A 9-year-old male came to the emergency room after he had purposefully stabbed himself in the mouth about 1 hour before. He said that he was “dared” to do it by some of his friends and had used a standard wooden pencil that was removed intact. He realized that he “didn’t poke himself very much” but he had been bleeding for a short time. The school officials had him suck on ice while his mother was contacted. She said that the bleeding had stopped when she arrived and he had not really complained of any pain, coughing, problems swallowing or talking. “He’s pretty much normal, but I saw blood back there and wanted to get it checked out,” she said. “It wasn’t very sharp, but I guess I shouldn’t have listened to my friends and did it,” he offered. He denied other trauma and said there was no pain unless he stuck his finger in the area of the injury. The past medical history showed the patient was taking stimulant medication for attention deficit disorder – combined type. He had a forearm fracture after a playground injury at age 7. His immunizations were current. The review of systems was negative.
The pertinent physical exam showed normal vital signs. He was quite active in the room talking animatedly about all the equipment. His general examination was normal. There was no external trauma noted to the face and neck. Just above the left tonsil on the tonsilar pillar was a 3-4 mm abrasion. Initially a small blood clot covered this area but by the end of the exam, it had fallen away and the base of the lesion was seen. There was no increased vascularity or edema to the area. Tongue blade inspection of the teeth, tongue, gingiva, buccal mucosa, palate, and uvula were normal. He had full range of motion in the temporomandibular joint. Cranial nerves were intake, and no pain was elicited with any maneuvers during the physical examination.
The diagnosis of a superficial soft palate injury was made. An otolaryngology resident was present in the emergency room seeing another patient and she also agreed that it was a superficial injury. The parent was educated about the potential complications of this type of injury and was to monitor the patient closely returning if any worrisome symptoms occurred. The patient was to followup in one week with his regular physician.
Oropharyngeal trauma is common and ranges from minor contusions to severe trauma of the head and neck. Sudden movement while having a foreign object in the mouth is a very common scenario with falls or collisions being common mechanisms. Common objects include toys, sticks, pens/pencils, chopsticks, toothbrushes, and popsicle sticks. Many of these injuries cause minimal problems such as a contusion to lips (i.e. “fat lip”).
In general, the more anterior the location the more common the injury and the less likely to have a severe injury (i.e. lips). Whereas posterior structures are more protected, but because of their location next to vital structures, the potential complications can be higher. Similarly, midline injuries tend to be less risk for complications than lateral injuries as lateral injuries are nearer to vital structures. Fortunately owing to the excellent blood supply to the oropharynx, most treated injuries are well-healed with good cosmetic and functional outcomes. High impact trauma (e.g. car accident), burns and animal bites are other types of trauma which do also cause injury to the oropharyngeal structures and are not discussed here.
General evaluation approach
The history should include mechanism of injury and if a foreign body caused the injury, if it was removed intact. A history of drooling, dysphonia, dysphagia, cough or obvious external swelling (possible subcutaneous emphysema) should increase the concern for complications. During the evaluation of oropharyngeal trauma, close inspection of the traumatized area and adjacent structures is important. This may necessitate local or general anesthesia. Evaluation for other injuries including dental occlusion, temporomandibular joint movement and for potential additional head and/or neck injury should be carried out. Cranial nerves should be evaluated. Carotid bruit evaluation is also performed as is appropriate. Use of computed tomography or computed tomography angiography may be needed to assist in evaluation and plan potential treatment especially if there is a concern for vascular injury. Non-accidental trauma should be considered if the history and injury seem discrepant or other injuries are noted. Similarly, psychiatric evaluation may be appropriate in the proper circumstances.
General treatment approach
Penetrating oral trauma management is controversial but often can be managed as an outpatient with good results. Irrigation, foreign body removal, hemostasis and debridement as needed should be the main general approach to treatment. Lacerations may communicate with adjacent spaces (e.g. through-and-through tear of oral gingival mucosa to the facial skin, or foreign body trauma that penetrates into potential neck spaces), so this must be considered when treating wounds. Exploration may be necessary and may necessitate local or general anesthesia. Use of prophylactic antibiotics in oropharyngeal trauma is controversial but if used, treatment for oral flora is appropriate. Rabies and tetanus vaccine status should be evaluated. External wound instructions and head injury instructions should be given as appropriate. Analgesic use (and antibiotic use) should be reviewed with the family. Patients should be instructed and encouraged to return to the emergency room for re-evaluation for bleeding, swelling, tenderness, increased pain or new pain, fever, increased secretions, difficulty swallowing or breathing, problems moving the neck or jaw or holding the head in an abnormal position, or if the family has any other concerns.
