The toothbrush: a rare but potentially life-threatening cause of penetrating oropharyngeal trauma in children

Toothbrushing-induced vestibular ulcerations with severe gingival defects

BACKGROUND

Daily toothbrushing is a routine approach for helping to keep the oral cavity healthy. However, using a toothbrush as an ordinary oral hygiene habit can also lead to adverse events.

CASE PRESENTATION

A 75-year-old man was referred by a periodontist for vestibular ulcerations with gingival defects. The patient reported no significant medical or social history, which might be associated with his symptoms. On examination, wide labio-buccal gingival defects, white attached gingiva and linear vestibular ulcerations were observed. With the help of the periodontist, a diagnosis of inappropriate toothbrushing-induced traumatic ulcerations was reasoned via an approach of aetiological elimination. The patient was put on a trial course of topical dexamethasone powder with lincomycin. The resolution of vestibular ulcerations was apparent after two weeks. He reported no similar oral ulcerations during the following nine years.

CONCLUSION

To our knowledge, this is the first case reported in the literature of vestibular ulcerations with severe gingival defects caused by inappropriate toothbrushing. The establishment of a correct diagnosis needs a close collaboration between periodontists and oral medicine specialists. Instruction on correct toothbrushing, especially for older people can be beneficial.

Transoral traumatic perforation of the pyriform sinus by a marker pen: report of an infant case

BACKGROUND

Perforation of the pyriform sinus, included in hypopharyngeal injury, is a rare condition typically caused by iatrogenic factors. We present a case of an infant who developed deep cervical and mediastinal abscesses due to a traumatic pyriform sinus perforation caused by accidentally falling with a marker pen in the mouth.

CASE PRESENTATION

An 11-month-old healthy male infant fell on a trampoline with a marker pen in his mouth. The patient developed swelling in the neck 3 h after the incident and was taken to a regional general hospital. Although a laryngoscopy showed no perforation in the oral cavity or posterior pharynx, a computed tomography (CT) scan revealed significant emphysema extending from the cervix to the mediastinum. The patient was transferred to our tertiary hospital and admitted to the intensive care unit, where he was mechanically ventilated, and antibiotic therapy was initiated. On day 3 of admission, a CT scan revealed deep abscesses in the cervical and upper posterior mediastinum with pneumomediastinum. Although his respiratory status stabilized and he was temporarily weaned, the fever recurred. Pharyngoesopagography revealed significant leakage of contrast from the left pyriform sinus to the mediastinum. Consequently, surgical drainage of the abscess was performed on day 10. Two low-pressure continuous suction drains were placed, one in the posterior mediastinum and the other close to the pyriform sinus. Pharyngoesophagography on postoperative day (POD) 7 demonstrated decreased contrast leakage into the posterior mediastinum. The patient was initiated on enteral nutrition through a nasogastric tube. The patient was discharged on POD 31 after the suction drains were replaced with open Penrose drains, and enteral nutrition via nasogastric tube was continued at home. The Penrose drains were removed on POD 54, and salivary leakage ceased on POD 111.

CONCLUSIONS

Although injuries to the oral cavity and posterior pharynx are more easily recognized, the existence of injury in the pyriform sinus can be challenging to evaluate. However, prompt and appropriate management, including intubation, antibiotic therapy, surgical drainage, and nutritional support, is critical in preventing life-threatening complications.

An Adult Case of Pharyngeal Injury Caused by Toothbrush

Most toothbrush-induced oral injuries occur in children and are relatively shallow, involving the oral mucous membranes and musculature, but rarely deeper layers. Here, the management of an adult case of pharyngeal injury caused by a toothbrush is discussed. A man fell while brushing his teeth, and his toothbrush stuck in his throat. Contrast-enhanced computed tomography showed a toothbrush stuck in the left parapharyngeal space, reaching the subcutaneous tissue of the posterior neck. The toothbrush was surgically removed because blind removal could damage major cervical arterioles and nerves. In intraoral injuries caused by deep penetrating toothbrushes, there is a risk that the injury extends to the major arterioles and nerves of the neck. The need for imaging studies, methods of removal, and possible complications should all be considered before taking an appropriate removal action.

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.

