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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 24  |  Issue : 4  |  Page : 176-178

Conservative management of a complicated pharyngeal perforation caused by oral blunt trauma


1 Department of Otolaryngeology, Ohoud Hospital, Medina, Kingdom of Saudi Arabia
2 College of Medicine, Alrayan Medical College, Medina, Kingdom of Saudi Arabia

Date of Submission24-Jul-2022
Date of Decision30-Aug-2022
Date of Acceptance03-Sep-2022
Date of Web Publication10-Nov-2022

Correspondence Address:
Dr. Nisreen Ghazi Albouq
Department of Otolaryngeology, Ohoud Hospital, Madinah
Kingdom of Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjoh.sjoh_34_22

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  Abstract 


In children, pharyngeal perforation is a very uncommon injury. Most of the time, it is caused by secondary instrumentation. Laceration of the pharyngeal wall poses a life-threatening risk if not detected and treated promptly. A high level of suspicion is required in such cases, so hospitalization is needed for observation until an accurate diagnosis can be made. Here, we described a case of pharyngeal perforation in a 5-year-old boy who had oral blunt trauma and developed pneumomediastinum, which we managed conservatively.

Keywords: Blunt trauma, complication, conservative management, pharyngeal perforation, pneumomediastinum


How to cite this article:
Albouq NG, Alahmadi JK, Felemban W, Alraddadi AF, Julaidan RA. Conservative management of a complicated pharyngeal perforation caused by oral blunt trauma. Saudi J Otorhinolaryngol Head Neck Surg 2022;24:176-8

How to cite this URL:
Albouq NG, Alahmadi JK, Felemban W, Alraddadi AF, Julaidan RA. Conservative management of a complicated pharyngeal perforation caused by oral blunt trauma. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2022 [cited 2023 Jan 30];24:176-8. Available from: https://www.sjohns.org/text.asp?2022/24/4/176/360837




  Introduction Top


Pharyngeal perforations are infrequent in children. They are mainly caused by instrumentation or external penetrating injuries,[1] such as when a child falls with a toothbrush or when he/she puts a stick, pencil, broom, or other items in his/her mouth.[2] Laceration of the pharyngeal wall can allow air, secretions, and bacteria to enter the parapharyngeal space and mediastinum, leading to life-threatening complications such as retropharyngeal abscesses, mediastinitis, or airway compromise.[1],[3] These injuries may go unnoticed until symptoms such as cervical pain and dysphagia along with other signs such as fever and subcutaneous emphysema appear.[2] We found just a few examples of cases that were similar to ours in the literature. Therefore, we are reporting on a 5-year-old child who went to the emergency department at Ohud Hospital; he had complained of mild throat pain for 2 h after putting a stick (broom) in his mouth. These symptoms could be misdiagnosed, so we recommend a high level of suspicion and immediate hospitalization and management to avoid complications that could be fatal.


  Case Report Top


A 5-year-old Saudi boy, not known to have any medical illness, presented with his family to the Emergency Department of Ohud Hospital, Madinah, Saudi Arabia. He had complained of throat pain for 2 h after he had inserted a stick (broom) in his mouth and hit a window sill. The pain was mild and associated with a small quantity of blood while spitting. He had no history of shortness of breath, dysphagia, odynophagia, hoarseness of voice, fever, loss of consciousness, vomiting, cyanosis, fatigability, or seizures. On examination, the patient looked well and was vitally stable: SpO2 was 97% on room air, his temperature was 36.9°C, his heart rate was 86 beats/min, and his respiratory rate of 26 breaths/min. There was no evidence of dehydration or respiratory distress. Oral examination revealed mild uvular edema. There was a laceration on the right side of the soft palate that was <1 cm long [Figure 1]. A flexible nasopharyngeal scope examination revealed a 2 cm linear defect at the posterior pharyngeal wall with no air or cavity, no active bleeding, no laryngeal edema, no pooling of secretions, and normal bilateral vocal cord mobility [Figure 2]. A lateral neck X-ray was done and it showed a significant amount of retropharyngeal air [Figure 3]. Computed tomography (CT) scan of the neck and chest was ordered and revealed retropharyngeal air bubbles at the nasopharynx and oropharynx levels extending to the upper mediastinum, resulting in pneumomediastinum [Figure 4].
Figure 1: Oral examination with laceration on the right side of the soft palate <1 cm long

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Figure 2: A flexible nasopharyngeal scope examination revealed a 2 cm linear defect at the posterior pharyngeal wal

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Figure 3: Lateral neck X-ray showing retropharyngeal air

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Figure 4: Computed tomography (CT) scan of the neck and chest showed retropharyngeal air bubbles at the nasopharynx and oropharynx levels extending to the upper mediastinum, resulting in pneumomediastinum

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The patient was admitted to the general ward and his vital signs were monitored closely. Laboratory investigation including complete blood count, electrolytes, renal function test, liver function test, and coagulation profile was done; all results were within the normal range. The patient received nothing by mouth, was kept on continuous intravenous (IV) fluid according to his weight and received the antibiotics cefuroxime and metronidazole through an IV line. One dose of dexamethasone 4 mg was given at time of admission for uvular edema. No surgical intervention was done.

