Clinical Review

Lesson of the Week: Penetrating intra-oral trauma in children

BMJ 1997; 314 doi: http://dx.doi.org/10.1136/bmj.314.7073.50 (Published 04 January 1997) Cite this as: BMJ 1997;314:50
  1. Robert C Law, registrarb,
  2. Claire A Fouque, senior house officere,
  3. Waddell Angus, senior house officerf,
  4. Cusick Eleri, consultant surgeonc
  1. a Bristol Children's Hospital, Bristol BS2 8EG
  2. b Department of Anaesthesia
  3. c Department of Paediatric Surgery
  4. d St Michael's Hospital, Bristol BS2 8EG
  5. e Department of Paediatrics
  6. f Department of Ear, Nose, and Throat Surgery
  1. Correspondence to: Miss Cusick

    Introduction

    The incidence of penetrating intra-oral trauma in children is unknown and most cases probably heal spontaneously without being seen by doctors.1 Occasionally these children develop acute life threatening complications. Retropharyngeal and mediastinal abscesses, mediastinitis, widespread emphysema, internal carotid artery thrombosis, and airway obstruction have all been reported. We recently treated two children with mediastinal sepsis after intra-oral injuries caused by toothbrushes.

    Case report

    Case 1

    A 13 month old girl presented to the accident and emergency department within two hours of an unwitnessed fall from a standing position with her toothbrush in her mouth. She looked well, with no respiratory distress or stridor but was noted to have a 1 cm abrasion to her right anterior faucial pillar. The tonsil was not pushed towards the midline, as occurs in peritonsillar abscess or bleeding lateral to the tonsillar bed. She was discharged home without treatment but returned to hospital 24 hours later with severe inspiratory and expiratory stridor and severely swollen cervical soft tissues. Radiography showed cervical surgical emphysema, a pneumomediastinum, widening of the prevertebral tissues displacing the trachea anteriorly, and a left pneumothorax.

    Her trachea was intubated after gaseous induction, and an examination under anaesthesia showed a retropharyngeal abscess draining into the base of the right pyriform fossa. A right sided neck exploration was performed, the abscess was drained percutaneously, and a left sided intercostal drain inserted.

    She was transferred to the intensive care unit, where she was mechanically ventilated for a week and treated with intravenous cefotaxime, penicillin, metronidazole, and fluconazole. The culture swab sent from the operating theatre grew pneumococci, Haemophilus influenzae, and yeasts.

    She remained feverish, and a right thoracotomy was performed to drain an abscess extending from the …

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