Impalement injuries of the palate in children: review of 131 cases

Do maxillary dentures protect the skull base from penetration injury?

Key Clinical Message

Foreign bodies penetrating from the oral cavity can damage surrounding tissues. This case is considered an extremely rare and fortunate instance in which a maxillary denture appeared to weaken the external force and change the direction of the scissors, preventing damage to vital organs.

Abstract

The patient was a 73-year-old man. While on a ladder pruning a plant, he accidentally fell. The gardening scissors passed through the maxillary sinus from the maxillary alveolus and penetrated below the zygomatic arch. At the time of injury, the patient was wearing a metal-frame denture on the maxilla, and contact between the cutting edge and the denture was speculated to have weakened the piercing force of the blade and changed the direction of the cutting edge. This extremely rare case demonstrates how a maxillary denture could reduce the severity of a penetrating injury caused by scissors.

Systematic Review of CT Angiography in Guiding Management in Pediatric Oropharyngeal Trauma

OBJECTIVES

Pediatric oropharyngeal trauma is common. Although most cases resolve uneventfully, there have been reports of internal carotid artery injury leading to devastating neurovascular sequelae. There is significant controversy regarding the utility of CT angiography (CTA) in children with seemingly minor oropharyngeal trauma. The goal of this study was to appraise changes in diagnosis and treatment based on CTA results.

METHODS

A comprehensive search of PubMed, Embase, CINAHL, Scopus, the Cochrane Ear, Nose and Throat Disorders Group Trials Register, and the ClinicalTrials.gov database was performed following PRISMA guidelines.

RESULTS

The search yielded 5,078 unique abstracts, of which 8 articles were included. A total of 662 patients were included, with 293 having any CT head/neck imaging, and 255 with CTA. Eleven injuries/abnormalities of the carotid were found on CTAs, comprising edema around the carotid (n = 8), potential intimal tear (n = 1), carotid spasm (n = 1), and carotid compression (n = 1). The pooled proportion of imaging findings on CTA that could lead to changes in clinical management was 0.00 (95% CI 0.00-0.43). Angiography was obtained in 10 patients, in 6 cases due to abnormal CTA. Angiography identified 1 patient with vessel spasm and two patients with carotid intima disruption without thrombus. No patient underwent vascular repair or suffered cerebrovascular injury.

CONCLUSION

Imaging with CTA yielded radiological abnormalities in a few instances. These results do not support the routine use of CTA in screening pediatric oropharyngeal trauma when balanced against the risk of radiation, as it rarely resulted in management changes and was not shown to improve outcomes.

LEVEL OF EVIDENCE

N/A Laryngoscope, 133:457-466, 2023.

The Utility of CTA in Pediatric Oropharyngeal Trauma: A Systematic Review and Meta-Analysis

OBJECTIVE(S)

To analyze the utility of computed tomography angiography (CTA) in identifying internal carotid artery (ICA) injury and reducing cerebrovascular accident (CVA) incidence in children presenting with normal neurologic exams after oropharyngeal trauma (OT).

DATA SOURCES

PubMed, Scopus, CINAHL, and Cochrane.

REVIEW METHODS

A systematic review and meta-analysis were performed following PRISMA guidelines. Of 1,185 studies screened, 95 studies of pediatric OT met inclusion criteria. Meta-analysis of proportions was performed.

RESULTS

A total of 1224 children with OT were analyzed. Excluding case reports, the weighted proportion of a CVA after OT was 0.31% (95% CI 0.06-0.93). If a child presented without neurologic deficits, 0.30% (95% CI 0.05-0.95) returned with new neurologic deficits. An ICA injury was identified in 0.89% (95% CI 0.16-2.74) of screening CTAs. No difference in CVA incidence was seen in children with screening CTA (0.52% [95% CI 0.02-2.15]) compared to children without screening CTA (0.42% [95% CI 0.06-1.37]). Patients who developed CVA had a higher proportion of injuries >2 cm, injuries at the posterior pillar or tonsil, and injuries with a writing utensil or popsicle stick compared to patients without CVA.

CONCLUSION

The proportion of children experiencing an ICA injury leading to CVA after sustaining OT is low. CTAs infrequently show ICA changes in children with normal neurological exams. Children who receive CTAs do not have a significantly lower incidence of CVAs than children who do not receive CTAs. Clinicians should weigh the risks and benefits of a CTA based on an individual child's presentation and discuss this with caregivers for shared decision-making. Laryngoscope, 133:25-37, 2023.

