Thrombosis of the internal carotid artery secondary to soft palate injury in children and childhood. Report of two cases

Ultrasound imaging for evaluation of impalement-related injuries to the oral cavity in pediatric patients: a case series study

BACK GROUND

An impalement-related injury to the oral cavity is common in pediatric patients at emergency department. A computed tomography evaluation is not always suitable in these cases. Herein, we aimed to present oral sonography findings from six pediatric patients presenting with impalement-related injury to the oral cavity.

CASE SERIES

All included patients were younger than 4 years and sustained injuries with a toothbrush, chopstick, water gun, and fork to the tonsils, submandibular gland area, uvula, and under the tongue.

CONCLUSION

Ultrasound imaging appeared useful in helping diagnose impalement-related injuries lateral to the midline.

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.

Internal Carotid Dissection as the Cause of Stroke in Childhood

Internal carotid artery (ICA) dissection is a cause of stroke, but it is often underdiagnosed in children. ICAs' risk factors and pathogenic mechanisms are poorly understood, and the treatment is still empirical. We report the case of a previously healthy 9-year-old girl who presented with involuntary hypertonic closure of the right hand associated with transient difficulty for both fine movements of the right arm and speech. She had a history of minor cervical trauma occurring 20 days prior to our observation without other associated risk factors. Magnetic resonance imaging and magnetic resonance angiography showed ischemic lesions due to the left ICA dissection. Treatment with both acetylsalicylic acid and levetiracetam allowed recanalization of the ICA associated with the resolution of clinical signs. Our clinical case suggests that the ICA dissection must be suspected early whenever a child manifests mild neurologic deficits after a cervical trauma, especially if they are associated with headache and/or cervical pain. Moreover, the management of ICA dissection must be improved.

Delayed pseudoaneurysm formation of the carotid artery following the oral cavity injury in a child: A case report

BACKGROUND

An impalement injury of the oral cavity is a common traumatic injury in children. In most cases, it is not accompanied by sequelae, but if foreign body residues are not found due to a minor injury, they may result in inflammatory responses and delayed vascular injuries in the surrounding tissues. Without early diagnosis and appropriate initial management, residual foreign bodies can cause serious complications and even mortality in some cases.

CASE SUMMARY

A 9-year-old boy suffered an intra-oral injury by a wooden chopstick, and the patient was discharged from the hospital after receiving conservative treatment for the injury. However, the patient was readmitted to the hospital due to intra-oral bleeding, and since neck hematoma and right internal carotid artery pseudoaneurysm formation were detected on computed tomography, emergency surgery was performed. A remnant fragment of a wooden chopstick was found during the operation, and a delayed rupture of the internal carotid artery caused by the foreign body was also found.

CONCLUSION

The failure of early detection and diagnosis of a residual foreign body may result in delayed vascular rupture.

Endovascular Treatment of Traumatic Transection of the Vertebral Artery Caused by Penetrating Injury to the Oropharynx in a Pediatric Patient

BACKGROUND

Pediatric isolated penetrating traumatic vertebral artery injuries require urgent multidisciplinary management as they may lead to potentially fatal posterior circulation ischemia.

CASE DESCRIPTION

We present a 19-month-old patient with an isolated penetrating vertebral artery injuries at the V2 segment of the right vertebral artery and report our strategy for her endovascular treatment which involved simultaneous coil embolization and foreign body removal.

CONCLUSION

Endovascular treatment can be considered first line treatment of oral penetrating injuries to the vertebral artery, where the penetrating object has an anterior to posterior trajectory.

Internal carotid artery dissection without intracranial infarct following a minor shoulder trauma: The second pediatric case and review of the literature

INTRODUCTION

Carotid artery dissections may occur in severe trauma such as motor vehicle accidents or may also develop due to minor trauma. We aimed to present a case with internal carotid artery dissection that referred to the pediatric neurology department due to speech impairment after minor shoulder trauma.

CASE

A previously healthy 10-year-old male patient was admitted to the pediatric emergency clinic due to headache, vomiting and speech impairment. In his story, we learned that he had bumped shoulder to shoulder with his friend about 6 h ago. He did not fall or hit his head. On his admission he could not speak and had right central facial paralysis. There was no infarct or diffusion limitation in MRI but MR angiography showed thinning in left internal carotid artery calibration. Fat-suppressed, non-contrast T1-weighted MRI showed that the left carotid artery had ring-shaped pathological signal changes. Low-molecular-weight heparin therapy was initiated with the diagnosis of carotid artery dissection (CAD). No hemiparesis or hemiplejia occurred in the follow-up of the patient. Within a few days, his speech improved. At the end of the first month, facial paralysis completely recovered.

CONCLUSION

In carotid artery dissections, prodromal symptoms such as transient ischemic attack, like in our patient, are rarely present in children. For good long term outcomes, it is very important to suspect, diagnose and initiate appropriate treatment in a rapid manner in carotid artery dissection before severe neurological findings such as acute ischemic stroke develops.

