Oropharyngeal trauma in children
- David W Roberson, MD
David W Roberson, MD
- Associate Professor
- Harvard Medical School
- Section Editor
- Richard G Bachur, MD
Richard G Bachur, MD
- Section Editor — Pediatric Trauma
- Professor of Pediatrics and Emergency Medicine
- Harvard Medical School
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — Adult and Pediatric Emergency Medicine
- Senior Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Clinical Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
Children often fall with objects in their mouths and may suffer trauma to the oropharynx. These injuries pose a significant diagnostic challenge because the vast majority will heal spontaneously without complications [1-4], but a small minority will develop deep neck infections or carotid artery injuries that cause major morbidity and mortality [5-10]. The approach to oropharyngeal blunt trauma relies on an assessment of the oropharyngeal wound, a rational use of diagnostic tools, primarily noninvasive radiologic techniques, and surgical intervention in selected patients.
This review covers the evaluation and management of wounds to the hard and soft palate, tonsils, and posterior pharyngeal walls. Dental and tongue injuries are discussed separately. (See "Evaluation and management of dental injuries in children" and "Evaluation and repair of tongue lacerations".)
Oropharyngeal injuries account for an estimated 1 percent of all pediatric trauma . A common mechanism involves a toddler or preschool child falling with an object in the mouth or having an item pushed into their mouth by a playmate or caregiver. Commonly reported objects include writing instruments (eg, pen, pencil), toothbrushes, Popsicle sticks, lollipops, eating utensils, and drinking straws [2,12]. Infrequently, the trauma may result from a blind finger sweep by a caregiver during a choking episode .
ANATOMY AND PATHOPHYSIOLOGY
The oropharynx consists of the following structures:
●Soft palate, uvula above
- Radkowski D, McGill TJ, Healy GB, Jones DT. Penetrating trauma of the oropharynx in children. Laryngoscope 1993; 103:991.
- Brietzke SE, Jones DT. Pediatric oropharyngeal trauma: what is the role of CT scan? Int J Pediatr Otorhinolaryngol 2005; 69:669.
- Schoem SR, Choi SS, Zalzal GH, Grundfast KM. Management of oropharyngeal trauma in children. Arch Otolaryngol Head Neck Surg 1997; 123:1267.
- Ratcliff DJ, Okada PJ, Murray AD. Evaluation of pediatric lateral oropharyngeal trauma. Otolaryngol Head Neck Surg 2003; 128:783.
- Suskind DL, Tavill MA, Keller JL, Austin MB. Management of the carotid artery following penetrating injuries of the soft palate. Int J Pediatr Otorhinolaryngol 1997; 39:41.
- Windfuhr JP. Aneurysm of the internal carotid artery following soft tissue penetration injury. Int J Pediatr Otorhinolaryngol 2001; 61:155.
- Joseph MM, Lewis S. Stroke after penetrating trauma of the oropharynx. Pediatr Emerg Care 2002; 18:179.
- Palmer AL, Strain JD, Henry DB, et al. Postanginal sepsis after oropharyngeal trauma. Pediatr Infect Dis J 1995; 14:249.
- Kaplan DM, Fliss DM, Peiser Y, et al. Internal jugular vein thrombosis in a child due to a 'pencil point injury' of the palate. Int J Pediatr Otorhinolaryngol 1998; 44:183.
- Pierrot S, Bernardeschi D, Morrisseau-Durand MP, et al. Dissection of the internal carotid artery following trauma of the soft palate in children. Ann Otol Rhinol Laryngol 2006; 115:323.
- Chauhan N, Guillemaud J, El-Hakim H. Two patterns of impalement injury to the oral cavity: Report of four cases and review of literature. Int J Pediatr Otorhinolaryngol 2006; 70:1479.
- Soose RJ, Simons JP, Mandell DL. Evaluation and management of pediatric oropharyngeal trauma. Arch Otolaryngol Head Neck Surg 2006; 132:446.
- Hengerer AS, DeGroot TR, Rivers RJ Jr, Pettee DS. Internal carotid artery thrombosis following soft palate injuries: a case report and review of 16 cases. Laryngoscope 1984; 94:1571.
- Deutsch MD, Kriss VM, Willging JP. Distance between the tonsillar fossa and internal carotid artery in children. Arch Otolaryngol Head Neck Surg 1995; 121:1410.
- Naidoo S. A profile of the oro-facial injuries in child physical abuse at a children's hospital. Child Abuse Negl 2000; 24:521.
- Bolz WE, Brouwer HG, Schoenmakers CH. Measurement of HbF concentration for diagnosing a case of Munchausen by proxy syndrome. J Pediatr 2006; 148:145.
- Randall DA, Kang DR. Current management of penetrating injuries of the soft palate. Otolaryngol Head Neck Surg 2006; 135:356.
- Hennelly K, Kimia A, Lee L, et al. Incidence of morbidity from penetrating palate trauma. Pediatrics 2010; 126:e1578.
- Hellmann JR, Shott SR, Gootee MJ. Impalement injuries of the palate in children: review of 131 cases. Int J Pediatr Otorhinolaryngol 1993; 26:157.
- ANATOMY AND PATHOPHYSIOLOGY
- Internal carotid artery injury (ICA)
- Deep neck space infection
- CLINICAL FEATURES
- Physical examination
- - Wound characteristics
- - Associated physical findings
- Laboratory evaluation
- Radiographic imaging
- - Plain radiographs of the neck and chest
- - Carotid ultrasound with oculoplethysmography
- - Computed tomography angiography (CTA)
- - Magnetic resonance angiography (MRA)
- - Carotid artery angiography (CAA)
- EVALUATION AND MANAGEMENT
- Initial stabilization
- Approach to diagnosis and management
- - High risk injury
- - Moderate risk injury
- - Low risk injury
- Wound management
- - Laceration repair
- - Tetanus prophylaxis
- - Empiric antibiotic therapy
- Child protection
- Deep neck infection
- Cerebral vascular thrombosis
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS
- Clinical features
- Approach to evaluation and management
- Wound care
- Follow-up instructions