Neck Trauma: Cervical Spine, Seatbelt Sign, and Penetrating Palate Injuries

Pediatric cervical spine, blunt cerebrovascular, and penetrating palate injuries are rare but potentially life-threatening injuries that demand immediate stabilization and treatment. Balancing the risk of a missed injury with radiation exposure and the need for sedation is critical in evaluating children for these injuries. Unfortunately, effective clinical decision tools used in adult trauma cannot be uniformly applied to children. Careful risk stratification based on history, mechanism and examination is imperative to evaluate these injuries judiciously in the pediatric population. This article presents a review of the most up-to-date literature on pediatric neck trauma.

An Orbital Abscess Secondary to Intraoral Impalement

Penetrating orbital trauma in the pediatric population is rare. Even more unusual is a secondary orbital infection following penetrating trauma. Here we present a highly unusual case of fulminant facial cellulitis with an orbital abscess in an otherwise healthy 3-year-old boy following a penetrating injury to the orbit from a point of entry on the gingiva-buccal sulcus, sustained during a fall while carrying a wooden lollipop stick. Examination of the retina revealed a focal injury at the inferior pole of the globe. The organisms cultured from pus sampled from the abscess and from the discharging intraoral wound revealed the same oral commensals while the MRI revealed a track in continuity with the orbital collection.

Sialocele Following Traumatic Dental Procedure: A Case Report and Review of Dental Complications

We present a case of a 17-year-old girl with sialadenitis and sialocele due to trauma sustained from a dental procedure. Our objectives are to review relevant literature and anatomy of the floor of the mouth and salivary glands and discuss potential complications of dental procedures.

Carotid Dissection and Cerebral Infarction From Posterior Oropharyngeal Trauma: The Diagnostic and Therapeutic Challenges

Posterior oropharyngeal trauma commonly occurs in children and frequently presents to the emergency department (ED). Rarely, serious infectious and neurologic sequelae result. Emergency providers are tasked with the challenge of diagnosing the minority with life-threatening complications while maintaining thoughtful stewardship regarding radiation exposure. A previously healthy 2-year-old girl sustained trauma to her posterior oropharynx with a toothbrush that resulted in a left carotid dissection. This dissection was diagnosed in the ED via computed tomography angiogram, Otolaryngology and neurosurgery were consulted in the ED, and anticoagulation therapy was initiated with aspirin. The child did initially well and was without neurologic deficit and no brain ischemia on magnetic resonance imaging. She was discharged home on aspirin therapy. Four days after initial injury, the child returned to the ED after a seizure. Computed tomography scan of the head demonstrated infarction at the junction of the left parietal and temporal areas. Although neurologic complications are rare, posterior oropharyngeal trauma in children is not. There are many diagnostic and therapeutic challenges in its management. This case is, to the authors' awareness, the first case report in the English literature of a known and treated carotid dissection in a child after posterior oropharyngeal trauma that resulted in stroke despite diagnosis and initiation of treatment. The diagnostic and therapeutic challenges of posterior oropharyngeal trauma in children are discussed in this article.

A forensic evaluation of impalement injuries

Impalement injuries transfix a victim in an inescapable or helpless position. A study was undertaken at Forensic Science SA from 2002 to 2016 of all impalement deaths. There were six vehicle accidents (M:F=5:1; age 14-67 years, average age 38.5 years) involving impalements with a tree branch ( n=2; groin and chest), a metal pipe ( n=2; leg and head), a metal bridge railing (groin) and a metal fence post (chest). Two cases (both males, aged 47 and 18 years) had slipped on fences/gates, with impalements of the ankle and groin. A case of suicide (male, aged 80 years) was impaled through the head on a bolt fixed to the floor. A homicide case (male, aged 27 years) involved impalement through the chest by a spear from a spear gun. In certain cases (e.g. with anogenital injuries), differentiating accidental from inflicted impalement injuries may be difficult. In equivocal cases, adequate scene evaluations with photographic documentation are required prior to autopsy, ideally with the object available for examination.

Primary Palate Trauma in Patients Presenting to US Emergency Departments, 2006-2010

Importance

The sequelae of palate trauma vary from minimal discomfort to major neurovascular injury. Infrequency of palate trauma and clinician unfamiliarity with the disease process may lead to variation in evaluation, treatment, and disposition in the emergency department (ED).