Delayed pneumomediastinum following oropharyngeal injury: A report of two pediatric cases

Few reports discuss the severity or course of progression of mediastinal emphysema following oropharyngeal trauma. We report two cases of mediastinal emphysema. The first case was of a 3-year-old girl who fell with a toothbrush in her mouth and the second was of a 10-month boy who tripped with a toy stick in his mouth. These patients were stable on initial examination. However, the patient in case one developed a fever and dysphagia 9 h after injury, and the patient in case two had swelled neck and dyspnea requiring intubation 20 h after injury. Both patients were diagnosed with pneumomediastinum via computed tomography. Therefore, it should be noted that although children with oral trauma appear stable immediately after injury, they may develop delayed mediastinal emphysema.

Accidental or intentional ingestion of toothbrushes: experience with 8 adult patients

PURPOSE

Ingestion of a toothbrush is an unusual event but may occur either accident or by intent. Radiological examinations play a crucial role in determining the exact location of the object within the gastrointestinal tract and in planning for its removal by endoscopic or surgical intervention.

METHODS

Medical and radiological records of 8 patients who had swallowed the broken heads or entire toothbrush were retrospectively reviewed. This series included 4 men and 4 women, ranging in age from 21 to 57 years (mean: 34 years).

RESULTS

Radiographs and computed tomography of the abdomen demonstrated the ingested toothbrushes within the stomach in 3, lodged in the duodenum in 1, and entrapped in various parts of the colon in 4 patients. They were removed by laparotomy in 3, laparoscopy in 2, colonoscopy in 2, and upper gastrointestinal endoscopy in 1 patient. There were no perforations or associated complications, and all patients had uneventful recoveries.

CONCLUSIONS

Ingested toothbrushes can be easily identified on radiological studies because of the radiopaque wires holding the nylon bristles. The plastic parts of it, however, are only visible on computed tomography. All cases would require endoscopic or surgical removal of the retained toothbrushes because spontaneous passage per rectum does not occur.

Impacted Pen Cap in Pharynx Leading to Pharyngojugular and Pharyngocutaneous Fistula in an Infant

Foreign body-related injuries to aerodigestive tract and large neck vessels are rare but can be catastrophic if not identified and treated in time. We report an infant with impacted foreign body (pen cap) in the pharynx which went unnoticed until it led to the formation of a fistula with the internal jugular vein (IJV) and massive hemorrhage. His course was complicated by ventilator-associated pneumonia, air leaks, shock, acute kidney injury, prolonged mechanical ventilation, and pharyngocutaneous fistula. The surgical removal of foreign body, ligation of IJV, closure of pharyngeal defect, and supportive treatment in pediatric intensive care unit led to a favorable outcome. This is the first case of pharyngojugular and pharyngocutaneous fistula following an impacted foreign body in the pharynx.

A transnasal foreign body penetrating the spinal cord from the nasopharynx

OBJECTIVE AND IMPORTANCE

This is the first article regarding a transnasal Foreign bodies (FB) penetrating the spinal cord. We tried to remove it safely with a bilateral approach by performing a nasal endoscopy and partial laminectomy.

CLINICAL PRESENTATION

During logging work, a tree hit the occipital region of a 47-year-old man, producing unconsciousness with left paresis. Although he did not remember his injuries due to traumatic amnesia, a computed tomography (CT) scan showed a metal rod lodged from the left side wall of the nasopharynx to the spinal column at the cranial-cervical transition.

INTERVENTION

A C1 laminectomy, partial occipital bone resection, and endoscopic intranasal extirpation were done jointly by an otolaryngologist and neurosurgeon under general anesthesia to safely remove the FB. All procedures were performed in the right lateral decubitus position so we could approach both the nasopharynx and occipital sides. The otolaryngologist withdrew the FB from the nasal cavity using an endoscope while the neurosurgeon monitored the occipital bone side. The FB was safely removed.

CONCLUSION

The site of penetration at the nasopharynx contracted gradually to a scar with no cerebrospinal fluid (CSF) leak. The patient was finally discharged 39 days after surgery with no motor/sensory paralysis.

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.

