PENETRATING TRAUMA OF OROPHARYNX

Presenter : Dessy Ekayusnita ,MD

Tutor : Syahrial M. Hutauruk, MD, ORL-HNS
Resource Person : dr. Rino, Sp. BV
 INTRODUCTION

Penetrating trauma is defined as an injury caused by an object breaking the skin and entering the
bod

Penetrating trauma of the oropharynx are common in children under the age of six

The majority of these injuries do not have significant or lasting sequelae, some can have detrimental
complications such as involvement of the internal carotid artery with subsequent neurological deficits
 ETIOLOGY

Oropharyngeal injuries account for an estimated 1 % of all pediatric trauma.

The most common objects causing impalement injuries in children are sticks,
pens/pencils, cylindrical toys, and straws

The mean age of patients presenting with impalement injuries has been reported as
being under 4 years of age.

Males are 2-3x more likely to be involved than females

A
N
A
T
O
M
Y
 ANATOMY

The base of the neck, is demarcated by the

Zone 1 thoracic inlet inferiorly and the cricoid cartilage
superiorly
Encompasses the midportion of the neck and
Zone 2 the region from the cricoid cartilage to the
angle of the mandible

The superior aspect of the neck & is bounded

Zone 3 by the angle of the mandible & the base of the
skull
Zones of the neck
Mechanism Of Injury
 The degree of injury depends on :
- the bio mechanics
- the efficiency with which energy is transferred from the object to the body
tissues

Inserted by
Low energy
The mechanism hand
of injury may be
categorized Medium and
Propelled
high energi
WOUND CHARACTERISTIC

• Small superficial lacerations or scratches (< 2 cm long) with

Depth clear wound margins and a visible base
• Lacerations > 2 cm in length or associated with a hanging
Length flap usually need repair

Location • Lateral wounds, have a greater risk of CIA injury than midline wounds.
• Injuries to the soft palate > wounds to the hard palate.

Foreign Body
•A protruding foreign body or concern for a retained foreign body
requires additional imaging to demarcate extent of injury and
localize involved anatomic structures
WOUND CHARACTERISTIC

Depth Length Location Foreign Body

• Small • Lacerations > • Lateral • A protruding

superficial 2 cm in length wounds, have foreign body
lacerations or or associated a greater risk requires
scratches (< 2 with a of CIA injury additional
cm long) with hanging flap than midline imaging to
clear wound usually need wounds.
margins and a repair demarcate
• Injuries to the
visible base soft palate >
extent of
wounds to the injury and
hard palate. localize
involved
anatomic
structures
 Plain radiographs of the
not generally recommended
neck and chest
RADIOGRAPHIC IMAGING

patient hospitalization & cooperation or sedation,

Carotid ultrasound with
oculoplethysmography
ultrasound findings may not correlate well with blood
vessel injury

CTA good sensitivity for air and subcutaneous foreign bodies

MRA unnecessary for oropharyngeal trauma in children

gold standard for radiologic imaging of children with ICA

CAA
injury
MANAGEMENT
Tongue
• No treatment or very limited debridement and cleansing
with saline

Palate
• The majority of injuries to the palate heal without
intervention if the edges of the wound are in close
proximity

Lateral oropharynx
• The highest risk for major sequelae because of the close
proximity to the Internal Carotid Artery (ICA)
• Prophylactic antibiotic therapy was initiated
TREATMENT

Conservative treatment

large avulsion flap, through-and-through wounds, or the need to

explore the wound for a foreign object should be referred to the
oral surgeon

prophylactic antibiotic
 Table 1. Clinical Guidelines for Treatment of Impalement Injuries of the Oropharynx9

A neurologic assessment of the patient can be achieved in a short time

If neurologic damage is suspected, immediate medical referral is indicated

Most palatal injuries will heal spontaneously without intervention, even perforating lesions of
the hard palate
A brief episode of intraoral bleeding which stops spontaneously is common, Profuse bleeding
which is life threatening is usually not a problem with these injuries

Avoid the impulse to suture the wound. Surgical intervention should be reserved for the rare
case of a large avulsion flap or need to explore for foreign objects.