Objectives

To measure the incidence of primary palate trauma visits to US emergency departments with analysis of demographics, disposition, and repair and to determine frequency and factors associated with head and neck imaging.

Design, Setting, and Participants

A retrospective analysis using the Healthcare Cost and Utilization Project Nationwide Emergency Department Sample was performed of 22 094 patients presenting to US emergency departments from 2006 to 2010 with a primary diagnosis of palate trauma. Data analysis was conducted from March 29, 2016, to November 18, 2017.

Main Outcomes and Measures

National estimates of palate trauma were calculated from weights available within the database. Palate repair was identified by International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes. Imaging was calculated from reliable Current Procedural Terminology coding facilities identified using a previously published method. Logistic models were calculated to identify clinical associations for admission, imaging, and palate repair.

Results

A total of 22 094 patients (13 967 male and 8121 female patients, 6 missing data on sex; median age, 2.8 years [interquartile range, 1.1-6.1 years]) with primary palate trauma presented to US emergency departments during the study period. Total hospital visits decreased from 4715 (1.58 per 100 000 people) to 3915 (1.26 per 100 000 people) during the 5-year study period. A total of 19 819 patients (89.7%) had routine discharge from the hospital, while palate repair (965 [4.4%]) and mortality (34 [0.2%]) were rare. Complicated palate trauma (odds ratio [OR], 5.32; 95% CI, 3.10-9.15), male sex (OR, 1.57; 95% CI, 1.11-2.21), codiagnosis status (OR, 2.75; 95% CI, 1.84-4.12), and residence in the Northeast vs South (OR, 2.73; 95% CI, 1.11-6.71) increased the likelihood of admission, which was infrequent (1027 patients [4.6%]). After restriction to reliable Current Procedural Terminology coding facilities, head and neck imaging occurred in 823 of 6897 patients (11.9%). Factors associated with head and neck imaging included living in a medium vs large metropolitan area (OR 1.62; 95% CI, 1.04-2.55), while living in the Midwest vs South region (OR, 0.43; 95% CI, 0.25-0.74) had a negative association with imaging.

Conclusions and Relevance

Although it is often suggested in the otolaryngology literature to perform imaging, primary palate trauma usually results in a routine discharge home without imaging or repair. Imaging frequency should be noted since palate trauma could have life-threatening neurovascular sequelae, which presents an opportunity to define and promote optimal management for potential neurologic sequelae in the patients who were not imaged.

Soft Palate Injuries During Orotracheal Intubation With the Videolaryngoscope

OBJECTIVE

The videolaryngoscope has gained popularity for providing superior visualization in intubations. A rare complication of this technology is soft palate injury. Through a literature review and case series, we highlight the risks associated with the Glidescope and McGrath videolaryngoscopes and the management of soft palate injuries.

METHOD

A case series of multi-institutional review of medical records was performed to identify patients with soft palate injuries from the videolaryngoscope. A literature review was also performed to analyze risk factors, mechanism of injury, complications, and management of palate injuries.

RESULTS

Of 9 cases, 3 resulted in soft palate perforations, which required primary closure. The remaining 6 patients sustained a soft palate laceration, which was treated conservatively. This injury commonly occurs when the intubator is focused on the video monitor and blindly inserts the Glidescope into the oropharynx. The rigid stylet used with the Glidescope increases the propensity for oropharyngeal injuries during blind insertions.

CONCLUSION

Proper training, an awareness of this potential complication, and direct oral cavity visualization are recommended while inserting the videolaryngoscope. Repair is recommended for through-and-through perforations or if a large hanging flap is present. Antibiotics should be considered for lacerations greater than 1 to 2 cm.

Blunt Intraoral Trauma Resulting in Internal Carotid Artery Dissection and Infarction in a Child

A 16-month-old child fell forward onto her toothbrush sustaining minor oropharyngeal injury. The following day, she became acutely lethargic with localizing neurologic signs of a cerebrovascular infarct. CTA and MR imaging demonstrated occlusion of the right internal carotid artery with a large right middle cerebral artery territory infarction. She was treated with decompressive craniectomy and anticoagulation but remained weak on the left side. Pediatric oropharyngeal injuries can rarely be complicated by internal carotid artery injury with dissection, thrombosis, or embolization to the cerebral circulation. For the best outcome, carotid dissection treatment requires prompt diagnosis at the initial onset of neurologic symptoms. However, further research is needed to determine the best management and advanced imaging work-up for neurologically intact children.

