Thrombosis of the internal carotid artery secondary to soft palate injury in children and childhood. Report of two cases

Trauma to the soft palate is a uncommon event during childhood. Stroke following intraoral trauma is also rare, but has been well documented by the current literature as a potentially serious complication. In this article, we report 2 cases of posttraumatic internal carotid artery thrombosis depicted by imaging studies. We discuss pathogenesis, and the literature is reviewed.

[Thrombosis of the internal artery secondary to soft palate injury: case report]

Stroke following intraoral trauma is a rare complication of a common childhood injury. In the literature these complications have been well documented, however this condition is still infrequent. In order to alert the physicians about this possible injury we report our experience with one case. Computer tomography and magnetic resonance imaging evidenced complete occlusion of the internal carotid artery. Pathogenesis of this oral trauma is discussed.

Histologic and physiologic effects of electrocautery, CO2 laser, and radiofrequency injury in the porcine soft palate

OBJECTIVES

This study was undertaken to compare the effects of electrosurgery, CO2 laser, and radiofrequency on the histological structure and physiological properties of the soft palate. These surgical techniques are used for stiffening and reducing the soft palate in the treatment of snoring and mild sleep apnea.

STUDY DESIGN

Fifteen pigs were divided into five groups.

METHODS

group 1 underwent electrosurgery incision of the lateral soft palate and excision of the uvula. Group 2 underwent the same procedure with the CO2 laser. Group 3 underwent CO2 laser ablation of the midline soft palate mucosa. Group 4 underwent radiofrequency volumetric reduction. Group 5 served as control. After 5 weeks the animals were sacrificed. Soft palate mucosa and muscle were subjected to tensiometric and histological analysis. Statistical analysis of tensiometric measurements was done with an ANOVA using a Bonferroni-Dunn correction.

RESULTS

Tensiometric measurements of the mucosa were increased over normal controls when the surgical technique resulted in mucosal disruption. When the surgical technique resulted in primarily muscle disruption (radiofrequency) tensiometric measurements of the muscle were increased over controls. Histological analysis demonstrated normal remucosalization in all specimens, with fibrosis increased at the site of the primary injury.

CONCLUSIONS

The type of injury produced resulted in identifiable patterns of physiological and histological change. Understanding of the effects of available surgical techniques is important in guiding our choice of surgical approach and allows us to better counsel our patients on their surgical options.

[Transendoscopic laser surgery of exercise-induced dorsal displacement of the soft palate in horses]

From 1995 to 1997 11 racehorses, one Hanoverian and one Pony were presented to the clinic with a sudden appearing, very loudly gurgling expiratory respiratory noise. Considering the preliminary report and the clinical and endoscopical findings, as exercise induced dorsal displacement of the soft palate (DDSP) was found to be the cause of the respiratory noise. The 13 horses were treated in general anaesthesia by transendoscopic coagulation of the caudal margin of the soft palate with a Neodym-YAG-Laser. This surgical intervention had to be repeated on four horses with unchanged signs. Eight of 13 horses (62%) did not show any respiratory noises after the operation. These horses were again successfully raced and ridden. Only an improvement was observed in two horses (15%), while in three patients (23%) the respiratory noise was unchanged after surgery. The laser chirurgic approach to the exercise induced DDSP offers, compared to previous therapies important advantages, like shorter recoveries, combined with similar success rates.

Management of oropharyngeal trauma in children

OBJECTIVE

To determine the indications for admission, requisite imaging studies, and urgent medical or surgical intervention.

DESIGN

We retrospectively reviewed the charts of 26 children (age range, 5 months to 14 years) who were seen by the otolaryngology service in the emergency department at the Children's National Medical Center, Washington, DC, from 1985 to 1993 and who were diagnosed as having oropharyngeal trauma. We specifically looked for common findings in the history and physical examination on initial presentation to predict the necessary steps in evaluation and management.

SETTING

Tertiary care pediatric referral center.

