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Journal of Indian Society of Pedodontics and Preventive Dentistry Official publication of Indian Society of Pedodontics and Preventive Dentistry
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CASE REPORT
Year : 2017  |  Volume : 35  |  Issue : 2  |  Page : 181-183
 

An infant case of intraoral penetrating injury with a toothbrush causing retropharyngeal and upper mediastinal emphysema


Department of Acute Critical Care Medicine, Juntendo University Shizuoka Hospital, Shizuoka, Japan

Date of Web Publication10-May-2017

Correspondence Address:
Youichi Yanagawa
Department of Acute Critical Care Medicine, Juntendo University Shizuoka Hospital, 1129 Nagaoka, Izunokuni, Shizuoka 410-2295
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JISPPD.JISPPD_114_16

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   Abstract 

A 2-year-old male child who was running and fell with a toothbrush in his mouth suffered an injury to the inside of his right cheeks. His mother noticed that the toothbrush had impaled his mouth, and removed it. On arrival, a wound was observed on the right cheeks and palate. His general condition was good. However, computed tomography revealed emphysema from the left side of epipharynx to the upper mediastinum. This patient shows the importance of not only checking the medical history and performing a physical examination but also performing an imaging examination.


Keywords: Intraoral penetrating injury, mediastinal emphysema, toothbrush


How to cite this article:
Jitsuiki K, Hashimoto A, Yoshizawa T, Yanagawa Y. An infant case of intraoral penetrating injury with a toothbrush causing retropharyngeal and upper mediastinal emphysema. J Indian Soc Pedod Prev Dent 2017;35:181-3

How to cite this URL:
Jitsuiki K, Hashimoto A, Yoshizawa T, Yanagawa Y. An infant case of intraoral penetrating injury with a toothbrush causing retropharyngeal and upper mediastinal emphysema. J Indian Soc Pedod Prev Dent [serial online] 2017 [cited 2019 Jul 24];35:181-3. Available from: http://www.jisppd.com/text.asp?2017/35/2/181/206029



   Introduction Top


Children frequently run around with objects in their mouths and tend to fall easily. Most cases can be managed in outpatient settings without further complications.[1] We report a case of accidental impalement injury and review the clinical aspects and management of this type of injury.


   Case Report Top


A 2-year-old male child who was running and fell with a toothbrush in his mouth suffered an injury to the inside of his right cheeks. Immediately after the accident, he lost consciousness for approximately 1 min, after which he regained consciousness and cried. His mother noticed that the toothbrush had impaled his mouth, and removed it [Figure 1]. She called an ambulance, and the he was transferred to our hospital. On arrival, he was crying uncontrollably, had a blood pressure of 114/102 mmHg, a heart rate of 180 beats per minute and a SpO2 of 100% in room air. A wound of approximately 5 mm in length was observed on the right cheeks and palate. The bleeding had already stopped. He vomited a few times with food debris containing a small amount of clotted blood. Nevertheless, his general condition was good. Head and neck computed tomography was used to check for the presence of foreign bodies; none were found. However, unexpectedly, the imaging revealed emphysema, which covered a wide range of the left side of epipharynx to the upper mediastinum [Figure 2]. He was transferred to Shizuoka Prefectural Kodomo Hospital on the same day due to the risk of mediastinitis and neck abscess. Our standard protocol for treating emphysema is as follows: For a small amount of emphysema, conservative management using antibiotics is first selected to resolve any anaerobic bacteria. If the patient is complicated with epiglottitis, tracheal intubation or tracheostomy is applied; if the patient is complicated with deep neck or mediastinal abscess, drainage is performed; if the patient is complicated with meningitis or a delayed-onset neurological deficit, additional symptomatic treatments are applied. After admission, he was treated with an infusion of antibiotics for just 2 days. After discharge on day 14 of hospitalization, he was free of any symptom for 6 months.
Figure 1: A toothbrush removed by a patient's mother. The toothbrush is not noticeably defective. It is about 17 cm in length

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Figure 2: Computed tomography on arrival. The computed tomography of the neck indicates retropharyngeal and upper mediastinal emphysema (arrow)

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   Discussion Top


Pediatric patients have a chance of suffering from intraoral injuries from such items as toothbrushes, pencils, or chopsticks.[1],[2] These cases are associated with a risk of direct brain injury, delayed cerebral infarction due to the injury of internal carotid artery, lethal brain swelling related to jugular vein thrombosis and deep neck abscess, even if their physical status or wound does not appear to be serious in nature.[3],[4],[5],[6],[7] This patient shows the importance of not only checking the medical history and performing a physical examination but also performing an imaging examination.