Masticator Space Foreign Body in a Child Presenting With Otorrhea and Granulation Tissue of the External Auditory Canal

OBJECTIVE

We report an unusual case of masticator space foreign body in a patient presenting with otorrhea and granulation tissue within the external auditory canal (EAC).

METHODS

Case report.

RESULTS

A 16-month-old male presented with fever, unilateral otorrhea, facial swelling, leukocytosis, and granulation tissue within the EAC that failed to respond to conventional medical treatment. Computed tomography scan showed EAC and middle ear opacification and soft tissue swelling involving the masticator space. Given concerns for malignancy, biopsies of tissue within the EAC and of a newly detected right buccal mass were performed, revealing granulation tissue. Concern persisted for neoplasm, however, and magnetic resonance imaging was obtained, showing a masticator space foreign body and possible osteomyelitis of the mandible and pterygoid plates. The patient underwent urgent operative removal of a 3 cm crayon fragment from the masticator space and debridement of granulation tissue arising from a small defect at the inferior medial cartilaginous EAC. He likely sustained foreign body injury several weeks earlier upon falling from standing height while biting a crayon. Postoperatively, he was observed in hospital on intravenous antibiotics and improved significantly. He has since fully recovered.

CONCLUSION

Masticator space foreign bodies may present with erosion and granulation tissue of the EAC.

Dissection of the Internal Carotid Artery following Trauma of the Soft Palate in Children

Objectives:

We undertook this report to underline the risks of lesions of the internal carotid artery after lateral oropharyngeal trauma in children and to discuss the diagnosis and treatment of this complication.

Methods:

We present 2 pediatric cases of carotid dissection following lateral soft palate trauma.

Results:

In 1 case, transient symptomatic cerebral ischemia occurred 24 hours after the initial traumatic injury. In both patients, the carotid dissection was assessed by magnetic resonance imaging with vascular and diffusion sequences. Treatment with low–molecular weight heparin calcium was maintained for several months. At the end of follow-up, both children were asymptomatic.

Conclusions:

We suggest noninvasive imaging of the carotid artery by enhanced computed tomographic scanning after trauma to the lateral part of the soft palate in children. Magnetic resonance imaging with vascular and diffusion sequences is useful in assessing the extension of the dissection toward the cerebral circulation and in early detection of cerebral ischemia. Anticoagulation with heparin probably reduces the risks of cerebral infarction. Patients must regularly undergo physical examination and noninvasive imaging of the carotid artery for at least 1 year after the traumatic injury.

Current management of penetrating injuries of the soft palate

Children present to emergency departments with soft palate impalement injuries on an infrequent though periodic basis. Although these usually heal without treatment, internal carotid artery thrombosis occurs on rare occasions due to vessel compression causing intimal disruption. Thirty-two cases have been reported in the English literature. Hospital observation for up to 72 hours had been recommended previously for all of these injuries because of a, “lucid interval,” usually present before onset of neurologic symptoms. Subsequent studies have shown a very low occurrence of carotid injury and support outpatient observation similar to that after minor head injury. This is further justified by the lack of evidence that any diagnostic study or therapeutic measure alters the ultimate prognosis and outcome. Laceration repair is suggested for retained foreign bodies, through and through injury, or if a large hanging flap is present. Antibiotic indications are not well defined but should be considered for lacerations over 1 to 2 cm in length.

Accidental oropharyngeal impalement injury in children: A report of two cases

Impalement injuries in children may be deeper and more complicated than anticipated. We experienced two cases of accidental impalement injuries, one was through the oral cavity and the other was to the neck. We review these cases and the management of these types of injuries.

CASE SERIES

In case 1, a 20-month-old girl fell from the table with a toothbrush in her mouth. She was conscious, without any apparent neurologic or vascular injuries. Examination revealed a 2 mm laceration with a small hematoma in the right posterior pharyngeal wall. Contrast-enhanced computed tomography (CECT) revealed an air tract penetrating between the mandibular ramus and cervical vertebrae, passing by the carotid sheath, and reaching under the skin of the right posterior neck. Surgical emphysema was extended from the pharynx to the mediastinum. In case 2, a 3-year-old girl fell while holding a pencil. Physical examination revealed a 5 mm laceration in front of her right ear lobe accompanied by a small hematoma. Her facial movement was asymmetric, and she could not close her right eye. CECT showed swelling of the right parotid gland with heterogeneous enhancement and free air just in front of the right carotid sheath, which suggested the object penetrated through the parotid gland. A diagnosis of peripheral facial nerve injury was made. Physicians need to be aware of the potentially life-threatening complications of impalement injuries in children, as well as the specific complications related to proximity to specific anatomic structures.

