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Boyraz M, Yüce S, Örmeci MT, Botan E. Thrombosis secondary to penetration of internal carotid artery due to soft palate impalement injury: A case report of hemiplegic syndrome and literature review. Int J Pediatr Otorhinolaryngol 2024; 176:111809. [PMID: 38096745 DOI: 10.1016/j.ijporl.2023.111809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 11/22/2023] [Accepted: 11/25/2023] [Indexed: 01/08/2024]
Abstract
Intraoral injuries are frequently encountered in emergency departments due to children's desire and curiosity to put objects in their mouths. However, forward falls with objects in children's mouths can cause impalement injuries to soft palate, retropharyngeal-peritonsillar, and retromolar tissues, leading to serious morbidity and even mortality. These transoral (soft palate, pharynx-tonsil, retromolar region) penetration injuries can especially result in damage to major vascular structures like the Internal Carotid Artery (ICA) due to their close proximity. Dissection, thrombosis, and subsequent stroke can occur in the delicate ICA as a result. In the presented case, a 3-year-old male child experienced internal carotid artery dissection following penetrating injury with a pen, as demonstrated by imaging studies. A literature review is provided along with the case of this child, who developed a reduction in middle cerebral artery (MCA) flow due to thrombosis in the ICA. The study encompasses all penetrating oropharyngeal traumas reported in individuals aged 0-18 years from 1936 to 2023. A search in PubMed and Google Scholar using keywords such as 'internal carotid artery injury,' 'penetrating trauma,' and 'children' yielded 78 case reports from a pool of 36,000 studies. The analysis excludes injuries in areas like tongue, cheek, gums, lips, and floor of the mouth, post-tonsillectomy injuries, and those from sudden braking vehicles. This review encompasses the evaluation, diagnosis, and treatment of penetrating injuries to the soft palate, pharyngeal wall, tonsil, and retromolar regions.
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Affiliation(s)
- Merve Boyraz
- TR Health Sciences University, Van Training and Research Hospital, Department of Pediatrics, Türkiye
| | - Servet Yüce
- Istanbul University, Istanbul Faculty of Medicine, Department of Public Health, Türkiye.
| | - Mehmet Tolgahan Örmeci
- TR Health Sciences University, Van Training and Research Hospital, Department of Radiology, Türkiye
| | - Edin Botan
- TR Health Sciences University, Van Training and Research Hospital, Pediatric Intensive Care Unit, Türkiye
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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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Pediatric Trauma. Emerg Med Clin North Am 2023; 41:205-222. [DOI: 10.1016/j.emc.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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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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Hankey PB, Cramer E, Tracy M, Zinkus TP, Brown JR. Internal carotid artery position to characterize risk for vessel injury in pediatric intraoral trauma. Int J Pediatr Otorhinolaryngol 2023; 164:111381. [PMID: 36434884 DOI: 10.1016/j.ijporl.2022.111381] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 10/30/2022] [Accepted: 11/11/2022] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The internal carotid artery (ICA) lies in close anatomic proximity to the oropharynx and is at risk for injury in the instance of intraoral trauma. The objectives of this study are to describe the position of the ICA relative to the oropharynx and identify patient risk factors related to its position. METHODS A total of 100 patients aged 12 months to 7 years 11 months who received computed tomography (CT) of the neck were randomly selected. The position of the ICA was determined by measuring its angular location relative to the center of the oropharynx (ICA angle) and the shortest distance from the oropharyngeal surface (OP-ICA distance). RESULTS Indication for imaging was controlled for in all reported data. Patient age was related to ICA angles on both the left (F = 8.06; P = 0.01; η2 = 0.08, 95% CI: 0.01-0.19) and right (F = 18.62; P < 0.001; η2 = 0.17, 95% CI: 0.05-0.29). Patient weight also was related to ICA angles on both the left (F = 7.08; P = 0.01; η2 = 0.07, 95% CI: 0.01-0.18) and right (F = 11.86; P < 0.001; η2 = 0.11, 95% CI: 0.02-0.24). Patient age was related to the left OP-ICA distance (F = 7.36; P = 0.01; η2 = 0.07, 95% CI: 0.01-0.19), as was patient weight (F = 4.82; P = 0.03; η2 = 0.05, 95% CI: 0.00-0.15). Across all measurements, no significant relationship was identified between ICA position and other patient variables, including sex and race/ethnicity. CONCLUSION The ICA of younger patients and those with lower body weight may be located more medially within the neck and closer to the oropharyngeal surface. This vessel position may place these children at greater anatomic susceptibility for ICA injury in the event of intraoral trauma.
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Affiliation(s)
- Paul Bryan Hankey
- Kansas City University College of Osteopathic Medicine, Kansas City, MO, USA; Children's Mercy Hospital and Clinics, Department of Otolaryngology, Kansas City, MO, USA
| | - Emily Cramer
- Children's Mercy Hospital and Clinics, Department of Otolaryngology, Kansas City, MO, USA
| | - Meghan Tracy
- Children's Mercy Hospital and Clinics, Department of Otolaryngology, Kansas City, MO, USA
| | - Timothy P Zinkus
- Children's Mercy Hospital and Clinics, Department of Radiology, Kansas City, MO, USA
| | - Jason R Brown
- Children's Mercy Hospital and Clinics, Department of Otolaryngology, Kansas City, MO, USA; University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA.
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Lodhia J, Chipongo H, Sadiq A, Khelef K, Bosco K, Dekker M. An Unusual Cause of Cerebral Infarction in a Tanzanian School Child. Child Neurol Open 2022; 9:2329048X221139411. [PMID: 36407557 PMCID: PMC9666708 DOI: 10.1177/2329048x221139411] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 10/09/2022] [Accepted: 10/27/2022] [Indexed: 02/15/2024] Open
Abstract
Pediatric stroke is uncommon. A traumatic cause of pediatric ischemic stroke is even rarer. Ischemic stroke due to intraluminal thrombus can be acutely treated with thrombolysis but various factors in sub-Saharan Africa make this unfeasible. We present a case of an eight-year-old Tanzanian boy who sustained penetrating trauma to his palate developing an ischemic stroke of his right middle cerebral artery territory.
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Affiliation(s)
- Jay Lodhia
- Department of General Surgery, Kilimanjaro Christian Medical Centre, P.O Box 3010, Moshi, Tanzania
- Faculty of Medicine, Kilimanjaro Christian Medical University College, P. O Box 2240, Moshi, Tanzania
| | - Hilary Chipongo
- Department of General Surgery, Kilimanjaro Christian Medical Centre, P.O Box 3010, Moshi, Tanzania
| | - Adnan Sadiq
- Faculty of Medicine, Kilimanjaro Christian Medical University College, P. O Box 2240, Moshi, Tanzania
- Department of Radiology, Kilimanjaro Christian Medical Centre, P.O Box 3010, Moshi, Tanzania
| | - Khadija Khelef
- Department of Internal Medicine, Kilimanjaro Christian Medical Centre, P.O Box 3010, Moshi, Tanzania
| | - Kenan Bosco
- Department of General Surgery, Kilimanjaro Christian Medical Centre, P.O Box 3010, Moshi, Tanzania
| | - Marieke Dekker
- Faculty of Medicine, Kilimanjaro Christian Medical University College, P. O Box 2240, Moshi, Tanzania
- Department of Internal Medicine, Kilimanjaro Christian Medical Centre, P.O Box 3010, Moshi, Tanzania
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Jardeleza C, North H, Taylor P, Lord D, Cheng A. A chopstick snapped in two: A serious pediatric transoral impalement injury requiring external approach (open neck) operative intervention. OTOLARYNGOLOGY CASE REPORTS 2021. [DOI: 10.1016/j.xocr.2021.100350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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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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