Year : 2010 | Volume
: 28 | Issue : 2 | Page : 134--136
A rare case of life-threatening penetrating oropharyngeal trauma caused by toothbrush in a child
S Sagar1, N Kumar1, M Singhal1, S Kumar1, A Kumar2,
1 Department of Surgery, Trauma Centre, AIIMS, New Delhi, India
2 Department of Radiology, Trauma Centre, AIIMS, New Delhi, India
Department of Surgery, Room no 306, J P N Apex Trauma Centre AIIMS, New Delhi - 110 029
We present a case of 10year-old boy with oropharyngeal injury caused by a toothbrush which penetrated the parapharyngeal space. Initial examination revealed broken end of the toothbrush in oral cavity with the head of the toothbrush having bristles, beyond the soft palate. Tongue and palate were lacerated and there were blood and oral secretions in the oral cavity. Patient was having bradycardia. Computed tomography (CT) scan showed the toothbrush head near the carotid artery, the carotid being laterally displaced. The foreign body was surgically removed without any intraoperative or postoperative complications.
|How to cite this article:|
Sagar S, Kumar N, Singhal M, Kumar S, Kumar A. A rare case of life-threatening penetrating oropharyngeal trauma caused by toothbrush in a child.J Indian Soc Pedod Prev Dent 2010;28:134-136
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Sagar S, Kumar N, Singhal M, Kumar S, Kumar A. A rare case of life-threatening penetrating oropharyngeal trauma caused by toothbrush in a child. J Indian Soc Pedod Prev Dent [serial online] 2010 [cited 2021 Jul 28 ];28:134-136
Available from: https://www.jisppd.com/text.asp?2010/28/2/134/66758
Oropharyngeal injuries are quiet common in children, and penetrating injuries carry high morbidity and can be fatal at times. Commonly, the penetrating injuries are caused by sharp-end objects and can be life threatening.
A 10-year-old boy was brushing his teeth with adult toothbrush while riding a bicycle outside his home when he suddenly lost control of his bike and fell on ground with brush in his mouth. The brush got broken from the middle and half of it got stuck in his mouth. There was bleeding from mouth and he was not able to speak. The child was brought by an ambulance to our trauma centre.
There was blood coming from his mouth and the broken end of the brush was visible in the mouth [Figure 1]. The boy was in severe pain and was not able to speak. Oral cavity was cleared of blood and secretions by active suction. The boy was maintained 100% saturation on oxygen, being given by nasal route. His heart rate was 54 beats per minute Bradycardia was suggestive of excess vagal discharge to the heart). There was laceration over the lateral margin of his tongue and soft palate and he was bleeding from there. The whole of the length of the brush was visible in the oral cavity and the part bearing the bristles was way beyond the soft palate and was not visible [Figure 2]. His oropharyngeal reflexes were intact and neurological examination ruled out any intracranial or spinal cord injury. There was no sign of emphysema and examination of neck was normal. A lacerated 1.5-cm linear wound was present on the prepucial skin with bruise over penile shaft.
After primary and secondary surveys, urgent computed tomography (CT) was done. Noncontrast CT of head and spine was normal. Contrast-enhanced CT scan of neck showed that the tooth brush had penetrated the postero-lateral part of pharyngeal wall and reached the parapharyngeal space beyond the carotid vessels, pushed them laterally at the level of 2nd cervical vertebrae [Figure 3]. Carotid vessels were not injured and there was no contrast leak on delayed film. There was no emphysema of the parapharyngeal space. Thorough study of the CT scan led to the conclusion that the tooth brush can be retrieved via oral route though there was a risk of damaging the internal carotid artery as the widest part of the head of the brush had passed beyond the carotid vessels.
The patient was taken to the operating room and fiberoptic oral intubation was done. The tooth brush was removed after widening of the entry wound by giving a release incision. The wound was sutured after achieving hemostasis. Lacerated wounds over tongue and palate were also sutured. Postoperatively, the patient was kept intubated and was shifted to the ICU. Intravenous antibiotics were given and close monitoring was done. The patient was extubated after 24 h and was discharged on third postoperative day without any complication.
Brushing of teeth has become an integral part of our daily routine and is regarded as very safe even in children. Tooth brush is made up of relatively pliable material and has smooth surface and round corners and is designed in such a way that it should not harm the delicate tissues of oral cavity. Even then cases have occurred where it has led to injury inside the oral cavity especially in children.  Most common sites of injury are gingivobuccal sulcus, buccal fat pad, soft palate, anterior faucial pillar, pharynx. , Most of these injuries are trivial in nature and nothing needs to be done in most cases. Penetrating intraoral injuries due to tooth brush are very rare and only few cases are recorded all over the world.
Our case signifies that a daily chore as simple as brushing of teeth should not be taken casually especially in children and must be done under the supervision of adults.
Removal of any intraoral foreign body specially when soft tissue penetration is suspected must never be done before completely investigating the case.  CT scan is a very useful investigation modality in such cases, and if vascular injury is suspected then CT angiography  is to be done before embarking upon removing the foreign body and services of vascular surgeon is of help in such cases.
After removing the foreign body, the wound left can be sutured or left open. It is better to leave the wound open if it is infected, has slough or necrotic tissue at its depth. A clean wound should better be sutured and closed. Leaving it open will unnecessarily subject it to very high bacterial load of oral secretions. Closing of an infected wound can lead to development of retropharyngeal abscess , and even life-threatening mediastinitis,  and for such wounds debridement and drainage is to be done. If it occurs, drainage of retropharyngeal abscess is required under antibiotic cover. Mediastinitis can lead to formation of mediastinal abscesses and the condition demands higher antibiotic cover and thoracotomy may be required in some cases. 
Antibiotic cover  is very important in cases of penetrating intraoral injuries as the oral cavity is bed to diverse species of bacteria both aerobic and anaerobic.  Wide antibiotic cover is essential, and if needed, antifungal drugs have to be added in the treatment. The choice of antibiotic depends on various factors like micro-organisms isolated from the wound,  patient's immunity status,  earlier antibiotic use, antibiotic resistance in the population, ICU antibiotic usage and most importantly postoperative complications,  if any. Frequent gargles and mouth rinse is important.
Carotid artery injury like tear or rupture, though rare, can be fatal.  If carotid artery tear is contemplated on Contrast Enhanced Computed Tomograpy (CECT) neck, CT angiography  should be done. Carotid artery tear is to be repaired and is better done by a vascular surgeon. Another complication is carotid artery thrombosis  which can later lead to stroke and paralysis. Late presentation of carotid artery injury can be dissecting aneurysm or carotid-jugular fistula.
Any cough or cold must be treated at the earliest as high pressure generated during these activities can push air through the wound and can compromise the airway and can also cause mediastinitis and pneumomediastinum with their complications. 
Through our case report, we would like to emphasize that parents should be more careful about the brushing activity of children and need to supervise it. Removal of impacted intraoral foreign body should not be tried in an emergency room. The extent of injury and the location of the foreign body must be established before removal. CECT scan and CT angiography are two very helpful diagnostic modalities. Clean wounds can be sutured and in doubt the wound can be left open with a close follow-up. Though prolonged intubation is not essential, the patient can be kept intubated for first 24 h to keep the airway secure and to allow the edema to subside. Prophylactic antibiotic cover can be given as infection, if occurs, is difficult to manage and carries high morbidity. Careful follow-up is needed to observe any change in speech pattern.
In the present case, after 1 month follow-up, patient is doing well with no significant speech defect.
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