Internal carotid artery thrombosis due to an unusual soft palate injury in a child

Intraoral trauma is commonly observed in young children due to their tendency to put objects in their mouth. Most of these injuries are minor, without significant morbidity. However, potentially fatal injuries could occur after penetrating trauma to the oral cavity and could initially present with minor clinical findings.

Pediatric considerations in craniofacial trauma

In many respects, craniofacial trauma in children is akin to that in adults. The appearance of fractures and associated injuries is frequently similar. However, the frequencies of different types of fractures and patterns of injury in younger children vary depending on the age of the child. In addition, there are unique aspects that must be considered when imaging the posttraumatic pediatric face. Some of these are based on normal growth and development of the skull base and craniofacial structures, and others on the varying etiologies and mechanisms of craniofacial injury in children, such as injuries related to toppled furniture, nonaccidental trauma, all-terrain vehicle accidents, and impalement injuries.

Primarily unrecognized thoracoabdominal impalement in a motorcyclist

In traffic accidents, fatal impalements are mostly seen in vehicle occupants injured by penetrating blunt-tipped objects such as fence posts or iron bars. Compared with this group of road users, the medical literature lacks reports on impaled motorcyclists. The article presents a case which deserves attention in several respects: 1. Both the impaling object and the victim were moving at the moment of penetration. 2. The lethal impalement trauma remained unrecognized until autopsy, particularly since the causative object did not get stuck in the wound track. 3. Two different body parts (head and trunk) were consecutively affected analogous to re-entry wounds in gunshots and stabs. 4. Due to the tubular shape and the sharp-edged end of the penetrating instrument (stanchion of a broken front-wheel's fork), clothing and soft tissues were punched out along the wound channel and partly remained lodged in the tube's cavity.

Oral and oropharyngeal impalement injury in pediatric patients--focus on rural environment

OBJECTIVE

This article describes a case series of oral and oropharyngeal impalement injuries in pediatric patients and highlights the peculiar etiological role of the rural environment.

STUDY DESIGN

The records of nine pediatric patients who presented with oropharyngeal impalement injuries were reviewed. The patients were all from various rural areas of South Africa. The article focuses on the challenges and risk of post-impalement injury infection in the context of a rural environment.

RESULTS

There were eight boys and one girl. The ages of the study participants ranged from 2 to 10 years. Object-to-head injury was the predominant etiopathogenic mechanism (six cases) compared with head-to-object injury (three cases). Six out of nine lesions were shallow. The hard palate was the single most commonly affected site. Two cases (2/9) of post-impalement injury infection were recorded.

CONCLUSION

Although the risk of infection post-oropharyngeal impalement injury is reported to be low, it remains, however, a legitimate concern in cases occurring in the rural environment. The specific challenges in terms of health infrastructures in the rural environment, especially in developing countries, may have an impact on the ways oropharyngeal impalement injuries are managed.

Palatal avulsion injury by a foreign body in a child

A 6-year-old girl who claimed to have fallen while playing with metal rod that resulted in palatal avulsion injuries was presented. Neither of the parents was around when the incidence happened. She was brought to the hospital because of pain, bleeding from the mouth, drooling of saliva mixed with blood and inability to feed or phonate appropriately. Examinations of the oral cavity revealed a triangular area of avulsion in the posterior aspect of the hard palate extending to the soft palate. She had examination under anaesthesia and wound repaired with 3-0 vicryl interrupted sutures after thorough wound debridement. She did well and was discharged from the clinic.

