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Curry SD, Christensen DN, Varman PM, Harp KA, Jones DT. Systematic Review of CT Angiography in Guiding Management in Pediatric Oropharyngeal Trauma. Laryngoscope 2023; 133:457-466. [PMID: 35561004 DOI: 10.1002/lary.30179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 04/25/2022] [Accepted: 04/29/2022] [Indexed: 11/08/2022]
Abstract
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.
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Affiliation(s)
- Steven D Curry
- Department of Otolaryngology - Head and Neck Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Dallin N Christensen
- Department of Otolaryngology - Head and Neck Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Pooja M Varman
- Creighton University School of Medicine, Creighton University, Omaha, Nebraska, USA
| | - Kimberly A Harp
- McGoogan Heath Sciences Library, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Dwight T Jones
- Department of Otolaryngology - Head and Neck Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
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Kawakami K, Oyama Y, Watanabe Y, Motoi H, Odaka M, Shiga K, Ito S. Delayed internal carotid artery occlusion and paralysis after oral trauma. Pediatr Int 2023; 65:e15594. [PMID: 37515346 DOI: 10.1111/ped.15594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 05/25/2023] [Accepted: 06/02/2023] [Indexed: 07/30/2023]
Affiliation(s)
- Kento Kawakami
- Children's Medical Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Yoshitaka Oyama
- Children's Medical Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Yoshihiro Watanabe
- Children's Medical Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Hirotaka Motoi
- Children's Medical Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Mao Odaka
- Children's Medical Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Kentaro Shiga
- Children's Medical Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Shuichi Ito
- Department of Pediatrics, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
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Poupore NS, Jungbauer WN, Nguyen SA, White DR, Pecha PP, Carroll WW. The Utility of CTA in Pediatric Oropharyngeal Trauma: A Systematic Review and Meta-Analysis. Laryngoscope 2023; 133:25-37. [PMID: 35394644 DOI: 10.1002/lary.30133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 03/17/2022] [Accepted: 03/25/2022] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Nicolas S Poupore
- Department of Otolaryngology - Head & Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
- University of South Carolina School of Medicine Greenville, Greenville, South Carolina, U.S.A
| | - W Nicholas Jungbauer
- Department of Otolaryngology - Head & Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
- University of Minnesota Medical School, Minneapolis, Minnesota, U.S.A
| | - Shaun A Nguyen
- Department of Otolaryngology - Head & Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - David R White
- Department of Otolaryngology - Head & Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Phayvanh P Pecha
- Department of Otolaryngology - Head & Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - William W Carroll
- Department of Otolaryngology - Head & Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
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McCollum N, Guse S. Neck Trauma: Cervical Spine, Seatbelt Sign, and Penetrating Palate Injuries. Emerg Med Clin North Am 2021; 39:573-588. [PMID: 34215403 DOI: 10.1016/j.emc.2021.04.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
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.
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Affiliation(s)
- Nichole McCollum
- Division of Emergency Medicine, Children's National Hospital, 111 Michigan Ave NW, Washington, DC 20010, USA.
