Oro-pharyngeal Injuries in Children: What’s the Risk?

Pharyngeal Injuries in Children

The scene:

You find your little (3-year-old) girl sitting on the bathroom floor crying, holding a toothbrush that has some blood on the brush-end. Asking her older siblings what happened (yelling at them like a frantic drill-sergeant is more like it!) you discover that she was brushing her teeth while jumping off the step stool, and fell.

For those of you with your own little monkeys, you are familiar with this scenario.

It might be a straw (most common), or a stick (what boy doesn’t like to whack stuff with a stick?), or pencil, or something else that should NEVER have come even close to their mouth, but there it is … Now with an injury to the soft palate or the back of the throat. The medical term is “oropharyngeal injuries”.

The topic of oropharyngeal injuries – both blunt (no hole in the mucosa covering) and penetrating (hole in the mucosa covering) – is a controversial area in Pediatrics.

Let’s first decide what to do right now, then review the risks and concerns.

Warning: Brace yourself, there is some scary information ahead.

Pharyngeal injury: What should you do right now?

What to do right now? Is this a big deal? Or can this wait until next week to visit the pediatrician? Do you even need to visit the doctor over this? I mean, she seems okay, right?

Let’s all take a deep breath, and assess the immediate risk:

The ABC’s – Airway, Breathing, Circulation

First: If your child IS having difficulty breathing or is losing consciousness, call 911. Now.

No? She’s crying vigorously? Her Airway and Breathing must be okay if she is crying – she’s breathing.

Okay, so no 911 call for an ambulance.

Do you need to visit a doctor at all?

Yes.

Let’s review why.

First, the Good News: despite the frequency of oropharyngeal injuries in children – this is very common in toddlers – there have been only rare reports of serious injuries.

Now, the Bad News: the injuries that have been reported are devastating and tragic.

Image: carotid injury following pharyngeal injury

Image: internal carotid location at back of throat

There have been reports of injury to the carotid artery resulting in stroke in children (and adults) following injuries to the side of the palate and back of throat. The medical term for this is “neurological sequelae,” meaning injuries to the brain.

Over many years, neurological sequelae have been reported anywhere from a few hours to several days following the initial oropharyngeal injury.

There is No Standard of Care

In most of medicine, a “standard of care” has evolved based on evidence. When a particular injury is common, but bad outcomes (“sequelae”) are extremely rare, and the cost of testing for them is extremely high, the standard of care for most of medicine is usually to simply wait and see.

But in the case of pediatric pharyngeal injuries, the bad outcomes can be so devastating (what could be more devastating than your child having a stroke or even dying??) that some physicians and medical centers have adopted a more aggressive testing protocol. Some centers order a CT scan of the neck and brain for reassurance that there is no visible injury to the carotid artery.

Other centers feel that, given the rarity of injury to the carotid artery, ordering CT imaging is not called for. Some centers simply hospitalize the child for some length of time (often overnight, but some for as long as 3 days) to monitor the child.

Other centers simply educate the parents on the neurological signs and symptoms to be alert for (changes in walking, talking, lethargy, and others) and allow them to go home, with instructions to return if there are any changes; these centers ask the parents to return for a visit with their pediatrician within days.

So, as you can tell, there is a broad range of management responses depending on where you take your child. This is one of those unusual areas of medicine where there is no agreed-upon standard of care.

What do I do?

In this case I do what I always do in medicine – I ask myself what I would do for my own child. This makes most of my decisions pretty easy.

If my own child had injured their pharynx with a pencil or something similar, I would go to my nearest Children’s Hospital Emergency Department, and request a CT scan of the carotid arteries (called a CT-Arteriogram, or “CTA”).

Many folks consider that pretty aggressive testing for an extremely rare outcome (carotid injury), but if my child (or your child) had a carotid artery injury and needed immediate treatment or neurosurgery to prevent a stroke or even death, I would want to know.

So, sorry for the scare.

The chances are that your little boogorhead will NOT have any bad outcome from an injury to the back of the throat.

But why take a chance? Take them to the ER of your Children’s Hospital and be reassured.

Resources:

A recent review of the medical literature was reported:  Evaluation and Management of Pediatric Oropharyngeal Trauma. Soose, Simons, Mandell. In the Archives of Otolaryngology Head and Neck Surgery, Vol 132: pg. 446-451.

This is a good review, and an explanation of how the authors – Pediatric ENT doctors – handle the decision on managing these children: http://archotol.ama-assn.org/cgi/reprint/132/4/446.pdf

_______________________________________

Hi, I’m Russell Faust, author of this medical education blog.

Russell Faust, PhD, MD boogordoctor

Image: Russell Faust

Let me know what topics are important to you and your child’s respiratory health.This article was suggested by a friend and mother of toddler who recently experienced an oral injury.

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Comments

  1. summer sutton says:

    Hi i have a 3 year old that fell on a broken sword (2/9/17) that i had just thrown away but he snuck it out of the trash and went to run from me and when i went to grab it he fell over our dog and it punctured the back of the throat to the left of the uvula. I rushed him to the closets ER i cheched in at 3:04 and was seen by the dr at 3:20 and the Dr looked in his mouth and said hes fine and i said he has a massive hole how is this fine? He said i see this all the time and it will heal itself and released us at 3:40. Seemed not concerned but now my son is running fever of 102.4 and puking and refuses to eat. I did make him an appointment for tomorrow with his PCP but now wondering if i need to go to another ER.

    • Russell A. Faust, PhD, MD says:

      Summer:
      Please take your son to the ER now.
      Be prepared for them to keep him overnight for observation.
      And please keep me updated on how he is doing!

  2. My 3year old girl was eating with wooden chopsticks and injured the top of her palet. Bleeding has stopped cleaned with salt water but small cut. Should I worry? She’s ok but I’m concerned

    • Russell A. Faust, PhD, MD says:

      Whenever you’re worried (and I ALWAYS listen to mother’s intuition!), see a professional!

  3. Jennifer B says:

    Hello! My son had a small plastic golf club & he took the club off & had just the stick in is mouth. He started crying & coughing out of no where & started to throw up from coughing & he threw up about 3 times & when he threw up there was a little bit of blood. He won’t let us see in back of his throat so we don’t know if it’s something small or major?. This was about an hour ago he hasn’t thrown up & he’s not crying but when he drinks his milk he does start to complain a little. Should we take him to the ER?

    • Russell A. Faust, PhD, MD says:

      Hi Jennifer:
      As I instructed you in reply by email: yes, go to the ER – preferably an ER of a Children’s Hospital!
      I posted this here for everyone to see.
      Please let me know how things went for your boy.

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