Trombose de artéria carótida interna relacionada a trauma de palato em criança

OBJETIVO: Relatar um caso de trombose de artéria carótida interna secundária relacionada a trauma de palato mole em criança. DESCRIÇÃO DO CASO: Criança admitida com quadro de alteração do nível de consciência, sonolência, afasia e hemiplegia direita; tinha antecedente de trauma corto contuso leve em palato mole há oito horas. A investigação tomográfica evidenciou acidente vascular isquêmico secundário à interrupção do fluxo sanguíneo em território de artéria cerebral média esquerda. A arteriografia mostrou oclusão da artéria carótida interna imediatamente distal à sua origem, com aspecto radiológico de "ponta de lápis", obstruindo o fluxo sanguíneo na região. A paciente foi submetida à investigação para doença pró-trombótica e cardíaca, contudo, não foi detectada nenhuma alteração. A administração de enoxaparina em dose terapêutica por três semanas conduziu à melhora clínica progressiva. Após três semanas de seguimento, a paciente não mostrava sequelas motoras. COMENTÁRIOS: As lesões intraorais são frequentes em crianças e a maioria evolui sem complicações. A trombose da artéria carótida interna é uma complicação rara, mas bem documentada destas lesões e decorre da compressão do vaso com trombogênese localizada. A taxa de mortalidade relatada é de 30% e as sequelas ocorrem em 85% dos casos.

Intracranial impalement with entrance site in the mandibular region: postmortem elucidation of an accidental fall on a wooden plant stick

A 78-year-old woman with a history of transient ischemic attacks was found in the doorway of her house in a somnolent and unresponsive condition. In the right mandibular region, a small skin wound was localized, which was surgically treated. Six days after admission to the hospital, an exploratory craniotomy was performed because of abnormal CT findings. Apart from tissue lesions and hemorrhages a small bone fragment was detected in the right cerebral cortex, which was removed. After 11 days in hospital, the patient died from failure of central regulatory functions. At the forensic autopsy, a 15 cm long wound track running upward from the skin wound in the right mandibular region through the bony skull base to the right parietal lobe of the brain was noted. Apparently, the surgically removed bone fragment had been displaced from the right middle cranial fossa. The site of the incident in the deceased's house was inspected again and a bamboo pole used to stabilize a potted plant standing on the floor was found and sent to the trace evidence laboratory. Analysis showed blood and tissue deposits from the victim. On the basis of all the findings and the circumstances of the case, a fatal impalement injury caused by an accidental fall could be assumed.

Internal maxillary artery pseudoaneurysm: a near fatal complication of seemingly innocuous pharyngeal trauma

A 2-year-old boy presented with persistent pain and oral blood loss after falling with a toothbrush in his mouth. Initial routine inspection of the oropharynx showed no abnormalities. Recurrent blood loss instigated a reinspection under general anesthesia revealing the head of the toothbrush embedded in the nasopharynx. The toothbrush was removed without problems but several hours later a near fatal rebleeding occurred, requiring aggressive fluid resuscitation. Subsequently, the patient was transferred to our pediatric intensive care unit for further evaluation and treatment. CT angiography (CTA) showed a pseudoaneurysm of the internal maxillary artery which was successfully coiled, and further recovery was uneventful. Pediatric pharyngeal trauma is a common entity with rare, but potentially life-threatening, complications. In case of pharynx lesions, bleeding, and persistent pain, flexible endoscopy by an otolaryngologist is mandatory. In case of persistent bleeding vascular imaging is essential with CTA being a reliable alternative for the more invasive angiography.

Incidence of morbidity from penetrating palate trauma

BACKGROUND

The true rate of neurologic sequelae and infection from penetrating palatal trauma in children is unknown, which leads to significant variation in testing and treatment.

OBJECTIVES

To (1) determine the incidence of stroke and infection in well-appearing children with penetrating palatal trauma and (2) describe patterns of testing and treatment for uncomplicated palatal trauma.

METHODS

We assembled a retrospective cohort of children aged 9 months to 18 years with palatal trauma seen in the emergency department (ED) at a tertiary care pediatric hospital. Patients met the following definition: well-appearing with normal neurologic examination and a palate laceration but no findings requiring immediate operative care. Stroke was defined as any abnormal neurologic examination secondary to palatal trauma. Infection was defined as cellulitis or abscess secondary to palatal injury. All abnormal computed tomographic angiography (CTA) findings, except for free air, were considered positive and potentially significant.

RESULTS

We identified 1656 potential subjects. A total of 995 of 1656 subjects were screened, and 205 of 995 met the case definition. A total of 122 of 205 had follow-up through at least 1 week after injury. The incidence of stroke in our study population was 0% (95% confidence interval [CI]: 0-2.5). One of 116 patients developed infection, for an incidence of 0.9% (95% CI: 0-5.3). A total of 90 of 205 (44%) subjects had CTA scans; the results of 9 (10%) were positive. No patients with positive CTA findings required operative care. No patients received anticoagulant medications.

CONCLUSIONS

The incidence of morbidity from penetrating palatal trauma in the well-appearing child is extremely low. Diagnostic evaluation in the ED did not prompt clinical interventions other than antibiotics.

