II. Epidemiology

  1. Oropharyngeal injury accounts for 1% Pediatric Trauma
  2. Most commonly occurs in preschool children

III. Mechanism

  1. Fall on object with open mouth

IV. Causes

  1. Pen
  2. ToothBrush
  3. Popsicle stick
  4. Straw

V. History

  1. Retropharyngeal infection or abscess
    1. Fever
    2. Unable to swallow secretions or Drooling
    3. Trismus
    4. Neck Pain or Torticollis
    5. Chest Pain (mediastinitis)
  2. Internal Carotid Artery injury
    1. Focal neurologic symptoms

VI. Exam

  1. See Trauma Evaluation
  2. Mouth
    1. Careful exam is critical
      1. Have suction available
      2. Use Tongue blade (consider with bite block)
      3. Avoid probing the wound site (significant re-bleeding may occur)
    2. Wound site
      1. Wound length, depth and location
      2. Retained Foreign Body
  3. Internal Carotid Artery related exam
    1. Complete Neurologic Examination
    2. Auscultate for Carotid Artery bruit

VII. Evaluation: Red Flags

  1. Deep (or potentially deep) throat wounds (esp. from sharp objects)
  2. Long Lacerations (>2 cm) or hanging flap (requires repair)
  3. Soft Palate injuries (higher risk for deep space injury)
  4. Lateral throat wounds (at Tonsillar Pillar region)
  5. Neurologic findings (new or fluctuating)
  6. Retained penetrating foreign body (do not remove, requires surgical management)
  7. Nonaccidental Trauma findings (follow local protocols)

VIII. Labs: Indicated for signs infection

IX. Imaging: Possible deep space injury or infection

  1. First-Line
    1. Chest XRay
    2. Lateral Neck XRay
      1. Soft tissue space normally <7 mm anterior to C2
      2. Soft tissue space normally <5 mm anterior to C3-4
  2. Second-Line
    1. CT Angiography Neck

X. Imaging: Suspected Internal Carotid Artery injury

  1. Precautions
    1. Acute neurologic findings should prompt emergent vascular Consultation and second-line tests
  2. First-line
    1. Carotid Ultrasound
  3. Second-line
    1. CT Angiography Neck
    2. MR Angiography Neck
  4. Third-line
    1. Carotid Artery Angiography

XI. Management: Triage

  1. Evaluate and manage airway and associated serious injuries first
    1. See Trauma Evaluation
    2. See ABC Management
    3. Control oropharyngeal bleeding (may require Advanced Airway)
    4. Cervical Spine Immobilization if indicated
  2. High Risk Penetrating Injury
    1. Indications
      1. Gun shot wound
      2. Stab Wound
      3. High velocity MVA
      4. Neurologic deficit or Carotid Bruit
      5. Uncontrolled, rapid Oral Bleeding
    2. Emergent stabilization (see above) and transfer to Level 1 Trauma Center
    3. Emergent Consultation with otolaryngology and vascular surgery or neurosurgery
    4. Manage as Zone 3 Penetrating Neck Trauma or Neck Vascular Injury in Blunt Force Trauma
  3. Moderate Risk Injury
    1. Indications
      1. Retained Foreign Body
      2. Deep wound (or unclear depth) with significant mechanism of injury (esp. posterolateral pharynx)
    2. Emergent CT Angiography Neck
    3. Consult Otolaryngology (and vascular surgery as indicated)
  4. Low Risk Injury
    1. Indications
      1. Superficial injuries (shallow depth, length <2 cm) and low risk mechanism
    2. No initial imaging needed unless red flag findings (see above)
    3. May discharge home with precautions to return for signs infection or neurologic changes
      1. Fever, Drooling, Trismus, Torticollis, Chest Pain
      2. Slurred speech or weakness

XII. Management: Pharyngeal Wound Related Management

  1. Tetanus Prophylaxis
  2. Laceration Repair (typically by otolaryngology in OR) Indications
    1. Protruding or Retained Foreign Body
    2. Laceration >2 cm
    3. Hanging flap (e.g. Palate)
    4. Tonsil avulsion
    5. Contaminated wound
  3. Antibiotic prophylaxis
    1. Indicated for oropharyngeal Lacerations that breach the mucosa
    2. Oral antibiotics
      1. Clindamycin 10 mg/kg (up to 600 mg) orally three times daily for 5-7 days OR
      2. Augmentin 25 mg/kg (up to 875 mg) orally twice daily for 5-7 days
    3. Intravenous antibiotics (hospitalized patients)
      1. Clindamycin 10 mg/kg (up to 900 mg) IV every 8 hours OR
      2. Unasyn 100 mg/kg/day IV divided every 6 hours (use adult dose >40 kg)

XIII. Complications

  1. Deep space oropharyngeal or deep space neck infection (<5% of cases)
    1. Retropharyngeal Abscess
    2. Mediastinitis
    3. Suppurative jugular venous thrombosis
  2. Internal Carotid Artery injury (<1% of cases)
    1. Carotid Artery Dissection
    2. Carotid Artery thrombosis
      1. Patients are typically lucid without deficit for first 3-60 hours after injury

XIV. References

  1. Claudius, Behar and Stoner in Herbert (2015) EM:Rap 15(11): 2-3
  2. Roberson in Bachur (2015) UpToDate, Accessed 11/2/2015

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