Development of Oropharyngeal Scope Type II with Integrated Tongue Depressor for Examination of the Oropharynx: NTOP2016 Study

The oropharynx is examined by focusing an electric light, penlight, or forehead mirror on a desired visual field using a tongue depressor. However, it is extremely difficult to obtain objective recorded evidence for display with these methods, and the tools for examination have remained virtually unchanged for the past century. Treatment of the pharynx/oral cavity is exceedingly difficult, particularly in elderly patients and children. Therefore, there is an increasing need to develop a method for displaying the visual field during oropharyngeal examinations which is acceptable to patients, which can easily be applied at all medical institutions, which can be displayed to third parties, and which can be used by doctors for recording data and determining treatment. We earlier developed a dedicated device for this purpose (Improved Type I) and have now made further improvements. This study aims to evaluate the utility of the improved type II oropharyngeal endoscope as a tool for objective examination.

An oral pharyngeal scope for objective oropharyngeal examination: a new device for oropharyngeal study

OBJECTIVE

There has been little progress in examination of the oropharynx with a light source such as electric light, a penlight, or a forehead mirror over the past 100 years. It is therefore necessary to develop methods to display and record oropharyngeal observations.

METHOD

Since the aim of this study was to assess the safeness to use from the perspective of physicians, medical staffs, patients, and patients' families and usefulness of pharyngeal scope, the number of devices was limited, the number of patients was not set based on hypothetical statistical tests.

RESULTS

A total of 150 volunteers were enrolled in this study. Among them, 96 underwent examination alone and the remaining 28 underwent treatment procedures. The study was done without any complications in all 150 cases. Most (91.3%) physicians hoped to continue using the new device if available. When comparing the use of the device for observation alone and for treatment procedures, there was no significant difference for evaluation items (p > .05) except convenience factor which received a significantly different (p = .0154) evaluation from physicians for observation alone and for treatment procedures. A positive evaluation was received about examination, recording/display and explanation from the patients and patients' families.

CONCLUSIONS

Our new device received positive evaluations by who underwent examination of the oral cavity and pharynx, recording of the results, and treatment procedures.

Anaesthetic and surgical management of airway penetrating injuries in children in resource-poor setting: Case reports

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Impacted penetrating injuries in airways of children create management challenges.

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Unavailability of ideal working tools worsens situations in resource-poor settings.

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Practitioners should think outside box and improvise what is available to save lives.

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Parents and caregivers should be responsive and keep sharp objects away from children.

Introduction

Impacted penetrating foreign body (FB) in the airway especially the postnasal space presents with management challenges. The challenges are worsened by lack of modern equipment in resource-poor settings. Two suchlike cases were managed in this report.

Presentation of cases

Case 1: A 4-year-old girl who fell on a metal rod in her mouth while playing alone. Examination revealed an agitated child in open mouth posture, with a silvery straight metallic object impacted on the hard palate and projecting from the mouth. X-ray of the post nasal space showed a radiopaque object through the hard palate impinging on the skull base.

Case 2: A 5-year-old male presented with swollen neck and difficulty in breathing following a fall on a sharp pencil while at play in school. The object which pierced through the neck was immediately removed by an attendant. Examination revealed a child in obvious respiratory distress with swollen neck, face and eyes with a slit measuring 2 cm over the crico-thyroid membrane (subcutaneous emphysema).

Discussion

With no available fibre-optic laryngoscope, classical Macintosh laryngoscopy was infeasible. With refusal of tracheostomy, the authors employed three-man intubation technique to successfully secure the airway for excision of the FB in first patient. The second was induced with IV ketamine since he could not tolerate the supine position and facemask. Due to falling oxygen saturation, an orotracheal intubation was done before a successful mid-level emergency tracheostomy was sited.

Conclusion

Penetrating airway injuries in children pose serious management challenges. Careful anticipation and quick intervention are helpful.

Oral injuries in children presenting to a Japanese pediatric emergency room

BACKGROUND

Oral injuries are common among children, but studies on oral injury according to the presence of foreign objects in the mouth are limited. The aim of this study was to compare injury patterns and their effects in children presenting to a Japanese pediatric emergency room (ER) with and without foreign objects in the mouth.

METHODS

Children who were brought to the ER at Tokyo Metropolitan Children's Medical Center with oral injuries between 1 January 2011 and 31 December 2012, were included. Information regarding mechanism of injury, object related to injury, required procedure, and disposition (i.e. placement after ER evaluation: hospitalization or discharge) was collected. Injured subjects with and without foreign objects in the mouth were compared.