Prophylactic antibiotic therapy, (penicillin) may be prescribed to prevent infection, especially in

wounds greater than 1 cm in greatest dimension.

Instructions similar to those given for minor head trauma should be explained to parents

Soft diet should be recommended for a few days

Close follow-up examinations are recommended.
Complicatons

 Neurologic sequele secondary to Carotid Artery Injury

 Identity & Chief Complaint

Male, 5 years old

Accidentally stuck a
skewer (satay wood
stick) on his tongue
7 hours prior to
admission
 MEDICAL HISTORY

7 hours prior Eating

to admission: sausage
Patient fell
using a
accidentally down 
skewer on the
stuck a skewer
side of the
skewer on his accidentally
road,
tongue and penetrated
suddenly
penetrated trough his
motorcycle
trough the tongue
almost hit the
right neck patient
MEDICAL HISTORY

Painful (+) VAS 4

No choking, shortness of breath nor cyanosis.

No complain of cough and hoarsness. No
hypersalivation or active bleeding

Brought to Cibitung Hospital  medication

only  referred to CM Hospital
PHYSICAL EXAMINATION

General condition:
Conscious, dyspnea (-),
Moderate ill, looks
stridor (-), retraction (-)
frightened

Vital sign:
• BP:110/70
• O2 Sat: 99%
• RR: 20x
• HR:100 x/min
ENT Examination

Ear

• Right and left ear: wide ear canal, no

discharge nor cerument, intact tympanic
membrane

Nose

• Right and left nostril: wide nasal cavity,

inferior turbinate eutrophy, no discharge nor
deviated septum, good air passage
ENT Examination

Neck :
Throat :
protrusion of the skin on
foreign body (skewer)
the right superior of the
on the 1/3 anterior of
level Va, in the posterior
the right tongue,
trigonum. There were no
clotting -, active
bleeding and open wound
bleeding -
visualized
 Laboratory Examination
(October, 1st 2018)
 Hb : 14 g/dl  AST : 22,8 u/L

 Ht : 41 %  ALT : 12,4 u/L

 WBC : 17.100 /ul • RBG : 185

• PT : 9,6 (10.1)
 Platelets : 553.000 /ul
• APTT : 29.7 (34.3)
 Ureum : 15,7 mg/dl
• Potassium : 3,6 mEq/L
 Creatinin : 0.207 • Sodium : 142 mEq/L
• Chlorde : 102 mEq/L
Radiological Findings

 ChestX-Ray and soft tissue

AP/Lateral review from
Cibinong Hospital, CM
Hospital, October, 1st
2018:
-No abnormalities on heart
and lung
- No foreign body appear in
cervical radiography or coli
region at this time
=> The extraction of the skewer has done with
Vascular surgery

=> We make incision 2 cm length on right colli

region until the skewer can be visualized

=> In the proximal and distal of tip skewer used

vicryl 3.0 as a marker

=> We pulled out the tip proximal of skewer. All

of the skewer has pulled out

=> Evaluation of bleeding, and wound care with

H2O2 and NaCl 0,9%
Discussion
 Children frequently fall with objects in their mouths and injure their oropharynx
and make the physician difficult to assess them accurately whilst awake
 The emergency care and management of these pediatric patients depends on
the size of the foreign bodies, the location of the injuries and hemodynamic
signs
 A foreign body in the oropharyngeal cavity may lead to tongue immobilization,
epiglottis exposing difficulties and limited submandibular motion, which make
anesthesia and airway management particularly complex
Discussion

 Airway management in oropharyngeal injuries is even more complicated in

children than that in adults. The cricoid cartilage, instead of glottis vera, is
the narrowest portion of the pediatric airway, and the mucosa of the cricoid
area lacks a substantial submucosal layer
 Antibiotic use covering oral flora remains empiric and can be justified with
contamination or with larger injuries, probably 1 to 2 cm