Management of pediatric penetrating oropharyngeal trauma

Penetrating oropharyngeal trauma (OPT) is common in young children. Complications are rare but can be severe and with delayed onset. Controversy exists about the evaluation and management of OPT, although most injuries in the stable child can be managed in the outpatient setting. Two pediatric OPT cases and a brief review of the literature are presented.

Oropharyngeal injuries in children

BACKGROUND

Oral cavity and oropharyngeal injuries are common among pediatric patients seen in emergency rooms for head and neck trauma. The appropriate treatment of such injuries is often controversial.

PATIENTS AND METHODS

Audit of 6 months' admissions to the pediatric emergency room in a secondary care referral center. Sixty-four patients were treated for various injuries. Charts were reviewed for relevant data.

RESULTS

Description of distribution of types and sites of injuries and discussion of treatment recommendations.

CONCLUSIONS

Most of oropharyngeal injuries heal without any intervention and therefore can be left untreated after being diagnosed. However, in certain injuries, treatment is indicated for better outcome results.

Stroke following a bicycle injury

Stroke is not an uncommon problem in children. However, stroke following intraoral trauma is rare. A high index of suspicion of neurological complications following apparently asymptomatic oral trauma helps to identify this peculiar form of childhood stroke.

Occult pharyngeal perforation secondary to ‘pencil injury’

Palatopharyngeal injuries due to impaction of rigid objects held in the mouth are common. Most are essentially innocuous injuries requiring no specific treatment. However, there is the potential for perforation of the pharyngeal wall with the subsequent development of serious infection such as retropharyngeal abscess or mediastinitis. This possibility is more likely to be suspected in the presence of a visible laceration or puncture wound at the site of impact in the mouth or pharynx. We report three cases in which occult pharyngeal perforation occurred without any clinical signs of breech of the pharyngeal wall. In all cases a lateral soft tissue neck X-ray was diagnostic of perforation, showing the presence of retropharyngeal air. We, therefore, advocate the routine performance of soft tissue neck X-rays in all patients who present with a history of falling on a rigid object held in the mouth.

Impalement injuries of the oral cavity in children: a case report and survey of the literature

BACKGROUND

Impalement injuries of the soft palate and oropharynx are common in children, especially those of preschool age. These injuries are particularly common in toddlers, given their propensity to fall easily while carrying objects in their mouths. Although most of these injuries do not have lasting sequelae, some can have devastating neurological complications, and consequently, careful assessment of the patient during the early stages of trauma is imperative. Close follow-up for up to 72 h, and parental counselling and instruction should be considered as part of their immediate care.

CASE REPORT

A case of toothbrush impalement in a 4-year-old child is presented. The foreign body was noted to be lodged in the cheek. After careful triaging, history taking and appropriate imaging, surgical removal of this brush was carried out uneventfully under general anaesthesia. No further complications were noted postoperatively, and because of the type of injury, the patient was discharged within 24 h and reviewed as an outpatient.

CONCLUSION

A survey of the literature confirms that most injuries of this kind can be treated conservatively, and in many cases, without surgical intervention. However, careful assessment by an experienced clinician is necessary to rule out other complications. The present paper discusses the prevalence, management and complications associated with impalement injuries of the oral cavity in children.

Two patterns of impalement injury to the oral cavity: Report of four cases and review of literature

Impalement injuries to the oral cavity are common, and typically resolve with minimal intervention. We encountered two distinct patterns of injury that required active intervention in four consecutive patients. The first two patients, aged 2 and 7 years, sustained injuries to the floor of mouth and subsequently developed infectious complications necessitating surgical drainage. The other two, aged 4 and 5 years, sustained injuries to the junction of the hard and soft palate, avulsing deep flaps that required repair. Neurovascular complications, despite their rarity have earned maximal discussion in the literature. We feel that traumatic lacerations and infectious complications have far more clinical relevance due to their frequency of occurrence, and should thus occupy a more prominent position in the management flow chart.

Extracranial internal carotid artery pseudoaneurysm

Extracranial internal carotid artery aneurysms are very uncommon entities. We present the case of a young girl who was transferred to our institution after development of a neck mass after Quincy tonsillectomy. The literature on extracranial carotid artery aneurysms is reviewed and reported.

Pediatric oropharyngeal trauma: what is the role of CT scan?