The Tokyo Fire Department announced the results of a study on infantile toothbrush-related injuries (http://www.tfd.metro.tokyo.jp/lfe/topics/201506/hamigaki.html). From 2010 to 2014, there were 207 cases of infantile toothbrush-related injury in which the injured child had been transported by an ambulance to a hospital. Among them, 97 (46.8%) cases occurred in children 1 year of age, and 61 (29.4%) cases occurred in children 2 years of age; 158 (76.3%) cases in total occurred in children either 1 or 2 years of age. Of these 158, 133 (64.3%) were induced by tripping and falling, 19 (9.2%) by collision and 14 (6.8%) by falling from a stool. Two of the 207 cases suffered life-threatening injuries, and 29 suffered moderate injuries that required admission. Accordingly, the Tokyo Fire Department concluded that it is necessary for parents and guardians to pay careful attention when infants are brushing their teeth.

Regarding the clinical consequences if emphysema is not found and treated in a timely manner, as mentioned above in the case presentation, the possibility of suffocation due to epiglottitis or lethal deep neck abscess, mediastinitis or meningitis increases.[8],[9],[10],[11] In addition, carotid injury or carotid inflammation may result in a delayed-onset neurological deficit.[6] Accordingly, we followed the patient for 6 months after the accident.

The pharynx and oral cavity are particularly vulnerable to injury in children who fall with a toothbrush or other implement in the mouth. These injuries may have serious consequences but may go unrecognized until symptoms appear.[12] Accordingly, identifying a pharyngeal perforation requires a high index of suspicion. In addition, educating parents or childcare providers on not allowing children to play with a toothbrush in their mouth might be important.


   Conclusion Top


As a pharynx and oral cavity are vulnerable to injury in children who fall with a toothbrush or other implement in the mouth, not only checking the medical history and performing a physical examination but also performing an imaging examination is important.

We obtained financial support from Pfizer Corporation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Uchino H, Kuriyama A, Kimura K, Ikegami T, Fukuoka T. Accidental oropharyngeal impalement injury in children: A report of two cases. J Emerg Trauma Shock 2015;8:115-8.  Back to cited text no. 1
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2.
Wang HF, Li WC, Xu N, Fu SL. Transoral penetrating craniocerebral injury by a bamboo chopstick in a child. J Clin Neurosci 2013;20:746-8.  Back to cited text no. 2
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3.
Pitner SE. Carotid thrombosis due to intraoral trauma. An unusual complication of a common childhood accident. N Engl J Med 1966;274:764-7.  Back to cited text no. 3
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4.
Slade PM, Larsen MP. Dysphagia, dysphonia and sore throat following cerebral infarction: An unexpected cause. BMJ Case Rep 2015;2015. pii: Bcr2015210091.  Back to cited text no. 4
    
5.
Chung SM, Kim HS, Park EH. Migrating pharyngeal foreign bodies: A series of four cases of saw-toothed fish bones. Eur Arch Otorhinolaryngol 2008;265:1125-9.  Back to cited text no. 5
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6.
Kono R, Ota S, Shimoe Y, Tanaka A, Kuriyama M. A child who developed internal carotid artery obstruction 2 weeks after incurring an intraoral blunt injury: A case report. Rinsho Shinkeigaku 2015;55:501-4.  Back to cited text no. 6
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7.
Hasegawa M. Should medical accidents be judged in criminal court? Establishing a new patient safety system in Japan. Kyorin University Hospital: Kyorin University chopstick case from the standpoint of an otolaryngologist. Jpn Med Assoc J 2012;55:159-65.  Back to cited text no. 7
    
8.
Chang HW, Lin WJ, Hu SY. Acute epiglottitis complicating an emphysematous abscess. CJEM 2013;15:184-5.  Back to cited text no. 8
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9.
Wilson CD, Kennedy K, Wood JW, Kumar TK, Stocks RM, Thompson RE, et al. Retrospective review of management and outcomes of pediatric descending mediastinitis. Otolaryngol Head Neck Surg 2016;155:155-9.  Back to cited text no. 9
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10.
Ku BD, Park KC, Yoon SS. Medically treated deep neck abscess presenting with occipital headache and meningism. J Headache Pain 2008;9:47-50.  Back to cited text no. 10
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11.
Liu CH, Lin CD, Cheng YK, Lin HC, Tsai MH. Deep neck infection in children. Acta Paediatr Taiwan 2004;45:265-8.  Back to cited text no. 11
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12.
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. 12
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    Figures

  [Figure 1], [Figure 2]



 

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    Abstract
   Introduction
   Case Report
   Discussion
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    References
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