxygen, reassess the airway.

Special Considerations in Children

In children – particularly infants and toddlers – several special aspects apply:

• Anatomy: The pediatric larynx is positioned higher (C3–C4 vs. C5–C6 in adults), the epiglottis is relatively large and omega-shaped, and the trachea is short. The working field is considerably narrower.
• Straight blade (Miller): Often better suited for infants and toddlers, as it directly lifts the epiglottis and thus provides better visualization of the hypopharynx.
• Time factor: Functional residual capacity relative to oxygen consumption is lower. Desaturation time is significantly shorter than in adults. Each attempt should be limited to a maximum of 30 seconds.
• Sedation/anesthesia: In non-unconscious children, foreign body removal with Magill forceps is only feasible after induction of anesthesia – otherwise the child will not remain still, and the risk of injury increases massively.

Common Application Errors and How to Avoid Them

Knowledge of common errors is at least as important as mastering the correct technique. The following errors are regularly observed in simulation training and clinical practice:

Error 1: Blind Manipulation Without Adequate Visualization

The most serious error. Magill forceps must never be inserted blindly into the pharynx. Without laryngoscopic vision, there is a risk of pushing the foreign body deeper, causing mucosal injuries, or damaging structures such as the epiglottis, vocal cords, or arytenoid cartilages.

Rule: No grasping without seeing.

Error 2: Incorrect Grip on the Forceps

Magill forceps are held like scissors – thumb and ring finger in the rings, index finger on the shaft for guidance. A common error is gripping the forceps in a palmar grip (like a hammer), which severely limits fine motor control.

Error 3: Excessive Force When Closing

Particularly with smooth or round foreign bodies (marbles, button batteries), operators tend to close the forceps with excessive force. The result: the foreign body is "flicked away" and driven deeper into the airway. Instead: apply measured, even pressure and try to encompass the foreign body rather than squeeze it.

Error 4: Premature Removal of the Laryngoscope

The laryngoscope is withdrawn before the foreign body is completely extracted. This results in loss of visualization, and the partially grasped foreign body can slip away. The laryngoscope remains in position until extraction is complete and post-extraction inspection has been performed.

Error 5: No Suction Readiness

Secretions, blood, or gastric contents frequently accumulate behind the foreign body. When the foreign body is removed, this material flows into the now patent airway. Without immediately available suction, aspiration can occur.

Error 6: Wrong Size Selection

Forceps that are too large in a child's pharynx cause mucosal lesions and block the view. Forceps that are too small in adults provide insufficient grip. Size selection should be made deliberately before use – not when the forceps are already in the mouth.

Error 7: Lack of Team Communication

Foreign body removal with Magill forceps is ideally a two-person task: one person manages the laryngoscope and forceps, the other handles suctioning, monitoring, and assistance. In the chaos of an emergency, this division of tasks is often neglected.

Complications

Even with correct application, complications can occur. The most common include:

• Mucosal lesions: Bleeding in the hypopharynx, at the epiglottis, or at the vocal cords
• Laryngospasm: Particularly with insufficient depth of sedation or in patients with heightened reflexes
• Foreign body dislocation into the trachea: The foreign body is inadvertently pushed deeper
• Dental injuries: Particularly during simultaneous laryngoscopy, when the laryngoscope is used as a lever against the upper teeth
• Edema formation: Repeated manipulation can lead to supraglottic edema, which secondarily compromises the airway

Every complication must be documented, and subsequent airway management adjusted accordingly. If subglottic foreign body location is suspected after a failed extraction attempt, immediate transfer for bronchoscopic retrieval is indicated.

Algorithm: Foreign Body in the Upper Airway

Magill forceps are one component in the overall foreign body airway obstruction algorithm. The AHA guidelines and ERC recommendations define the following escalation steps:

1. Conscious patient, effective cough present: Encourage coughing. No instrumental intervention.
2. Conscious patient, ineffective cough:
   • Adults and children > 1 year: 5 back blows, then 5 abdominal thrusts (Heimlich maneuver)
   • Infants < 1 year: 5 back blows, then 5 chest thrusts
3. Unconscious patient: Begin CPR (chest compressions generate intrathoracic pressure and may mobilize the foreign body). With each positive-pressure ventilation: inspect the mouth.
4. Foreign body visible in the hypopharynx: Laryngoscopy and extraction with Magill forceps under direct vision.
5. Foreign body not reachable, persistent obstruction: Consider a surgical airway (cricothyrotomy in adults, needle cricothyrotomy in children as a last resort).

Remember: Magill forceps are used in step 4 – i.e., only after failed basic measures or when the foreign body is visualized during laryngoscopy as part of advanced airway management.

Maintenance and Reprocessing

Like any surgical instrument, Magill forceps must be properly reprocessed after use. The exact reprocessing steps follow the hygiene plan of the respective institution; in general, the following applies:

• Immediate gross cleaning after use (remove blood, secretions)
• Machine reprocessing in a washer-disinfector or validated manual reprocessing
• Sterilization in a steam sterilizer (autoclave, 134 °C)
• Function check: Inspect the closing mechanism, spring tension, and surface integrity. Corroded forceps or those that no longer close properly must be discarded.

In the emergency bag, Magill forceps should be stored in sterile packaging and regularly checked for expiration date and package integrity.

Practical Training

Foreign body removal with Magill forceps under laryngoscopic vision is a skill that requires regular hands-on training. Coordinating the laryngoscope in the left hand, forceps in the right hand, and simultaneous visual control can only be understood theoretically from text – motor proficiency develops through practice on manikins and in simulation scenarios. In the Emergency Physician Refresher Course by Simulation Tirol, you have the opportunity to train exactly these skills under realistic conditions, receive feedback, and identify common errors in a safe learning environment before they become relevant in real patient care. Because an instrument that you have to use correctly for the first time in a real emergency is not an instrument – it is a risk factor.