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.

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.

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.

Traumatic thrombosis of internal carotid artery sustained by transfer of kinetic energy

A 31-year-old male patient with a fatal thrombosis of the internal carotid artery caused by gun shot injury was presented in this case report. The patient was referred to the hospital with a diffuse edema on his left cheek. On otolaryngologic examination, there was a bullet entrance hole at the left mandibular corpus. No exit hole could be found. The finding from his axial computed tomography of neck and paranasal sinuses was normal. On neurological examination, a dense right hemiparesis was observed. In his cerebral angiogram, left common carotid artery was totally obliterated. Diffuse ischemia was observed in the left cerebral hemisphere. Despite intensive interventions, the patient died 4 days after the accident. In the autopsy, a large thrombosis was obtained in the left common carotid artery. This case emphasizes a fatal kinetic energy effect in vascular structures. It is stressed that a gun shot injury could be fatal with its indirect kinetic energy effects at subacute phase.

Pediatric stroke: a review

Stroke is relatively rare in children, but can lead to significant morbidity and mortality. Understanding that children with strokes present differently than adults and often present with unique risk factors will optimize outcomes in children. Despite an increased incidence of pediatric stroke, there is often a delay in diagnosis, and cases may still remain under- or misdiagnosed. Clinical presentation will vary based on the child's age, and children will have risk factors for stroke that are less common than in adults. Management strategies in children are extrapolated primarily from adult studies, but with different considerations regarding short-term anticoagulation and guarded recommendations regarding thrombolytics. Although most recommendations for management are extrapolated from adult populations, they still remain useful, in conjunction with pediatric-specific considerations.

Pediatric traumatic carotid, vertebral and cerebral artery dissections: a review

Traumatic cerebral dissections are rare but potentially dangerous conditions that through improved diagnostics have recently gained increased interest. However, there is still a significant lack of knowledge on the natural history, as well as on the best treatment options. Most of the literature on this topic consists of case reports and retrospective studies with no prospective randomized controlled studies. In our review, we highlight the fact that there is no level 1 evidence for the natural history of cerebral dissections or for the best treatment. We present 26 case studies derived from 70 pediatric patients affected by dissections, occlusions, and pseudoaneurysms.

Perforation of and intubation through the palatoglossal fold

Perforation of pharyngeal soft tissues on intubation is rare. We present a case where the endotracheal tube punctured the palatoglossal fold before passing into the trachea. The patient was ventilated for eight days in intensive care before identification of the complication. It is difficult to estimate the frequency of pharyngeal perforation as it rarely occurs. There is however; an increased incidence in difficult intubations, emergency airway management, inexperienced operators and technique used.

Extracranial traumatic carotid artery dissections in children: a review of current diagnosis and treatment options

OBJECT

Currently, no diagnostic or treatment standards exist for extracranial carotid artery dissection (CAD) in children after trauma. The purpose of this study was to review and describe the characteristics, diagnosis, and treatment of this rather uncommon sequelae of pediatric trauma.

METHODS

A systematic review of the literature was performed to examine the pertinent studies of traumatic extracranial carotid artery (CA) injuries in children.

RESULTS

No randomized trials were identified; however, 19 case reports or small case series consisting of 34 pediatric patients were found in the literature. The diagnosis of CAD was made in 33 of 34 patients only after the onset of ischemic symptomatology. Twenty-four of 34 patients underwent cerebral angiography to confirm diagnosis; MR angiography affirmed the diagnosis in 6 of 34 patients. There was little published experience with CA ultrasonography or CT angiography for diagnosis. Thirty of 34 patients were treated with medical therapy or observation; 2 of 4 patients treated with observation alone died. There was little experience with open surgical treatment of CAD in the pediatric population, and there were no studies on the endovascular treatment of traumatic CAD in children. The literature does not support anticoagulation therapy over antiplatelet therapy.

CONCLUSIONS

As a result of this review of the literature, the authors propose the algorithms for the evaluation and treatment of traumatic extracranial CADs in children. These recommendations include utilizing MR angiography as a screening tool in cases in which the clinical suspicion of CAD is high, using conventional cerebral angiography to confirm the diagnosis, implementing antiplatelet therapy as initial medical management, and reserving endovascular stenting in cases of failed medical treatment.

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.

Penetrating injury to the pharynx by a toothbrush in a pediatric patient: a case report

Penetrating injury of the pharynx is rare, but it can cause serious sequelae in children. A 12-month-old boy was impaled with a toothbrush in the retropharyngeal space after falling from a baby-bed. The point of the toothbrush was embedded beside the carotid artery and was removed by endoscopic surgical technique. The patient was discharged without neurological complication or abscess formation. We present a rare case of a penetrating injury by a toothbrush and discuss such injuries.