| | - Sabrina Guse
- Division of Emergency Medicine, Children's National Hospital, 111 Michigan Ave NW, Washington, DC 20010, USA; George Washington School of Medicine and Health Sciences, 2300 I St NW, Washington, DC 20052, USA
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Neck CT angiography examinations for pediatric oropharyngeal trauma: diagnostic yield and proposal of a new targeted technique. Pediatr Radiol 2020; 50:1602-1609. [PMID: 32621012 DOI: 10.1007/s00247-020-04737-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 04/26/2020] [Accepted: 05/22/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Neck computed tomography (CT) angiography is commonly ordered for pediatric patients with soft palate trauma to exclude vascular injury. Debate exists regarding what type of imaging is indicated in this setting, particularly amid growing concern that standard neck CT angiography results in considerable radiation exposure. OBJECTIVE To assess the diagnostic yield and estimated dose reduction of a novel targeted protocol extending from the skull base to the hyoid bone to evaluate pediatric oropharyngeal trauma. MATERIALS AND METHODS A retrospective imaging and medical chart review was performed of patients for whom a neck CT angiography was obtained for an indication of oropharyngeal trauma between 2008 and 2018. Effective dose and size-specific dose estimates (SSDEs) were estimated for standard and targeted neck CT angiography protocols with calculation of percent dose reduction of the targeted exams. RESULTS Ninety-eight CT angiography examinations were reviewed. No cases were positive for neurological or major vessel injury; one case was positive for small vessel extravasation. Clinically significant nonvascular findings included phlegmonous change, retained foreign body, retropharyngeal/mediastinal air and pterygoid process fracture. With the exception of mediastinal air, all findings would have been included in the targeted protocol. Effective dose and SSDE were calculated for all cases where CTDIvol (volume CT dose index) had been reported (n=72). There was a statistically significant reduction in dose for the targeted protocol with an effective dose decrease of 69.7%±10.5% (P=0.009) and SSDE decrease of 53.9%±14.7% (P=0.01). Limiting ionizing radiation to the lung apices, esophagus and thyroid gland provided the greatest dose savings. CONCLUSION Based on low diagnostic yield and high radiation dose associated with standard neck CT angiography for evaluating oropharyngeal trauma, a targeted protocol is recommended, resulting in significantly less dose to the neck, while preserving diagnostic yield.
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Song N, Liu F, Liu Y. The chopstick: a rare and serious cause of penetrating oropharyngeal trauma in a 6-year-old. Br J Hosp Med (Lond) 2020; 81:1. [PMID: 32730163 DOI: 10.12968/hmed.2019.0267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Ningying Song
- Department of Otorhinolaryngology-Head and Neck Surgery, Sichuan University West China Hospital, Chengdu, China
| | - Feng Liu
- Department of Otorhinolaryngology-Head and Neck Surgery, Sichuan University West China Hospital, Chengdu, China
| | - Ying Liu
- Department of Otorhinolaryngology-Head and Neck Surgery, Sichuan University West China Hospital, Chengdu, China
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Pediatric penetrating oropharyngeal trauma. Can J Anaesth 2019; 66:836-837. [PMID: 30877590 DOI: 10.1007/s12630-019-01345-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 02/16/2019] [Accepted: 02/18/2019] [Indexed: 10/27/2022] Open
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Carotid Dissection and Cerebral Infarction From Posterior Oropharyngeal Trauma: The Diagnostic and Therapeutic Challenges. Pediatr Emerg Care 2019; 35:e17-e21. [PMID: 30608333 DOI: 10.1097/pec.0000000000001708] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
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.
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Hirsch A, Popovsky E, Nigrovic L, Burns M. A Brush with Danger. Clin Pract Cases Emerg Med 2018; 2:373-374. [PMID: 30443635 PMCID: PMC6230368 DOI: 10.5811/cpcem.2018.8.39195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 08/04/2018] [Accepted: 08/08/2018] [Indexed: 11/11/2022] Open
Affiliation(s)
- Alexander Hirsch
- Boston Children’s Hospital, Harvard Medical School, Division of Emergency Medicine, Boston, Massachusetts
| | - Erica Popovsky
- Boston Children’s Hospital, Harvard Medical School, Division of Emergency Medicine, Boston, Massachusetts
| | - Lise Nigrovic
- Boston Children’s Hospital, Harvard Medical School, Division of Emergency Medicine, Boston, Massachusetts
| | - Michele Burns
- Boston Children’s Hospital, Harvard Medical School, Division of Emergency Medicine, Boston, Massachusetts
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Smith A, Ray M, Chaiet S. Primary Palate Trauma in Patients Presenting to US Emergency Departments, 2006-2010. JAMA Otolaryngol Head Neck Surg 2018; 144:244-251. [PMID: 29392282 DOI: 10.1001/jamaoto.2017.3071] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
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.