Contusions usually need only localized cooling to help vasoconstriction with resolution in a few days. Abrasions and lacerations are both considered infected wounds as the epithelium is damaged with superficial or deeper structures exposed. Antibiotics may be used, especially for large or more complicated injuries.
Frenula injuries often bleed copiously. Minor injury to the gingival frenulum may just need cold packs but suturing may be needed to control hemostasis. The lingual frenulum is injured less often but treated the same way. Injuries to the teeth or jaws usually requires evaluation and treatment planning by a dentist. Radiographs usually help with treatment planning. A tooth that is dislocated should be retained in position if possible. An avulsed tooth can be transported in the child’s or parent’s mouth for possible reimplantation. Alternatively, milk or water are other transport mediums. The tooth should not be manipulated but gently placed into the transportation device. Tongue lacerations often bleed copiously as they also have good blood supplies. They also usually heal quickly and well. Long or deep lacerations or those with a high risk of deformity (e.g. anterior split tongue) may require suturing with loose sutures as tighter sutures may cause tissue necrosis.
Buccal mucosa injuries are usually superficial but deeper or flap injuries may need additional treatment. Similarly gingival injuries may need additional evaluation and treatment. Salivary glands and Stensen’s duct may also need specific evaluation.
Injuries to the tonsils, uvula and palate are not very common and usually are due to sharp objects being placed into the mouth. Because of increased risk of potential complications, these locations may need additional evaluation (such as computed tomography or evaluation under general anesthesia) and/or treatment (additional suturing, hospitalization, etc.). Again like most oropharyngeal injuries, many of these can be treated with diligent inspection, foreign body removal, and hemostasis with appropriate evaluation by specialists and appropriate followup. Outpatient treatment requires careful instruction of the parents to return immediately if any red flag symptoms occur.
Foreign body injuries of the buccal mucosa, mouth floor, palate, and tongue usually occur when there is a object in the mouth and the child suddenly falls. These injuries are often unwitnessed. These should be inspected and palpated (which may require some type of anesthesia) to make sure the entire foreign object is removed. The external wound can belie deeper potential injury so it is important to carefully inspect the entire area surrounding the injury. Deeper injuries can be very difficult to identify and symptoms may occur over long periods of times as noted below. Imaging with computed tomography or computer tomographic angiography can be helpful for appropriate injuries.
Potential problems of penetrating oropharyngeal injuries includes:
- Airway obstruction
- Foreign body retention/obstruction
- Subcutaneous emphasema
- Infection – localized or in adjacent structures or spaces, and can cause severe infection such as abscess, mediastinitis, or sepsis. A review of deep neck infections can be found here.
- Vascular injury to the internal carotid artery and internal jugular vein can cause dissection, thrombosis, and pseudoaneurysm
These potential problems can occur minutes to years after the trauma.
Questions for Further Discussion
1. What are indications for referral to an otolaryngologist for an oropharyngeal trauma?
2. What type of sutures are generally used for treatment of oropharyngeal trauma?
3. What are indications for hospitalization for oropharyngeal trauma?
- Age: School Ager
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Marom T, Russo E, Ben-Yehuda Y, Roth Y. Oropharyngeal injuries in children. Pediatr Emerg Care. 2007 Dec;23(12):914-8.
Zonfrillo MR, Roy AD, Walsh SA. Management of pediatric penetrating oropharyngeal trauma.
Pediatr Emerg Care. 2008 Mar;24(3):172-5.
Aremu SK, Makusid MM, Ibe IC. Oro-cranial penetrating pencil injury. Ann Saudi Med. 2012 Sep-Oct;32(5):534-6.
Lalitha RM, Ranganath K, Prasad K, Agrawal K, Perumal M. Potential danger of toothbrushes for children. J Investig Clin Dent. 2011 May;2(2):148-50.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa