Dangers of Oral Injuries in Active Children

Reference: Curry SD, et al. Systematic Review of CT Angiography in Guiding Management in Pediatric Oropharyngeal Trauma. Laryngoscope. March 2023 Date: January 30, 2024 Guest Skeptic: Dr. Alexandra (Ali) Espinel is an Associate professor of pediatrics and otolaryngology at Children’s National Hospital and George Washington University. She is also the director of the Pediatric Otolaryngology Fellowship at Children’s National Hospital. Case: You’re working the morning shift in the emergency department (ED) when you encounter a 3-year-old boy and his family. His parents tell you that he was getting ready to go off to daycare and brushing his teeth while standing on a step stool by the sink. He slipped and the toothbrush poked him in the back of the mouth. Initially, his parents noticed that he was bleeding from his mouth and saw what looked like a wound towards the back of his throat. The boy cried immediately afterwards but has otherwise been acting like himself. On your exam, you notice a small penetrating intraoral injury just lateral to the soft palate without evidence of continued bleeding. His parents ask you, “Is he going to be, okay? We’re glad he’s not bleeding anymore. Do you think he needs any imaging to see if he hurt anything?” Background: Kids like to put things in their mouths. Kids like to run around. Sometimes, kids may fall while having something in their mouth which may cause damage to their oropharynx. The ensuing damage can vary. It could be blunt trauma or penetrating trauma. We get concerned about injuries to the soft palate because of possible deep space neck infection and the risk of injury to the carotid artery behind it which has been associated with thrombosis, dissection, and cerebral infarctions. These super scary complications have been reported in the literature but seem relatively rare. We have many clinical decision tools for imaging in pediatric head trauma [1] or abdominal trauma [2]. But we do not have any of the same tools for oropharyngeal injury which means that there is wide variation about which imaging studies are ordered. Clinical Question: What is the role of CT angiography (CTA) in the diagnosis and management of pediatric oropharyngeal trauma?  Reference: Curry SD, et al. Systematic Review of CT Angiography in Guiding Management in Pediatric Oropharyngeal Trauma. Laryngoscope. March 2023 Population: Patients <18 years old with trauma to the oropharynx. They included meta-analyses, systematic reviews, randomized control trials (RCTs), case-control and cohort studies, case series and case reports. Excluded: Oropharyngeal trauma combined with other severe head injury or multisystem trauma, not primary research, non-English publication Intervention: CTA Comparison: No CTA Outcome: radiologic and clinical outcomes including infection, injury to vasculature, cerebrovascular injury, and neurologic abnormalities. Type of Study: Systematic Review and Meta-Analysis of diagnostic studies. Authors’ Conclusions: “Imaging with CTA yielded radiological abnormalities in a few instances. These results do not support the routine use of CTA in screening pediatric oropharyngeal trauma when balanced against the risk of radiation, as it rarely resulted in management changes and was not shown to improve outcomes.” Quality Checklist for Systematic Review Diagnostic Studies: The diagnostic question is clinically relevant with an established criterion standard. Yes The search for studies was detailed and exhaustive. No. The methodological quality of primary studies was assessed for common forms of diagnostic research bias. Yes. The assessment of studies was reproducible. Yes There was low heterogeneity for the primary outcome. Yes. The summary diagnostic accuracy is sufficiently precise to improve upon existing clinical decision-making models. No. Results: The initial search identified 5,