Oropharyngeal Trauma

Is that minor puncture in the posterior pharynx more major than it appears?

That Popsicle stick is such a pain in the neck!

 

How many times do I have to yell at my kids for jumping around with sticks in their mouths?  Seriously… playing basketball with a lollipop in your mouth isn’t a great idea children!!  But nevertheless, inevitably, a child is going to present to you with an intraoral / oropharyngeal injury suffered as a result of a stick-like object in the mouth getting thrust backwards.

  • The incidence of this situation seems palpable, but actual numbers are not known.
  • Potential Complications that must be considered during the evaluation:
    • Bleeding
      • Often stops prior to arrival
      • Peristent hemorrhage (the palantine, jugular, and carotid vessels live right behind there) can life threatening
    • Laceration
      • Often is small, puncture like… and the depth can be deceiving
      • Large avulsions or through and through soft palate injuries may actually require operative closure, but the vast majority do not require closure
    • Retained Foreign Bodies
    • Infection
      • May lead to localized infection
      • Cases also exist of severe retropharyngeal abscess, mediastinitis, and sepsis.
      • ENT literature often advocates for empiric antibiotics; however, this has not been proven to be necessary.  Others advocate for antibiotics only for large wounds that require closure.  Use you best judgment.
    • CNS insult
      • Penetrating trauma may lead to carotid artery dissection or pseudoaneurysm formation.
      • Significant blunt trauma can also produce inflammatory response significant enough to lead to thrombus formation within the carotid artery.
      • Either way, it isn’t good for the brain.
      • Neurologic symptoms can present shortly after the injury or in a delayed fashion (1-3 days or even years).
      • This is naturally the biggest concern: fortunately it is extremely rare – but that does generate the biggest dilemma: For this severe complication that is very rare, what is the appropriate evaluation?

Evaluation

  • Thorough H+P (naturally) – but make sure you get a good visual inspection of the area (although I wouldn’t probe it!!)
  • Lateral Neck film
    • May help identify foreign bodies
    • May show free air (not sure of the true relevance of this).
  • Ultrasound
    • While I would really like to say that this is a well-studied and valid approach to investigate for large blood vessel injury, I cannot find any specific literature to advocate for the use of ultrasound in this setting.
    • Perhaps this would be a good research project… but it would have to be done over a long period of time because there won’t be that many true injuries.
  • CT Angio
    • Reported to have a sensitivity of 90-100% and specificity of 98.7-100% for detecting carotid injury.
    • There is NO CONSENSUS on who requires a CT:
    • Unstable patients, difficult to assess patients (uncooperative), or those in whom you are concerned for vascular injury should get a CTAngio (naturally).
    • Recall that the appearance of the wound can be deceiving (and you don’t even need to have a puncture to lead to thrombosis of the carotid).
    • Injury (puncture or bruising) over the lateral aspects of the posterior pharynx / tonsillar pillars is more concerning than a midline injury.
    • Difficult to draw the line of what is reasonable when you are trying to balance a large dose of radiation plus IV contrast versus a very rare but potentially severe complication.
  • If you do not image, VERY STRICT anticipatory guidance and discharge instructions need to be clearly discussed (get back to the ED pronto at the first suspicion of any neurologic finding!).

 

Zonfrillo MR, Roy AD, Walsh SA. Management of pediatric penetrating oropharyngeal trauma. Pediatric Emergency Care. 2008 Mar;24(3):172-5.

Soose RJ, Simmons JP, Mandell DL. Evaluation and management of pediatric oropharyngeal trauma. Arch Otolaryngol Head Neck Surg. 2006 Apr;132(4):446-51.

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