Injury to the Palate -- General Information
General:
- Injuries to the palate are relatively common in the pediatric population.
- A child’s propensity to place objects in their mouth, along with their unsteady gait, make trauma to the palate more common in these patients.
- Most palatal injuries heal without medical intervention due to the palate’s high healing capacity.
- The carotid artery, with its close proximity to the lateral peritonsillar and palatal tissues, is susceptible to injury with trauma to the posterior oropharynx.
- Neurologic sequelae following palatal injury have been reported in 32 cases due to compression or thrombosis of the ICA and subsequent cerebral ischemia.
- Although infection is rare, deep neck infections are possible with penetrating injuries to the oropharynx and empiric antibiotics should cover oral flora.
Presentation:
- The mean age for presentation is less than 4 years of age with males being 2x as likely as females.
- The most common objects are sticks, pens, pencils, toys, and straws.
- Sticks were implicated in roughly 25% of all cases.
- Report of bleeding occurs in 87% at time of injury yet only 3% at time of presentation.
- An otolaryngology consult is requested in 87% of cases (Shoose).
Surgical Repair:
- Surgical repair is typically indicated for penetration injuries with risk of foreign body, gross contamination, large avulsions, or hanging palatal flaps.
- Some surgeons advocate for surgical intervention if the injury is >2cm
- Repair can be accomplished with either primary repair or with rotational flaps.
- There are many reports of spontaneous healing of the palate, even with large, gaping perforations.
Antibiotics:
- Antibiotics are not typically required due to the oral cavity’s general resistance to infection.
- Antibiotics may be indicated if there is gross contamination or in large lacerations requiring surgical repair.
- In general, lacerations >1cm may benefit from empiric antibiotics
- Empiric antibiotics should cover oral flora.
- Ampicillin-sulbactam for inpatients
- Amoxicillin–clavulanate potassium for outpatients
- A prospective randomized trial in 100 patients demonstrated no statistical significance between the group receiving antibiotics and the group without. (Alteri)
- Tetanus vaccination status should be assessed with oropharyngeal injuries
Neurologic Complications:
- Neurologic complications are exceedingly rare, yet can be devastating if they occur.
- It is estimated that vascular events occur in <1% of palatal injuries (Hennely).
- In a retrospective cohort study of 205 children with palatal injuries that did not undergo operative repair:
- None had a stroke
- Only one patient developed an infection
- In a retrospective cohort study of 205 children with palatal injuries that did not undergo operative repair:
- In reported cases, vascular compromise occurred following a “lucid interval” typically between 24 and 48 hours after injury.
- Complications occurring up to 72 hours post-injury have been reported.
- Parents should be encouraged to seek treatment if their child experiences:
- Decreased level of consciousness
- Unilateral weakness
- Excessive irritability
- Headache or changes in vision
- Neck swelling or bleeding of the mouth
Diagnostic Studies:
- Much debate exists about the need for imaging following palatal injury
- Carotid ultrasound, MRA, and CTA remain the most useful choices in practice, as they are minimally invasive.
- CTA is often the preferred modality due to its high sensitivity and widespread availability
- If carotid involvement is suspected, the “gold standard” is carotid angiography. However, this is often considered overly invasive.
Interventions for Neurologic Complications:
- The best interventional method is yet to be determined, however, immediate diagnostic imaging will help guide further therapy.
- Medical options include anticoagulation or thrombolysis.
- Anticoagulation should be initiated with confirmed ICA thrombosis before neurologic sequelae occur
- These carry the risk for uncontrolled bleeding from injury site or hemorrhagic stroke
- Anticoagulation should be initiated with confirmed ICA thrombosis before neurologic sequelae occur
- Surgical options include embolectomy, grafting, and shunting of the occluded ICA
Hospitalization:
- Indicated for cases requiring potential surgical intervention:
- Foreign body, gross contamination, large avulsions, or hanging palatal flaps
- Indicated for patients with potential airway compromise, <1 year of age, unreliable social circumstances
- Debate exists about hospitalization merely to observe for potential neurologic complications and is generally not indicated.
Suggested Reading:
- David A. Randall, MD, and D. Richard Kang, MD. Current management of penetrating injuries of the soft palate. Otolaryngology–Head and Neck Surgery (2006) 135, 356-360
- Hennely, K. et al. Incidence of morbidity from penetrating palate trauma. Pediatrics 2010.
- Ryan J. Soose. Evaluation and Management of Pediatric Oropharyngeal Trauma. Arch Otolaryngol Head Neck Surg. 2006
- Radowski D, McGill TJ, Healy GB, Jones DT: Penetrating trauma of the oropharynx in children. Laryngoscope. 103:991-94, 1993.
- Altieri M, Brasch L. Antibiotic prophylaxis in intraoral wounds. Am J Emerg Med 1986;4:507–10