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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 26  |  Issue : 2  |  Page : 132-134

Penetrating injury to the floor of mouth in a child: Management of a challenging case


1 Department of Paediatric Surgery, MKCG Medical College, Berhampur, Odisha, India
2 Department of General Surgery, MKCG Medical College, Berhampur, Odisha, India
3 Department of Paediatric Surgery, IMS Banaras Hindu University, Varanasi, Uttar Pradesh, India

Date of Submission25-Jan-2021
Date of Acceptance17-Dec-2021
Date of Web Publication10-Feb-2022

Correspondence Address:
Dr. Pranay Panigrahi
Department of Paediatric Surgery, IMS Banaras Hindu University, Varanasi - 221 005, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmgims.jmgims_12_21

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  Abstract 


Penetrating injuries of the oro-maxillofacial region are not only rare but difficult to manage in the pediatric age group. We report a case of a six-year-old girl who was injured with a penetrating reinforcing bar (rebar) in the floor of the mouth, where both ends of the rebar protruded out. The girl fell off a partially constructed terrace and was hanging with the rebar in her neck for hours. On examination, the vital structures of the neck were not involved. The child was taken for surgery after stabilization, abiding by COVID protocols. The rebar was removed under ketamine sedation with repair of the injury in the floor of her mouth. The postoperative period was uneventful and the child was discharged on the fifth postoperative day. Managing this pediatric trauma emergency was challenging in terms of imaging, securing an airway, and assuring parents about the choices for intervention during lockdown.

Keywords: Accident, floor of mouth, metal rod, pediatric age, penetrating injury, trauma


How to cite this article:
Dash MR, Mallick SN, Mishra K R, Panigrahi P. Penetrating injury to the floor of mouth in a child: Management of a challenging case. J Mahatma Gandhi Inst Med Sci 2021;26:132-4

How to cite this URL:
Dash MR, Mallick SN, Mishra K R, Panigrahi P. Penetrating injury to the floor of mouth in a child: Management of a challenging case. J Mahatma Gandhi Inst Med Sci [serial online] 2021 [cited 2022 May 24];26:132-4. Available from: https://www.jmgims.co.in/text.asp?2021/26/2/132/337427




  Introduction Top


Oral maxillofacial penetrating injuries by assault are uncommon. These are mostly associated with a history of accidental fall over a sharp object. Mortality in these cases has been reported to be in the range of 3%–10% if the vital structures of the neck are involved or a component of cranial penetration is present.[1],[2]

Management of such patients, especially when they belong to the pediatric age group, is challenging due to the patient's inaccessibility to the nearest tertiary care center. General anesthesia and securing the airway is of paramount importance for exploring the neck anatomy and achieving hemostasis. We outline the challenges faced during management of penetrating neck injury with a rebar in this case report.


  Case Report Top


A 6-year-old girl from a remote village presented with a penetrating iron rod (reinforcing bar or rebar) in the floor of her mouth. The child had accidentally fallen off an unfinished terrace (which was without a parapet). In this case, a working parent without a babysitter (because of financial constraints) was the reason behind the child playing without an adult's vigilance.

The girl was seen hanging from the rebar by her neck. She was released by cutting the rebar and transported to the nearest primary health care. The child was then referred to our tertiary care center. On admission, the child was conscious but irritable and her neck was held at a fixed position. There was no history of vomiting or loss of consciousness. Initial assessment and primary survey were done as per the Advanced Trauma Life Support protocols.[3]

On examination, her vitals were stable. On auscultation, no added respiratory sounds were heard. No visible thoracic injury was present. Focused assessment with sonography in trauma of the abdomen and pelvis revealed no abnormal findings.