RESULTS

Three hundred and nineteen subjects were included in analysis. Median age was 26 months. Labial mucosa, tongue, buccal mucosa, and teeth were major locations of injury. Tumble (i.e. fall from standing) was the leading mechanism of injury (50%). Seventy-one subjects (22%) were holding foreign objects in the mouth when injury occurred. A toothbrush was the most common object (31%). Subjects with foreign objects in the mouth were more likely to injure the posterior parts of the mouth, and to require imaging (P = 0.04) and hospital admission (P < 0.001). This was also the case for children with injury due to tumble.

CONCLUSIONS

Tumble (i.e. fall from standing) was the most common mechanism of injury. Furthermore, requirement for medical resources increased if children had foreign objects in their mouth. Preventive measures should focus on educating parents about the dangers associated with children moving around while holding objects in the mouth.

Is it safe to use a toothbrush?

AIM

To systemically collect and summarize the literature on case reports concerning adverse events associated with the oral use of a toothbrush.

MATERIALS AND METHODS

Two electronic databases were searched for articles published up to October 2013 to identify appropriate studies using focused search terms and 'case reports' as a filter. Results. A comprehensive search identified 419 unique titles and abstracts. Ninety-four studies met the eligibility criteria. In total, 118 subjects (age range = 1-60 years) presented adverse events related to the oral use of a toothbrush. Events could be summarized in five categories, of which ingestion was the most reported problem among the individuals (50 cases). This was followed by impaction of a toothbrush (27 cases). Reports more frequently involved females and children were more likely to have injuries compared to males and adults. Most of the cases that presented with adverse events of the oral use of a toothbrush were referred for treatment to a physician.

CONCLUSIONS

The combined evidence related to serious adverse events as presented in case reports showed that the oral use of a toothbrush can be associated with ingestion, impaction, instant trauma, gingival traumatic injury and seizures. Given the incidence of reporting, important recommendations are that a toothbrush should not be used to induce vomiting, nor should people walk or run with this device in their mouths, especially children.

Endotracheal intubation of a paediatric patient with an umbrella wire embedded in the palate to the posterior wall of the nasopharynx using a GlideScope video laryngoscope

The penetration of foreign bodies into the oropharynx can be life-threatening. Airway management in patients who have a foreign body penetrated into their oropharynx is a challenging problem for the anaesthetist. In this case report, we aimed to share our experience of endotracheal intubation performed with GlideScope video laryngoscopy in a 3-year-old, 15 kg patient. The patient underwent general anaesthesia to facilitate the removal of an umbrella wire that had become embedded in her soft palate.

Novel diagnostic device for oral and pharyngeal examinations of children: folding-scope for the oral and pharyngeal cavities

Although children may dislike and/or resist oral and pharyngeal examination with a tongue depressor, they enjoy lollipops on sticks, eating with spoons, forks, and chopsticks, and brushing their teeth. Many reports have noted this apparent contradiction, since paediatric patients are often treated after toothbrushes or chopsticks penetrate the pharyngeal wall. We therefore developed a novel device to observe the inside of the mouth without using a flashlight, tongue depressor or head mirror. We previously developed the AWS for tracheal intubation through the mouth for anaesthesia and emergency situations, along with a new device to observe the inside of the oral cavity simultaneously. We have developed a new attachment to the AWS for observations inside the oral cavity and pharynx. Our newly developed oral and pharyngeal examination system is a useful tool for diagnostic examinations and may also enable treatment without causing discomfort or distress to patients and their families.

Novel diagnostic device for oral and pharyngeal examinations of children: folding-scope for the oral and pharyngeal cavities

Although children may dislike and/or resist oral and pharyngeal examination with a tongue depressor, they enjoy lollipops on sticks, eating with spoons, forks, and chopsticks, and brushing their teeth. Many reports have noted this apparent contradiction, since paediatric patients are often treated after toothbrushes or chopsticks penetrate the pharyngeal wall. We therefore developed a novel device to observe the inside of the mouth without using a flashlight, tongue depressor or head mirror. We previously developed the AWS for tracheal intubation through the mouth for anaesthesia and emergency situations, along with a new device to observe the inside of the oral cavity simultaneously. We have developed a new attachment to the AWS for observations inside the oral cavity and pharynx. Our newly developed oral and pharyngeal examination system is a useful tool for diagnostic examinations and may also enable treatment without causing discomfort or distress to patients and their families.