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Affiliation(s)
- Aaron Smith
- Department of Otolaryngology-Head and Neck Surgery, University of Tennessee Health Science Center, Memphis
| | - Meredith Ray
- School of Public Health, University of Memphis, Memphis, Tennessee
| | - Scott Chaiet
- Department of Otolaryngology-Head and Neck Surgery, University of Tennessee Health Science Center, Memphis.,Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison
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11
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Neiner J, Free R, Caldito G, Moore-Medlin T, Nathan CA. Tongue Blade Bite Test Predicts Mandible Fractures. Craniomaxillofac Trauma Reconstr 2015; 9:121-4. [PMID: 27162567 DOI: 10.1055/s-0035-1567812] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Accepted: 07/18/2015] [Indexed: 10/22/2022] Open
Abstract
The aim of the study is to evaluate the utility of a simple tongue blade bite test in predicting mandible fractures and use this test as an alternative screening tool for further workup. This is a retrospective chart review. An institutional review board approved the retrospective review of patients evaluated by the Department of Otolaryngology at a single institution for facial trauma performed from November 1, 2011, to February 27, 2014. Patients who had a bite test documented were included in the study. CT was performed in all cases and was used as the gold standard to diagnose mandible fractures. Variables analyzed included age, sex, fracture type/location on CT, bite test positivity, and operative intervention. A total of 86 patients met the inclusion criteria and of those 12 were pediatric patients. Majority of the patients were male (80.2%) and adult (86.0%; average age: 34.3 years). Fifty-seven patients had a negative bite test and on CT scans had no mandible fracture. Twenty-three patients had a positive bite test and a CT scan confirmed fracture. The bite test revealed a sensitivity of 88.5% (95% CI: 69.8-97.6%), specificity of 95.0% (95% CI:86.1-99%), positive predictive value [PPV] of 88.5% (95% CI: 69.8-97.6%), and negative predictive value [NPV] of 95.0% (95% CI: 86.1-99.0%). Among pediatric patients, the sensitivity was 100% (95% CI: 29.9-100%), specificity was 88.9% (95% CI: 68.4-100%), PPV was 75.0% (95% CI: 19.4-99.4%), and NPV was 100% (95% CI: 63.1-100%). The tongue blade bite test is a quick inexpensive diagnostic tool for the otolaryngologist with high sensitivity and specificity for predicting mandible fractures. In the pediatric population, where avoidance of unnecessary CT scans is of highest priority, a wider range of data collection should be undertaken to better assess its utility.
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Affiliation(s)
- John Neiner
- Department of Otolaryngology, LSU Health Shreveport, Shreveport, Louisiana
| | - Rachael Free
- Department of Otolaryngology, LSU Health Shreveport, Shreveport, Louisiana
| | - Gloria Caldito
- Department of Otolaryngology, LSU Health Shreveport, Shreveport, Louisiana
| | - Tara Moore-Medlin
- Department of Otolaryngology, LSU Health Shreveport, Shreveport, Louisiana
| | - Cherie-Ann Nathan
- Department of Otolaryngology, LSU Health Shreveport, Shreveport, Louisiana
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Larem A, Sheikh R, Al Qahtani A, Khais F, Ganesan S, Haidar H. Oropharyngeal trauma mimicking a first branchial cleft anomaly. Laryngoscope 2015; 126:E224-E226. [PMID: 26372111 DOI: 10.1002/lary.25643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2015] [Indexed: 11/09/2022]
Abstract
We present a unique and challenging case of a remnant foreign body that presented to us in a child disguised as a strongly suspected congenital branchial cleft anomaly. This case entailed oropharyngeal trauma, with a delayed presentation as a retroauricular cyst accompanied by otorrhea that mimicked the classic presentation of an infected first branchial cleft anomaly. During surgical excision of the presumed branchial anomaly, a large wooden stick was found in the tract. The diagnostic and therapeutic obstacles in the management of such cases are highlighted. In addition to exploring the existing literature, we retrospectively analyzed a plausible explanation of the findings of this case. Laryngoscope, 126:E224-E226, 2016.
