Journal of Emergencies, Trauma, and Shock

CASE SERIES
Year
: 2015  |  Volume : 8  |  Issue : 2  |  Page : 115--118

Accidental oropharyngeal impalement injury in children: A report of two cases


Hayaki Uchino1, Akira Kuriyama2, Kenji Kimura3, Tetsunori Ikegami1, Toshio Fukuoka2,  
1 Department of Emergency Medicine, Kurashiki Central Hospital, Okayama, Japan
2 Department of General Medicine, Kurashiki Central Hospital, Okayama, Japan
3 Department of Medical Research and Education, Kurashiki Central Hospital, Okayama, Japan

Correspondence Address:
Dr. Akira Kuriyama
Department of General Medicine, Kurashiki Central Hospital, Okayama
Japan

Abstract

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.



How to cite this article:
Uchino H, Kuriyama A, Kimura K, Ikegami T, Fukuoka T. Accidental oropharyngeal impalement injury in children: A report of two cases.J Emerg Trauma Shock 2015;8:115-118


How to cite this URL:
Uchino H, Kuriyama A, Kimura K, Ikegami T, Fukuoka T. Accidental oropharyngeal impalement injury in children: A report of two cases. J Emerg Trauma Shock [serial online] 2015 [cited 2019 Aug 17 ];8:115-118
Available from: http://www.onlinejets.org/text.asp?2015/8/2/115/145403


Full Text

 Introduction



Impalement injuries of the face and neck, including the mouth, are common in the pediatric population. Children frequently run around with objects in their mouths or hands and tend to fall easily. A review of the literature revealed that impalement injuries most commonly affect children aged 6 years or younger. [1] Most cases can be managed in outpatient settings without further complications. However, a small number of injuries can result in severe complications, some of which may be life-threatening. Retropharyngeal and mediastinal abscesses, mediastinitis, widespread emphysema, internal carotid artery thrombosis, and airway obstruction have been reported. [2],[3] It is essential for physicians to be aware of these potentially lethal complications in the acute and delayed phases and to properly manage them. We recently experienced two consecutive cases of accidental impalement injuries; one was through the oral cavity and the other was to the neck. We report these cases and review the clinical aspects and management of these types of injuries.

 Case Reports



Case 1

A 20-month-old girl accidentally fell from the table while holding a toothbrush in her mouth. Her mother immediately removed the toothbrush and found minor intraoral bleeding; she was brought to our emergency department (ED). On admission, 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, and bleeding had already stopped by the time she arrived at the ED. Ecchymosis was noted close to the mastoid under the earlobe, which suggested penetration of the toothbrush all the way from the oral cavity.

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. No evidence of extravasation and intimal injury of the carotid artery were seen. Surgical emphysema was extended from the pharynx to the mediastinum [Figure 1], which indicated continuation of the wound through the mediastinum. This complication could potentially lead to mediastinitis or mediastinal abscess.{Figure 1}

The child was admitted for close observation, and intravenous antibiotic therapy with ampicillin sulbactam was started. Five days after hospitalization, she developed a fever and a localized abscess with cellulitis appeared on the posterior neck. The abscess required incision and drainage. She recovered uneventfully thereafter, and was discharged 15 days after the injury without complications. Nine days subsequent to discharge, her posterior neck incision had healed well, as had the intraoral site of penetration.

Case 2

A 3-year-old girl accidentally fell from a chair while playing with her brother; she had been holding a pencil in her hand. She was found lying on the floor with the pencil sticking out from just below her right ear. She removed the pencil immediately by herself and subsequent oozing stopped spontaneously. Her mother reported that the pencil had been fully intact upon removal, and thus it was presumed that it had been completely removed from her neck.

On admission, she was alert and crying while seen by the physician. Physical examination revealed a 5 mm laceration accompanied by a small hematoma in front of her right ear lobe [Figure 2]. No other injuries were found. However, her facial movement was asymmetric while she was crying, with no movement of the corner of the mouth and brow on the right side [Figure 3]. In addition, she could not close her right eye tightly. Those findings suggested a right facial nerve injury, which could be either central or peripheral. To rule out intracranial pathology, a CECT was performed. No evidence of intracranial injury or cranial bone fracture was found. CT revealed swelling of the right parotid gland with heterogeneous enhancement and free air just in front of the right carotid sheath [Figure 4], which suggested that the object penetrated through the parotid gland to that depth. No extravasation was noted.{Figure 2}{Figure 3}{Figure 4}

A clinical diagnosis of peripheral facial nerve injury was made. It was thought that the facial nerve was damaged just outside of the stylomastoid foramen due to her clinical manifestations. Conservative management was chosen because impalement injuries have the aspect of blunt injuries, and we did not believe that the facial nerve was transected. In addition, surgical intervention would have required a large incision to her face, which may have been associated with cosmetic problems later. She was admitted for observation and intravenous antibiotics. She had an uneventful course. But her facial nerve paralysis did not recover, and she was discharged 4 days after her injury. She is still being followed in an outpatient clinic, and gradual neurologic improvement has been observed at 3 months after discharge.

