New Guidelines for Treatment of Trauma to the Pediatric Pharynx

Newswise — Trauma incurred by children to the part of the pharynx at the back of the mouth is largely underreported and underestimated by the medical community. Many of these injuries, classified as oropharyngeal, are not observed and when viewed by parent or guardian do not receive physician care unless there are associated symptoms such as bleeding, dysphagia (difficulty in swallowing), or pain.

Severity from these injuries can be divided into three categories: Grade 1: abrasion or ecchymosis without mucosal disruption, Grade 2: puncture wound or simple laceration ≤ one cm, and Grade 3: laceration > one cm or any laceration with an oronasopharyngeal fistula or large mucosal flap.

Although most cases heal without any long-term consequences, prior reports of oropharyngeal trauma have linked such injuries, via hidden internal carotid artery (ICA) injury, to disastrous complications, such as aphasia, hemiplegia (paralysis on one side of the body), and even death, in otherwise normal and healthy children.

Debate does exist regarding which imaging studies, if any, are warranted to screen for hidden ICA injury in pediatric oropharyngeal trauma. The recommended imaging study in many pediatric treatment facilities ranges from computed tomography (CT) to lateral neck X-ray to no screening test. Furthermore, even within a single institution that recommends diagnostic imaging, there is considerable variability in which patients are actually imaged. Although the incidence of complications is rare following such injuries, the potential for devastating neurologic illness in healthy, active children necessitates a more standardized protocol that addresses issues such as radiologic work-up, hospital admission criteria, surgical and/or medical therapy, and follow-up.

Pediatric otolaryngologists have sought to determine patterns and correlations in medical decision-making that would suggest a logical and systematic process for the evaluation and management of oropharyngeal injuries. The authors of "Evaluation and Management of Pediatric Oropharyngeal Trauma" are Ryan J. Soose MD, Jeffrey P. Simons MD, and David L. Mandell MD, all from the Department of Pediatric Otolaryngology, Children's Hospital of Pittsburgh, PA. Their findings will be presented at The Twentieth Annual Meeting of the American Society of Pediatric Otolaryngology (ASPO) http://www.aspo.us/ being held May 27-30, 2005, at the J.W. Marriott Las Vegas Resort in Las Vegas, NV.

Methodology: Charts were retrospectively reviewed for all inpatients and outpatients with a diagnosis of oropharyngeal injury at Children's Hospital of Pittsburgh in a six-year period from 1998 to 2004. Some 107 charts were examined, encompassing young patients who had suffered an impalement-type injury to the soft palate, tonsillar region, or poster lateral pharyngeal wall. Other mechanisms of trauma to the oropharynx such as gun shot wounds and motor vehicle accidents were excluded.

Records were evaluated for the following clinical data points: age, sex, date of presentation, bleeding (at injury and at presentation), time from injury to presentation, mechanism (object) of injury, wound severity, site of injury, presence of foreign body, whether the patient was evaluated by an otolaryngologist, presence of neurologic symptoms, screening radiology tests and results, surgical therapy and indications, hospital admission and duration, antibiotic therapy, complications, and follow-up.

Data was analyzed to determine whether any clinical factors indicated which patients were more likely to undergo the following interventions: 1) computed tomographic angiography (CTA) 2) surgical therapy in the operating room, 3) hospital admission, and 4) antibiotic administration. The relationship between the patients' clinical factors and the presence of positive radiographic findings and/or clinical complications was also analyzed.

Results: The 107 charts of children (mean age = 3.8 years) with traumatic oropharyngeal injuries found the interventions included 1) antibiotic administration (n=77); 2) computed tomographic angiography (CTA) (n=52); 3) inpatient admission (n=44); and 4) surgical therapy (n=16). The following factors were significantly associated with an increased likelihood of undergoing CTA to rule out occult internal carotid artery damage: 1) injury to the lateral soft palate; 2) high wound severity score; and 3) otolaryngology consultation. Radiographic abnormalities (including free air, parapharyngeal edema, and hematoma) were found in 16 of 52 CTAs and were not associated with any of the specific clinical factors listed above. There were no cases of internal carotid artery injury or subsequent neurologic disorders, but in one case a suspicious hematoma required follow-up conventional angiography.

Conclusions: This research effort establishes guidelines for decision making for medical management of children with oropharyngeal injuries. Key among the recommendations is that all patients who are at risk for a carotid injury (lateral soft palate or peritonsillar wounds), regardless of wound severity, should be offered a CTA (or the institution's preferred imaging study) to evaluate for vascular injury. Indications for surgical exploration include closure of most grade 3 wounds (large tissue flap or oronasal fistula), hemostasis, difficult awake exam, and removal of foreign body. The study also suggests admission for patients who show neurologic changes, are sedated from the operating room or CTA, have an unreliable home situation, or have associated symptoms such as pain and dysphagia that limit oral intake. Overnight stays for observation of neurologic status is not recommended because these complications are rare and do not always occur in the first twenty-four hours. Antibiotic prophylaxis in grade 2 and 3 wounds is called for because of the mucosal disruption associated with these wounds.