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Affiliation(s)
- Aisha Larem
- Otorhinolaryngology, Head and Neck Surgery, Department of Surgery, Hamad Medical Corporation, Doha, Qatar.,Weill Cornell Medical College, Doha, Qatar
| | - Rashid Sheikh
- Otorhinolaryngology, Head and Neck Surgery, Department of Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Abdulsalam Al Qahtani
- Otorhinolaryngology, Head and Neck Surgery, Department of Surgery, Hamad Medical Corporation, Doha, Qatar.,Weill Cornell Medical College, Doha, Qatar
| | - Frat Khais
- Otorhinolaryngology, Head and Neck Surgery, Department of Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Shanmugam Ganesan
- Otorhinolaryngology, Head and Neck Surgery, Department of Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Hassan Haidar
- Otorhinolaryngology, Head and Neck Surgery, Department of Surgery, Hamad Medical Corporation, Doha, Qatar
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Uchino H, Kuriyama A, Kimura K, Ikegami T, Fukuoka T. Accidental oropharyngeal impalement injury in children: A report of two cases. J Emerg Trauma Shock 2015; 8:115-8. [PMID: 25949044 PMCID: PMC4411573 DOI: 10.4103/0974-2700.145403] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Accepted: 03/28/2014] [Indexed: 11/04/2022] Open
Abstract
UNLABELLED 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.
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Affiliation(s)
- Hayaki Uchino
- Department of Emergency Medicine, Kurashiki Central Hospital, Okayama, Japan
| | - Akira Kuriyama
- Department of General Medicine, Kurashiki Central Hospital, Okayama, Japan
| | - Kenji Kimura
- Department of Medical Research and Education, Kurashiki Central Hospital, Okayama, Japan
| | - Tetsunori Ikegami
- Department of Emergency Medicine, Kurashiki Central Hospital, Okayama, Japan
| | - Toshio Fukuoka
- Department of General Medicine, Kurashiki Central Hospital, Okayama, Japan
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Abstract
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.
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The tin whistle: a rare and serious cause of penetrating oropharyngeal trauma in children. Case Rep Emerg Med 2014; 2014:562418. [PMID: 25197581 PMCID: PMC4147197 DOI: 10.1155/2014/562418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Accepted: 07/23/2014] [Indexed: 11/18/2022] Open
Abstract
Impalement injuries of the oral cavity are common in children and the potential for serious complications including internal carotid artery thrombosis can be unnoticed. We present a patient who sustained a penetrating injury in which a "tin whistle" caused herniation of the parotid gland which was not detected on clinical examination. We discuss the challenging clinical examination, the role of investigations, and consequences of these injuries aiming at increasing awareness and optimizing patient management.
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Hennelly KE, Fine AM, Jones DT, Porter S. Risks of radiation versus risks from injury: A clinical decision analysis for the management of penetrating palatal trauma in children. Laryngoscope 2013; 123:1279-84. [PMID: 23404330 DOI: 10.1002/lary.23962] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2012] [Revised: 10/17/2012] [Accepted: 12/06/2012] [Indexed: 11/09/2022]
Affiliation(s)
- Kara E. Hennelly
- Division of Emergency Medicine; Boston Children's Hospital; Boston; Massachusetts
| | - Andrew M. Fine
- Division of Emergency Medicine; Boston Children's Hospital; Boston; Massachusetts
| | - Dwight T. Jones
- Department of Otolaryngology; University of Nebraska Medical Center; Omaha; Nebraska; U.S.A
| | - Stephen Porter
- Division of Pediatric Emergency Medicine; The Hospital for Sick Children; Department of Pediatrics; University of Toronto; Toronto; Ontario; Canada
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Internal maxillary artery pseudoaneurysm: a near fatal complication of seemingly innocuous pharyngeal trauma. Case Rep Crit Care 2011; 2011:241375. [PMID: 24826317 PMCID: PMC4010017 DOI: 10.1155/2011/241375] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2011] [Accepted: 09/13/2011] [Indexed: 11/18/2022] Open
Abstract
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.