OBJECTIVES/HYPOTHESIS

Pediatric oropharyngeal trauma (OPT) is a common injury in children with rare, but at times severe complications including carotid injury and dissection of air/micro-organisms into the deep tissues of the neck or chest. Cervical CT scan with contrast (CT angiography (CTA)) is nearly universally available and may enhance the evaluation of OPT patients by screening for these potentially devastating complications.

STUDY DESIGN

Retrospective record review, systematic review of the literature.

METHODS

Twenty-three patients diagnosed with OPT from 1997 to 2003 at Boston Children's Hospital were identified by database review. Records were reviewed for site and mechanism of injury, use of diagnostic studies, management, and outcomes. Results were compared to previously published reports. The current literature was reviewed to assess the level of evidence pertaining to the evaluation of OPT patients with CT scan. An extrapolation was made to the general trauma literature to further evaluate the ability of CT angiography to detect carotid injury.

RESULTS

Demographics and mechanism of injury in the current series were unchanged from previous reports. CT demonstrated superior detection and localization of free air. Systematic review of OPT literature revealed data on the use of CT scan as evaluation tool were lacking. Extrapolations to the trauma literature strongly indicate helical CTA has high sensitivity and specificity in detecting carotid injury.

CONCLUSIONS

Pediatric oropharyngeal trauma is a common injury with rare, but severe complications. The routine use of CT scan with contrast may assist in the evaluation of these patients to detect injuries that could lead to severe complications. Collection of prospective data on the ability of CT scan to detect carotid injuries is needed but may not be feasible.

Delayed signs and symptoms after oropharyngeal trauma in a child

Injury to the oropharynx can be potentially life threatening. Innocent-looking injuries of the oropharynx may result in intravascular thrombosis of the internal carotid artery. The symptoms often appear some time after the initial injury. We present a case in which an apparently minor injury of the oropharynx developed into a life-threatening thrombus stretching from the internal carotid to the brain. Our patient underwent endarterectomy and thrombectomy. The case is presented with a review of the literature.

Aneurysm of the internal carotid artery following soft tissue penetration injury

Aneurysms of the extracranial arteries are in most cases secondary to atherosclerosis but may also be due to degeneration, congenital abnormalities, trauma or unclear etiology. They present either with bulging in the lateral pharyngeal wall or the neck. Therefore, otolaryngologists are often among the first physicians to see the patient. In this report, we present a case of spontaneous oral bleeding that was caused by a pseudoaneurysm following 2 weeks after a soft tissue penetration injury in a child. The facial swelling of the child was initially diagnosed to be mumps by its pediatrician and the fever treated with aspirin. A pseudonaneurysm of the internal carotid artery was identified by arteriography as the source of the abrupt oral bleeding and required immediate surgical treatment including radiological means. Our report should illustrate the importance of careful preoperative evaluation as well as a high index of suspicion especially in children, where evaluation of history is difficult.

[Thrombosis of the internal artery secondary to soft palate injury: case report]

Stroke following intraoral trauma is a rare complication of a common childhood injury. In the literature these complications have been well documented, however this condition is still infrequent. In order to alert the physicians about this possible injury we report our experience with one case. Computer tomography and magnetic resonance imaging evidenced complete occlusion of the internal carotid artery. Pathogenesis of this oral trauma is discussed.

Internal jugular vein thrombosis in a child due to a 'pencil point injury' of the palate

Penetrating trauma of the soft and hard palate are common in children and have been termed 'pencil point injuries.' Although such injuries are usually minor, the English literature has reported over 25 cases complicated by thrombosis of the internal carotid artery. We describe an unusual case of a 6 year old girl who presented with fever, cervical swelling and torticollis, following a pencil point injury. Physical examination and CT scan confirmed the diagnosis of internal jugular vein thrombosis (IJVT). The management of pencil point injuries and IJVT in children is reviewed and the possible mechanisms of IJVT in the case described here, are discussed.

Carotid artery thrombosis and stroke after blunt pharyngeal injury

A 2-year-old child fell on a toothbrush, sustaining a pharyngeal injury. Eighteen hours later, localizing symptoms of a cerebrovascular accident became evident. Magnetic resonance angiography showed occlusion of the internal carotid artery and a cerebral infarction. She was treated with anticoagulation and made a complete recovery. Pharyngeal injuries may be complicated by internal carotid artery thrombosis and embolus. Management includes prompt diagnosis, anticoagulation, and carotid artery exploration in selected cases.