RESULTS

Indications for admission were (1) concern about neurologic injury, (2) concern about vascular injury, (3) radiographic evidence of retropharyngeal free air or abscess, (4) pneumomediastinum, and (5) unreliable adult supervision at home. Six patients required surgery; 3 underwent retropharyngeal aspiration or incision and drainage procedures; 2 required neck explorations; and 1, who had an impaled foreign body in the parapharyngeal space, underwent surgical extraction. There were no vascular, neurologic, or other permanent injuries.

CONCLUSIONS

Oropharyngeal trauma may result in palatal and posterior pharyngeal wall injury requiring closure of lacerations and management of retropharyngeal free air. Rarely does an injury lead to retropharyngeal abscess or significant pneumomediastinum. Lateral oropharyngeal injuries require increased concern about potential neurovascular impairment. However, neither the mechanism of injury nor the degree of injury correlates with the potential for neurovascular sequelae. Since neurovascular involvement may not become clinically apparent until days or weeks after the incident, admission for observation alone should be based on the distance from the patient's home to the hospital and on the level of reliable adult supervision. Indications for medical and surgical treatment of internal carotid artery thrombosis remain controversial.

Management of the carotid artery following penetrating injuries of the soft palate

Penetrating injuries of the soft palate are not uncommon in the pediatric population. The majority are minor, requiring only conservative treatment. Despite the close proximity of the carotid artery to lateral soft palate and tonsillar fossa, the incidence of carotid injury is low. When carotid injury does occur, it is usually secondary to blunt trauma to the carotid with a resultant thrombosis. A concomitant neurologic deterioration often follows occurring from 3 h to 3 days after the initial injury (Hengerer et al. (1984). Laryngoscope 94, 1571-1575). The potential neurologic sequelae of such an injury make these seemingly innocuous wounds a diagnostic and management dilemma for the clinician. We present an unusual case of an internal carotid artery pseudoaneurysm in a neurologically intact child following soft palate impalement. We review the diagnostic evaluation including angiography and magnetic resonance angiography, the surgical approach, and postoperative issues including anticoagulation. The literature is reviewed and a discussion regarding the approach to penetrating injuries of the soft palate is presented.

Angina bullosa hemorrhagica

Angina bullosa hemorrhagica is characterized by acute blood blisters, mainly on the soft palate. Elderly patients are usually affected and lesions heal spontaneously without scarring. The pathogenesis is unknown, although it may be a multifactorial phenomenon. Trauma seems to be the major provoking factor and long term use of steroid inhalers has also been implicated in the disease. No underlying hematologic or immunopathogenic disorder has been found. Treatment is symptomatic. We present a 67-year-old patient with recurrent oral blood blisters which were diagnosed as angina bullosa hemorrhagica. Trauma by dental injections and use of steroid inhalers were identified as etiologic factors in this case. Erosions healed with a week. Although this is a benign condition, it may result in acute airway obstruction. Recognition is, therefore, of great importance for dermatologists.

Palatal trauma: an unusual cause of a parotid sinus

A case is described of a 3-year-old boy who presented with a seemingly trivial injury to his soft palate, who went on to develop a parotid sinus as a result of a retained foreign body. This is a rare clinical problem and it highlights the difficulty in the clinical assessment of a palatal injury--especially in children. The child had the foreign body removed successfully 5 months after the initial injury and made an uneventful recovery.

Modifications of the palatal crib habit-breaker appliance to prevent palatal soft tissue embedment

The authors recommended the use of an acrylic palatal button and .040 to .045 inch palatal wires as modifications to the palatal crib appliance. By enhancing the strength of the wire, and providing anterior support, these modifications can reduce the likelihood of the crib becoming embedded in the palatal soft tissues.

[The histogenetic characteristics of the epithelial tissues of the mucosa of the pharyngeal and oral surfaces of the soft palate in ontogeny and under experimental conditions]

Processes of the development and growth of the soft palate mucosas in ontogenesis and also proliferation, growth and differentiation of epithelial structures were studied in the experiment. The epithelium of the soft palate nasal surface was established to be more labile and to be characterized with polymorphism forming single-layer and pseudostratified structures. Under these conditions the oral surface epithelium keeps stratified structures firmly. On the basis of discovered differences of the epithelium biological qualities a suggestion is made on the different genetic origin of epithelial tissues of mucosas of the soft palate oral and pharyngeal surfaces.

