Penetrating craniofacial injury in a pediatric patient

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.

Toppled television sets and head injuries in the pediatric population: a framework for prevention

Injuries to children caused by falling televisions have become more frequent during the last decade. These injuries can be severe and even fatal and are likely to become even more common in the future as TVs increase in size and become more affordable. To formulate guidelines for the prevention of these injuries, the authors systematically reviewed the literature on injuries related to toppling televisions. The authors searched MEDLINE, PubMed, Embase, Scopus, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Cochrane Library, and Google Scholar according to the Cochrane guidelines for all studies involving children 0-18 years of age who were injured by toppled TVs. Factors contributing to injury were categorized using Haddon's Matrix, and the public health approach was used as a framework for developing strategies to prevent these injuries. The vast majority (84%) of the injuries occurred in homes and more than three-fourths were unwitnessed by adult caregivers. The TVs were most commonly large and elevated off the ground. Dressers and other furniture not designed to support TVs were commonly involved in the TV-toppling incident. The case fatality rate varies widely, but almost all deaths reported (96%) were due to brain injuries. Toddlers between the ages of 1 and 3 years most frequently suffer injuries to the head and neck, and they are most likely to suffer severe injuries. Many of these injuries require brain imaging and neurosurgical intervention. Prevention of these injuries will require changes in TV design and legislation as well as increases in public education and awareness. Television-toppling injuries can be easily prevented; however, the rates of injury do not reflect a sufficient level of awareness, nor do they reflect an acceptable effort from an injury prevention perspective.

Management of an unusual craniofacial impalement injury by a metallic foreign body

Craniofacial penetrating injuries caused by foreign bodies other than bullets or glass from traffic crashes are quite rare. Hence, there is a lack of knowledge regarding systematic management strategies or analysis of complications for craniomaxillofacial surgeons. Between 2002 and 2010, 82 patients underwent surgery for penetrating craniofacial injuries in 2 craniomaxillofacial trauma centers. Among these patients, we included patients who had retained foreign metallic bodies. Data regarding age, sex, injury materials, entrance, injured structures, operative records, and complications were reviewed retrospectively for 8 patients. All of the patients were evaluated precisely in the emergency department without removal of retained materials, and a multidisciplinary team approach was performed for the removal of the foreign body under general anesthesia.In this study, 6 men and 2 women presented with penetrating injuries that retained metal objects. The mean age of the patients was 44.3 years. All of the patients were hemodynamically stable, and no active bleeding was found. However, all of the patients had postoperative complications. Three patients had damaged vascular structures, and 3 patients had injuries to facial nerve branches. Seven patients had posttraumatic stress disorder. Two patients underwent subsequent emergent procedures because of massive bleeding and cerebrospinal fluid leakage.Penetrating injuries in the head and neck regions are complicated. Although a multidisciplinary team approach was performed from initial management to outpatient management in patients with unusual impalement injuries, numerous postoperative complications still remained. Preoperative patient informed consent was important.

Craniofacial injuries from television tip-over

BACKGROUND

Craniofacial injuries caused by television (TV) sets falling on small children are becoming a frequent event seen in emergency departments. Injuries occur primarily to the head and neck regions and range from contusions to intracerebral hemorrhage, which at times can be fatal.

OBJECTIVES

Epidemiology and potential complications from TV tip-over injuries are presented.

CASE

Three cases of craniofacial injuries are described from blunt trauma incurred from TV tip-over events.

CONCLUSIONS

It is important to teach parents about the dangers of the new large slim TV sets and the occurrence of injuries when these are not secured properly or placed away from the reach of the child.

Chopstick injury penetrating the skull base: a case report

We describe an unusual case of a foreign body penetrating the skull base and lodging in the posterior fossa. A 38-year-old woman fell onto a chopstick while eating, causing it to impact into her mouth. The chopstick penetrated the oropharynx and the occipital bone via the jugular foramen to enter the posterior fossa intracranially, piercing the tentorium cerebelli and leaving a fractured tip in the occipital lobe. Three-dimensional reconstructive computed tomographic scans were obtained to view the trajectory and position of the chopstick. Reconstructed angiography revealed the proximity of the carotid artery and the jugular vessels to the foreign object. Safe access to the chopstick was via an occipital craniotomy to retrieve the distal portion and an ipsiplateral retrosigmoid craniectomy to remove the proximal end. Provision was made to gain proximal control of all major nearby vessels in the event of any hemorrhage. Trauma causing penetration of a foreign body into the posterior fossa of the skull is rare due to its surrounding thick bone. Appropriate preoperative planning, including 3-D computed tomographic images and angiograms, are integral in the surgical approach for the safe removal of such objects.

An unusual case of child head injury by coat hanger*

Traumatic brain injury is the leading cause of morbidity and mortality among children suspected of child abuse. Penetrating cranio-facial injuries are generally rare in the pediatric age group and are caused by both accidental and inflicted mechanisms. We report an unusual case of a 2-year-old female who was admitted to a pediatric emergency room with an industrial stainless steel coat hanger impaled in her skull. Pertinent clinical forensic medicine examination, coupled with home inspection and interviews by the local law enforcement, revealed a horrible episode of domestic violence.