The patient was examined daily by an ear, nose, and throat (ENT) consultant and his team. After he had been in hospital for 4 days, the posterior pharyngeal wall had healed, the uvula was normal and he had not developed a fever during his stay. A CT scan of his neck and chest was repeated and showed a large resolution of pneumomediastinum with only small air pockets remaining. The patient was discharged home on oral antibiotics and advised to eat a soft diet. He was given an outpatient department appointment for follow-up. The patient came to the follow-up appointment with no new complaints and the posterior pharyngeal wall was intact.


  Discussion Top


Pharyngeal perforation due to blunt trauma is rare. Early detection is a cornerstone to preventing life-threatening complications. Our 5-year-old patient presented 2 h after a blunt injury to his oral cavity that caused a 2 cm pharyngeal perforation. Pain is the most typical warning sign of pharyngeal perforation, as in our case.

The best screening method for detecting a probable pharyngeal injury is a fiber optic endoscopic examination because contrast-enhanced radiologic examinations frequently fail to detect hypopharyngeal injuries.[4],[5] The endoscopic examination would also show the exact size and location of the damage, which is required for subsequent workup and therapy.[6]

Niezgoda et al.[7] examined 11 patients with pharyngoesophageal perforation as a result of blunt neck trauma. Patients with a laceration <1 cm were managed conservatively while patients with large perforations were managed surgically.[7] Rowley et al.[2] reported on a 2-year-old child who presented with pharyngeal perforation following a perioral injury with a toothbrush and managed conservatively by ensuring the patient received nothing by mouth alongside IV fluid and systemic antibiotics.

More recently, nonoperative medical management of traumatic pharyngoesophageal perforation in selected cases has been advocated.[8] Hagr et al.[9] reported a case of a 23-year-old man who had a 2 cm posterior pharyngeal wall tear caused by blunt trauma. Even though the perforation was limited to the pharynx, they opted for surgical repair because of the size of the tear and the easy accessibility for repair. Optimal management of pharyngeal perforations in children remains controversial. When young children present early, nonsurgical therapy consisting of broad-spectrum antibiotics and esophageal rest has a success rate of almost 100%.[10]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Luqman Z, Khan MA, Nazir Z. Penetrating pharyngeal injuries in children: Trivial trauma leading to devastating complications. Pediatr Surg Int 2005;21:432-5.  Back to cited text no. 1
    
2.
Rowley H, Christian J, Dennis A. Pharyngeal perforation: An easily missed finding following intra-oral injury. J Accid Emerg Med 1995;12:145-6.  Back to cited text no. 2
    
3.
Tostevin PM, Hollis LJ, Bailey CM. Pharyngeal trauma in children-accidental and otherwise. J Laryngol Otol 1995;109:1168-75.  Back to cited text no. 3
    
4.
Fetterman BL, Shindo ML, Stanley RB Jr., Armstrong WB, Rice DH. Management of traumatic hypopharyngeal injuries. Laryngoscope 1995;105:8-13.  Back to cited text no. 4
    
5.
Ahmed N, Massier C, Tassie J, Whalen J, Chung R. Diagnosis of penetrating injuries of the pharynx and esophagus in the severely injured patient. J Trauma 2009;67:152-4.  Back to cited text no. 5
    
6.
Colby C, Moore C. Pharyngeal trauma: Two unique case reports. Open J Clin Diagn 2012;2:59-62.  Back to cited text no. 6
    
7.
Niezgoda JA, McMenamin P, Graeber GM. Pharyngoesophageal perforation after blunt neck trauma. Ann Thorac Surg 1990;50:615-7.  Back to cited text no. 7
    
8.
Dolgin SR, Wykoff TW, Kumar NR, Maniglia AJ. Conservative medical management of traumatic pharyngoesophageal perforations. Ann Otol Rhinol Laryngol 1992;101:209-15.  Back to cited text no. 8
    
9.
Hagr A, Kamal D, Tabah R. Pharyngeal perforation caused by blunt trauma to the neck. Can J Surg 2003;46:57-8.  Back to cited text no. 9
    
10.
Weber TR. Esophageal rupture and perforation. In: O'Neill JA, Rowe MI, Grosfeld JL, Fonlkalsrud EW, Coran AG, editors. Pediatric Surgery. Medina kingdom of Saudi Arabia: Mosby; 1998. p. 937-40.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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