 Discussion



Impalement injuries are relatively common in young children, and boys are two to three times more likely to experience these type of injuries than girls. [4] The most frequent mechanism of injury is a fall while holding an object in the mouth or hands. The most common objects associated with these injuries include toothbrushes, toys, writing instruments, sticks, and in Asia, chopsticks. [2],[4] Although most injuries are unintentional, an innocuous wound might be deeper than anticipated. Physicians need to manage these injuries carefully, as some injuries may have life-threatening complications.

Management of impalement injuries should begin with an assessment of life-threatening complications such as airway obstruction and hemorrhage. Though rare, subsequent complications, including carotid artery thrombosis, pneumomediastinum, and mediastinal abscess, should be managed in a timely fashion.

Due to their close proximity to key structures such as the skull base, injuries to other areas, including the cervical vessels (carotid artery, vertebral artery, and jugular vein), the trachea, the esophagus, the nerves, and the spinal vertebrae and cord, should be investigated and managed properly. Our second case had right facial nerve injury that can be serious for a small girl for cosmetic reasons. Superficial lacerations typically heal spontaneously and surgical intervention can generally be avoided.

Infectious complications secondary to such injuries do occur. It is reported that 4-8% of intraoral wounds develop complications such as those seen in our first case. [5],[6] In addition, despite the lack of any guidelines, prophylactic antibiotics are administered in 87-92% of cases. [7] Especially in cases that involve penetration through the floor of the mouth, we feel that 24 h of observation in the hospital accompanied by antibiotic prophylaxis with adequate oral flora coverage are advocated, regardless of admission status.

Neurologic sequelae secondary to carotid artery injuries are rare, but have been documented since 1966. [8] The problem is that a lack of consistency exists in the decision-making process with regard to imaging, surgical, and medical therapy, and hospital admission. For instance, recommended screening radiographic tests range from none to CECT. [7],[9],[10],[11] A recent review by Brietzke and Jones advocates the use of CT/CT angiography (CTA) as first-line measures in the evaluation of oropharyngeal trauma. [12] However, it is controversial whether a CT/CTA should be used for extremely low-risk patients, due to potential complications associated with contrast material, as well as the cost of these examinations. Previous studies with anticoagulants have shown improvement of peripheral flow in infarcted areas, indicating some potential benefits. [13] The Eastern Association for the Surgery of Trauma (EAST) has published a guideline for the practice management of the blunt cerebrovascular injury. [14] This guideline proposes treatment according to the grade suggested by Biffl et al. [15] The grading scheme defines Grade I, as intimal irregularity with <25% narrowing and Grade II, as dissection or intramural hematoma with >25% narrowing. The EAST guideline proposed a recommendation (Level II) on the treatment option for Grade I and II injury as follows; "barring contraindications, grade I and II injuries should be treated with antithrombotic agents such as aspirin or heparin". Therefore, if intimal injuries are detected before the onset of neurologic signs and symptoms, anticoagulation therapy may be advocated. However, further research on this potential benefit is needed.

Because complications are rare, previous studies have suggested that hospital admission is not necessary and merely provides a false sense of security to both parents and physicians. Hospitalization is recommended for patients in whom further complications are anticipated. For patients with evidence of retropharyngeal air, hematoma, abscess, or pneumomediastinum, hospitalization is mandatory. A lucid interval of up to 60 h has been seen in patients between the initial trauma and the onset of neurologic symptoms. [16] Therefore, duration of hospitalization should be longer than this latency period. If the follow-up takes place in the outpatient setting, close observation for symptoms such as vomiting, seizures, neck swelling, or bleeding from the mouth is recommended for 48-72 h.

This study only described two extreme cases, and this represents a major limitation of our findings. However, emergency physicians should be aware of the potentially life-threatening complications associated with impalement injuries and manage them with caution.

 Conclusion



Impalement injuries in the pediatric population may be deeper and more complicated than anticipated, even if the wounds appear innocuous. Physicians need to be more aware of the potentially life-threatening complications, as well as the specific complications related to proximity to specific anatomic structures.

Due to the rarity of life-threatening complications, routine imaging cannot be recommended for patients with accidental impalement injuries. It is difficult to identify any specific clinical factors that might lead to higher suspicion of severe injuries such as vascular injuries; however, the risks of injury must be balanced against the risks and costs associated with imaging tests and decisions must still be made to obtain images as needed. When imaging tests are performed, CTA seems to be a reasonable choice.

 Acknowledgment



The authors wish to sincerely thank Ms. Ryoko Ono for revising the figures. Written consent to publish was obtained from the patients' families.

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