A 25-year-old male with cerebral palsy was transferred from another hospital to the neuro-intensive care unit for a second opinion concerning seizures. Intubation had been carried out prior to the transfer. He was subsequently diagnosed with severe myoclonic activity causing secondary respiratory distress.

He was extubated 5 days after admission, but re-intubated 2 days later due to recurrent myoclonus and respiratory distress. During subsequent wake-up calls, he appeared agitated; and a mouth gag was inserted to prevent airway was observed, preventing extubation.

Three days after the re-intubation, an MRI of the cerebrum was performed and as a coincidental finding revealed a foreign body in the upper airway, with the shape of a mouth gag (Figs. 1, 2, 3, 4, 5).

Fig. 1
figure 1

Magnetic resonance imaging of the brain showing the displaced gag (arrow)

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Fig. 2
figure 2

Extracted gag

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Fig. 3
figure 3

Cross-sectional view of magnetic resonance imaging demonstrating the gag (arrow)

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Fig. 4
figure 4

Magnetic resonance imaging demonstrating the gag in the nasopharynx and laryngopharynx

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Fig. 5
figure 5

Magnetic resonance imaging providing a view of the gag located in the pharynx

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The gag was uneventfully retracted with Magill forceps. The following day, the patient was successfully extubated.

A displaced—but not missed—mouth gag is potentially life-threatening. The use of any medical device should be used cautiously. Just as instrument counts are a part of WHO’s Surgical Safety Checklist, a similar approach concerning the use of medical devices in the intensive care setting could appear useful in order to avoid patient hazards.