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Hennelly K, Kimia A, Lee L, Jones D, Porter SC. Incidence of morbidity from penetrating palate trauma. Pediatrics 2010; 126:e1578-84. [PMID: 21041279 DOI: 10.1542/peds.2010-1059] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Kara Hennelly
- Division of Emergency Medicine, Children's Hospital Boston, 300 Longwood Ave, Boston, MA 02115, USA.
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Donaruma-Kwoh MM, Wai S. Oropharyngeal Lesions and Trauma in Children. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2010. [DOI: 10.1016/j.cpem.2010.05.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Enomoto K, Nishimura H, Inohara H, Murata J, Horii A, Doi K, Kubo T. A rare case of a glass foreign body in the parapharyngeal space: pre-operative assessment by contrast-enhanced CT and three-dimensional CT images. Dentomaxillofac Radiol 2009; 38:112-5. [DOI: 10.1259/dmfr/69946733] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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CT angiography in pediatric extremity trauma: preoperative evaluation prior to reconstructive surgery. Hand (N Y) 2008; 3:139-45. [PMID: 18780090 PMCID: PMC2529130 DOI: 10.1007/s11552-007-9081-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2007] [Accepted: 10/19/2007] [Indexed: 01/08/2023]
Abstract
Computed tomographic angiography (CTA) is a noninvasive modality for evaluating the vascular system and planning treatment strategies. The goal of this study was to validate the clinical utility of CTA in assessment of suspected pediatric extremity traumatic vascular injury, prior to emergent and delayed reconstructive surgery. A retrospective review was performed of all operative patients under 18 years of age who underwent multidetector-row CTA for evaluation of suspected extremity vascular injury. Parameters investigated included age, type of injury, referral source, temporal relationship between the injury and the CTA, CTA findings, operations performed, intraoperative findings, and clinical outcome. Between January 2002 and September 2005, 10 pediatric patients (6 males/4 females; mean age 8 years old, range 3-17) sustained either blunt (N = 8) or penetrating (N = 2) trauma and underwent CTA of the upper (N = 5) or lower extremities (N = 5). A total of 30% (3/10) of patients were referred from the emergency department acutely, 50% (5/10) were referred from the inpatient wards subacutely, and 20% (2/10) were referred from the outpatient clinics electively. Half (N = 5) underwent CTA to evaluate need for vascular repair, whereas half (N = 5) underwent CTA to evaluate local vasculature for flap reconstruction. Overall, 40% (4/10) of CTA findings were normal, whereas 60% (6/10) revealed traumatic vascular injuries. Pertinent nonvascular findings included soft tissue defects (60%, 6/10), fractures (40%, 4/10), and contracture deformities (20%, 2/10). In all cases, procedures were completed without complications, and intraoperative findings confirmed those from CTA. At a mean follow-up of 28 months, all injuries have healed without complications. CTA is a reliable noninvasive modality to evaluate pediatric patients with suspected traumatic extremity vascular injury and to plan treatment strategies for both vascular repair and extremity reconstruction.
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Abstract
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.
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Abstract
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.
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Raska GM, Cordova SW, Lema R, Goldwasser MS. Management of Penetrating Trauma to the Soft Palate: A Case Report. J Oral Maxillofac Surg 2007; 65:1279-85. [PMID: 17577489 DOI: 10.1016/j.joms.2006.10.056] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2006] [Revised: 07/26/2006] [Accepted: 10/26/2006] [Indexed: 10/23/2022]
Affiliation(s)
- Gary M Raska
- Oral and Maxillofacial Surgery, Carle Foundation Hospital, Urbana, IL 61801, USA.
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Chauhan N, Guillemaud J, El-Hakim H. Two patterns of impalement injury to the oral cavity: Report of four cases and review of literature. Int J Pediatr Otorhinolaryngol 2006; 70:1479-83. [PMID: 16530851 DOI: 10.1016/j.ijporl.2006.02.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2005] [Accepted: 02/02/2006] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Nitin Chauhan
- The Department of Pediatrics, The Stollery Children's Hospital, Edmonton, Canada
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