Surgical repair of iatrogenic soft palate defects in two horses

A 4-year-old Thoroughbred filly was referred for evaluation of a soft palate defect that had been created several weeks earlier during surgical correction of epiglottic entrapment, performed transorally. Surgical correction of the defect was performed via mandibular symphysiotomy. At 85 days after repair, the horse raced successfully. A 2-year-old Thoroughbred filly was admitted for evaluation and treatment of epiglottic entrapment. The soft palate was lacerated during transnasal division of the entrapping membrane. A 2-cm full-thickness soft palate laceration was repaired transorally.

Penetrating trauma of the oropharynx in children

Penetrating trauma of the oropharynx is not an uncommon problem in the pediatric population. Innocuous injuries with minor soft-tissue trauma have been associated with severe neurologic sequelae. A review of 77 oral trauma cases that occurred from 1981 to 1990 at Boston Children's Hospital was undertaken to see if constant factors could be identified so that a treatment protocol might be outlined for these patients. Twenty-three (30%) patients sustained injury to the soft palate and peritonsillar area. Fifty percent of these cases required surgical debridement and repair. None of the 23 patients developed neurological sequelae. Physical examination may not correlate with the development of symptoms nor the mechanism of injury. Care should be taken during the examination to identify any neurological problems that may not relate to the degree of injury. Conservative management can be entertained if no abnormal neurologic findings are noted.

Impalement injuries of the palate in children: review of 131 cases

Impalement injuries of the soft palate and oropharynx are common injuries especially in children. Devastating neurologic sequelae secondary to thrombus propagation in the internal carotid artery are rare but well-documented complications of these innocuous appearing injuries. Neurologic sequelae have been reported anywhere from 3 to 60 hours after the injury. Protocols that include hospitalization up to 72 hours have been advocated. In order to evaluate the effectiveness and practicality of such protocols, all hospital admissions for palate injuries in the past 17 years were reviewed. Of the 131 cases reviewed, no complications were discovered during hospitalization, nor were there any complications in these patients seen in follow up. Based on this review, the majority of soft plate and oropharyngeal impalement injuries can be managed on an outpatient basis. Parental counseling, similar to instructions given in instances of mild head trauma, as well as close follow up in the office are felt to be a more reasonable and as well as a safe treatment plan. A suggested instruction form is presented.

Horner's syndrome caused by intra-oral trauma

A 7-year-old boy developed a Horner's syndrome after falling on a stick that penetrated his peritonsillar soft palate. He did not suffer from any major vascular injury, and pharmacologic testing indicated a preganglionic lesion. We review previously reported cases of oculosympathetic paresis caused by surgical and nonsurgical intra-oral trauma. Because of the proximity between sympathetic and vascular structures in the lateral and parapharyngeal space, Horner's syndrome in the setting of intra-oral trauma should prompt evaluation of the internal carotid artery. Magnetic resonance imaging may be a reasonable noninvasive method for this investigation.

Caustic ingestion injuries of the upper aerodigestive tract

Few reports have described in detail the injuries that occur to the oral cavity, pharynx, and larynx following caustic ingestion. The role of dynamic radiographic studies to delineate the extent of damage has been minimized. In-depth radiographic analysis of such cases has not, to our knowledge, been previously reported. In order to examine the injuries and functional abnormalities of these sites following caustic ingestion, the records of The Johns Hopkins Swallowing Center were reviewed. Five patients were identified as having significant upper aerodigestive tract caustic injuries. All patients had dysphagia, epiglottis injuries, and incomplete laryngeal protection with aspiration. Four of five had sustained some degree of esophageal stenosis. Also noted were pharyngeal muscle dysfunction, nasopharyngeal regurgitation, tongue fixation, and hypopharyngeal stenosis. Roentgenographic findings are described and illustrated. The multidisciplinary approach to the management and rehabilitation of these patients is discussed.

An unusual case of traumatic haematoma of soft palate

Ingestion of small bones often causes oropharyngeal trauma. I present an unusual case of a potentially life-threatening haematoma of the soft palate caused by a chicken bone. To my knowledge, this is the only case reported in the English literature.