Lesson of the Week: Penetrating intra-oral trauma in childrenBMJ 1997; 314 doi: https://doi.org/10.1136/bmj.314.7073.50 (Published 04 January 1997) Cite this as: BMJ 1997;314:50
- Robert C Law, registrarb,
- Claire A Fouque, senior house officere,
- Waddell Angus, senior house officerf,
- Cusick Eleri, consultant surgeonc
- a Bristol Children's Hospital, Bristol BS2 8EG
- b Department of Anaesthesia
- c Department of Paediatric Surgery
- d St Michael's Hospital, Bristol BS2 8EG
- e Department of Paediatrics
- f Department of Ear, Nose, and Throat Surgery
- Correspondence to: Miss Cusick
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.
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 posterior oropharynx into the right superior mediastinum. The mediastinal collection did not recur, but she required four further neck explorations to drain retropharyngeal collections. She initially received parenteral nutrition but subsequently was fed through a nasogastric tube and then by percutaneous gastrostomy. She was discharged home nine weeks after the injury and was well at the time of writing.
A 2 year old girl was brought to the accident and emergency department after a fall down a flight of stairs with an adult toothbrush in her mouth. This was pulled out by her mother, resulting in some bleeding. The only finding on examination was a small laceration of the soft palate, and she was discharged without treatment. Her parents remained concerned, however, and refused to leave the department.
Over the next two hours she became unwell and was noted to be drooling saliva and to have a swollen neck and poor peripheral perfusion; oxygen saturation varied considerably according to her head position. She was intubated easily after an intravenous induction and was transferred to the intensive care unit. She developed cervical surgical emphysema and right upper lobe collapse but no pneumomediastinum or pneumothorax. Examination under anaesthesia showed a 2 cm full thickness longitudinal tear in the left pyriform fossa, extending down into the superior mediastinum. A nasogastric tube was inserted under direct vision and placed on continuous suction. She was initially fed parenterally and was given intravenous cefuroxime, gentamicin, metronidazole, and fluconazole.
She developed mediastinitis and acute lung injury and required three weeks of mechanically assisted ventilation. Despite a persistent fever no organism was cultured and no focal collections required surgical drainage. She was discharged home four weeks after injury and remained well.
Children often put sharp objects in their mouths. The most common items responsible for injuries include toothbrushes, toys, sticks, pens, and pencils, and, in Asia, chopsticks.2 3 4 Injuries are most likely to be sustained by toddlers who are still unsteady on their feet and fall on to the object.2 3 4 There is a reported strong male predominance.3 4 Injuries tend to occur in the posterolateral oropharynx, and initial symptoms are usually limited to minor oral bleeding.2 4
Several anatomical points are important. The prevertebral fascia divides into two layers in front of the vertebrae: the anterior layer, or alar part, and the posterior layer, or prevertebral part. The alar part fuses with connective tissue on the posterior surface of the oesophagus, thus limiting the retrovisceral space largely to the neck. The more dorsal space between the two layers of prevertebral fascia (danger space) extends from the base of the skull to the diaphragm and may be important in allowing infections to spread into the mediastinum. The carotid artery lies lateral to the tonsil.5
One major complication of penetrating pharyngeal injury is infection with abscess formation or mediastinitis, or both.1 2 Both of our patients developed mediastinal infection secondary to soiling of the retropharyngeal space. In case 1 there were localised abscesses in both the retropharyngeal space and mediastinum and extensive mediastinal emphysema; mediastinitis and a secondary acute lung injury developed in case 2.
Another serious complication is airway obstruction as a result of emphysema or abscesses.1 2 In both cases the airway was compromised and required intubation. This was largely due to surgical emphysema, which in case 1, was further complicated by anterior displacement of the posterior pharyngeal wall.
Carotid thrombosis is a rare complication occasionally seen in injuries of this kind.4 6 This is believed to follow an intimal tear caused by compression of the artery against the cervical vertebrae at the time of the injury.7 The clot may propagate distally and result in widespread cerebral infarction. Classic symptoms are an initial lucid interval followed by deterioration in consciousness level, hemiplegia, and aphasia.2
The potential for rare life threatening delayed complications has led to uncertainty about optimal early management. Patients with symptoms must be admitted to hospital, but the management of the larger, symptom free population remains controversial. Some suggest admission for only those with lateral injury or retropharyngeal trauma because they are most at risk of adverse sequelae.1 Others conclude that all symptom free children should be managed at home and their parents instructed which symptoms should prompt a return to hospital.3 4 These conclusions were based on the observation that serious complications were rare and may develop even after discharge following a 48 hour admission.
Three retrospective reviews of penetrating oropharyngeal trauma in children have been published.2 3 4 Hellman et al described 131 hospital admissions. Their only complication was one case of facial cellulitis. Radkowski et al reviewed 23 cases that required hospital admission. Complications included one case of buccal cellulitis, one pneumomediastinum which resolved spontaneously, and one case of pneumonia.3 Kosaki et al reported on 12 patients, three of whom developed complications and were admitted2; the nine others were treated as outpatients. One patient developed surgical emphysema, one developed subcutaneous, mediastinal, and retropharyngeal emphysema, and one developed a retropharyngeal abscess requiring surgical drainage.
Care must be taken to ensure that patients who are discharged are able to eat and drink. In inpatients enteral feeding is widely accepted as being preferable to parenteral nutrition, but the risk of gastrooesophageal reflux, leading to further contamination of the wound, needs to be considered. There is no consensus on the need for antibiotics or surgical exploration in uncomplicated cases, although the urge to suture minor wounds should be resisted.1 8
Each of the children we have described here was initially discharged. Hospital staff need to know about the potential complications of such penetrating injuries and be aware that symptoms may be rapid in onset and life threatening. If symptom free children are discharged home parents need to be instructed to observe their child closely for 72 hours and should be given a list of specific symptoms to look out for.4
We feel that, as the complications of these injuries may be so devastating, parents need to be made aware of the dangers of allowing toddlers to walk around with sharp objects in their mouths. Toothbrushing must be supervised, and although dental hygiene should be encouraged, toothbrushes must not be presented as toys. We have asked toothbrush manufacturers to place a warning on toothbrush packaging, and several leading companies will be amending their packaging in the near future.