Penetrating trauma of the oropharynx in children

Thrombosis secondary to penetration of internal carotid artery due to soft palate impalement injury: A case report of hemiplegic syndrome and literature review

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.

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.

Internal carotid artery position to characterize risk for vessel injury in pediatric intraoral trauma

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.

Transoral penetrating upper cervical injury: a case report

Transoral penetrating foreign body injury of the neck involving the cervical spine is a rare condition. We present an injury caused by transoral penetration of a broken piece of a wooden plank into the neck with injury to the upper cervical spine in a 31-year-old male patient. The foreign body was removed transorally with the patient making a full recovery under close observation and was discharged and followed up with no complications. This paper highlights the types of neck injuries, the key points to be considered in zone III neck injury in light of existing literature and a discussion on the management of these patients.

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.

Multiple cranial nerve injuries and neck abscesses caused by a transorally penetrating organic stick

Foreign bodies cause a remarkable number of otolaryngological emergency visits and occasionally result in life-threatening conditions and later-emerging complications. Patient recovery depends on the detection and proper extraction of all foreign materials. Despite various obtainable diagnostic tools, adequate anamnesis forms the basis of clinical reasoning and should direct later examinations and radiological imaging. This case report describes a challenging patient with a unique trauma mechanism: many pieces of a fragmented organic foreign body emerged within 1 year of the initial injury, leading to repeated operations, a long period in an intensive care unit and a long-term swallowing and speech dysfunction.

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.

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.

The tin whistle: a rare and serious cause of penetrating oropharyngeal trauma in children

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.

Post-traumatic pseudoaneurysm of internal carotid artery: a cause of intractable epistaxis

In this case report, the authors are presenting a case of a 35-year-old lady who presented to our clinic with recurrent episodes of massive epistaxis and loss of right eye vision for last 6 months following road traffic accident. There was no other significant medical and surgical history. Bleeding episodes were sometimes very severe with loss up to 400-500 cc and would stop spontaneously. She was given multiple blood transfusions after these episodes. A complete otorhinolaryngological examination including rigid endoscopy and coagulation investigation did not reveal any abnormality. CT with contrast of paranasal region showed blood within the right sphenoid sinus with linear fracture of the lateral wall with post-traumatic cavernous pseudoaneurysm of internal carotid artery localised to right sphenoid sinus. That was managed successfully by embolisation using a detachable balloon and a coil. She was followed up in the clinic at 6 weeks and 6 months interval with no symptoms.

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.

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.

Carotid dissection and stroke after tonsillectomy and adenoidectomy

Carotid dissection and cerebral infarction are extremely rare complications of tonsillectomy and adenoidectomy. We describe a 12-year-old boy who presented with a right internal carotid dissection and right middle cerebral artery infarction, associated with tonsillectomy and adenoidectomy. We discuss the risk factors that may predispose patients to these complications.

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.

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.

Intractable epistaxis related to cavernous carotid artery pseudoaneurysm: treatment of a case with covered stent

Although epistaxis is commonly seen in otorhinolaryngologic practice, it may rarely become a severe and life-threatening problem. Pseudoaneurysm of internal carotid artery (PICA) is an uncommon, but potentially fatal cause of epistaxis. Optimal management demands rapid recognition and treatment to give the best functional outcome. High suspicion and carotid arteriography is essential for diagnosis. In this article, a 28-year-old male case with post-traumatic cavernous PICA localized to sphenoid sinus and presenting with intractable epistaxis was reported. The patient was managed by endovascular covered stent application successfully. In differential diagnosis of patients with intractable epistaxis and isolated sphenoid sinus lesions, PICA should be considered. Early treatment with covered stent of aneurysm can be a life saving therapeutic approach.

Evaluation of Pediatric Lateral Oropharyngeal Trauma

OBJECTIVE: We reviewed the mechanism of injury, presentation, and evaluation of children with trauma to the lateral oropharynx.

STUDY DESIGN AND SETTING: We conducted a retrospective review of patients in an urban pediatric emergency department with trauma to the lateral oropharynx over a 5-year period.

RESULTS: Forty-eight patients were identified with documented injuries of the lateral oropharynx placing the internal carotid artery at risk of injury. The average age was 42 months, with a male-to-female ratio of 1.5:1. Seventy-seven percent of patients had a documented neurologic examination. Examinations were normal in all cases. Computed tomography scans were obtained in 14 patients, identifying 3 patients with carotid abnormalities. Angiography subsequently diagnosed intimal injuries in 2 of the 3 patients. There were no known cases of neurovascular compromise.

CONCLUSION: Contrast-enhanced computed tomography may be an effective screening examination in this patient population, helping to determine which children should be admitted for angiography and observation.

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.

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.

Recurrent unilateral tonsillitis secondary to a penetrating foreign body in the tonsil

We report a case of an impacted foreign body in the tonsil presenting as recurrent unilateral tonsillitis. A completely embedded foreign body should be considered in cases of recurrent unilateral tonsillitis.

Penetrating oral foreign body presenting as an aural polyp

A case of a penetrating oral foreign body presenting with an aural polyp is described. The possibility of a penetrating oral injury should be considered whenever a child's fall is unwitnessed, as it is easily overlooked. An underlying foreign body should be considered in cases where an aural polyp fails to respond to standard therapy. MRI may be the best imaging technique to identify plastic foreign material.

Management of the carotid artery following penetrating injuries of the soft palate

Penetrating injuries of the soft palate are not uncommon in the pediatric population. The majority are minor, requiring only conservative treatment. Despite the close proximity of the carotid artery to lateral soft palate and tonsillar fossa, the incidence of carotid injury is low. When carotid injury does occur, it is usually secondary to blunt trauma to the carotid with a resultant thrombosis. A concomitant neurologic deterioration often follows occurring from 3 h to 3 days after the initial injury (Hengerer et al. (1984). Laryngoscope 94, 1571-1575). The potential neurologic sequelae of such an injury make these seemingly innocuous wounds a diagnostic and management dilemma for the clinician. We present an unusual case of an internal carotid artery pseudoaneurysm in a neurologically intact child following soft palate impalement. We review the diagnostic evaluation including angiography and magnetic resonance angiography, the surgical approach, and postoperative issues including anticoagulation. The literature is reviewed and a discussion regarding the approach to penetrating injuries of the soft palate is presented.

Penetrating injury to the oral cavity: a case report and review of the literature

Penetrating injury to the oral cavity, although rare, may cause serious morbidity and mortality in the pediatric population. Impalement injuries are known to cause delayed vascular injury to the internal carotid artery, leading to significant neurologic sequelae. We present an unusual case of impalement injury and make recommendations regarding the successful evaluation and management of such injuries.