The rebar had entered through the left submandibular triangle of the patient, 1 cm below the body of mandible and 3 cm anterior to the angle of the mandible on the left side. Minimal bloody ooze was seen from the entry wound [Figure 1]. The exit wound was of 6 mm diameter, with the ribbed rebar present on the right side avulsing out the first deciduous upper molar tooth. The anterior two-thirds of the tongue was involved. After proper resuscitation, the girl was shifted to the operating room, unscreened for COVID.
Figure 1: (a and b) Oblique position of rebar causing restriction of neck movement

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Written consent for life risk in intervention and the need for tracheostomy was obtained. Using intravenous ketamine (1 mg/kg) and glycopyrrolate (0.01 mg/kg), the rebar was painted with 2% lidocaine jelly and gently pulled back from the entry wound in a slight screwing motion (Video 1 available on the website

). This provided space for laryngoscopy. Laryngoscopy was performed with manual in-line stabilization of the cervical spine, and the glottis was visualized. The cuffed 5.0 endotracheal tube was gently passed through the glottic opening into the trachea. The cuff was inflated, and the endotracheal tube was securely fixed. The oral cavity was inspected with removal of a small clot and debris. The tongue laceration was repaired using three interrupted 4-0 polyglycolic acid sutures. Bleeding was minimal which favored endotracheal intubation. The entry wound on the neck was left open to facilitate drainage. Toileting of the entry wound was done with chlorhexidine solution diluted in warm normal saline. The patient was shifted to intensive care and extubated after four to 6 h of elective ventilation. Postoperative noncontrast computerized tomography of the brain revealed no skull bone fracture. Soft tissue edema was evident in the floor of mouth. Oral sips were initiated after 24 h [Figure 2]. Solid food was started after 72 h postoperatively and the girl was discharged on the 5th day with advice to follow-up after 3 weeks.
Figure 2: 24 h postoperative period

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  Discussion Top


Penetrating neck trauma in the pediatric age group is uncommon, but it is a matter of concern. They are life threatening because of profuse bleeding which causes hemodynamic shock or obstruct airway. Thus, airway management remains the first priority during resuscitation, apart from hemodynamic stability. This was challenging in our case due to the oblique position of the rod stuck on the anterior chest wall limiting the slightest neck movement to the left side [Figure 3]. Imaging was not feasible due to the restricted mobility of the child's neck and her agile behavior on subtle maneuvering. Preimaging sedation was risky as we had no option for securing the airway. Most reports in literature recommend imaging as important to the surgical outcome, which was not possible in our case.[4] Further, operating an unscreened pediatric patient in early phases of the COVID pandemic was challenging.

The reported incidences for traumatic airway injury for blunt and penetrating trauma are 0.4% and 4.5%, respectively.[5] In this case, there was no airway injury or associated thoracic injury on the initial survey. Planning for surgical exploration was not feasible because of lack of anesthesia and proper airway control. Hence, removal of the rebar under sedation and percutaneous tracheostomy were the viable options in the worst-case scenario.
Figure 3: Ribbed rebar of 40 cm × 6 mm dimension video-removal of iron rod under sedation

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Prior tracheostomy was not attempted here. This was because, first, the anterior neck was not accessible due to the acutely turned neck to the side. Second, the child was irritable and stabilization of the anterior aspect of the neck for tracheostomy was compromised, warranting sedation anyway. The clear oral cavity without clots and absence of frank bloody ooze near the neck wound obviated immediate tracheostomy. In this case, the facial artery was spared from injury by rebar entry in the submandibular triangle. Also, the lingual artery was uninjured despite exit through the tongue.[6] The dilemma in removing the rebar when the airway was inaccessible was a major setback. Unavailability of pediatric flexible fiber-optic laryngoscope is quite common in most health-care setups.[7] We attempted active pulling of the rebar after lubricating the engaging length of the rod as it was the only option we had.

Repair of the external wound was not attempted so as to facilitate drainage of secretions due to the possibility of submandibular or sublingual gland injury.[8] Moreover, the wound was contaminated, increasing the possibility of infection if closed.[9],[10]

Multidisciplinary strategic intervention was the key to such traumatic penetrating injuries and this case shows the approach to managing unusual trauma situations in emergency.

Acknowledgments

The authors would like to thank Dr. Rakesh K Ludam, Assistant Professor, Department of Anaesthesia, and Prof. Mamata Sahoo, Prof. and Head, Department of Otorhinolaryngology, MKCG Medical College, Odisha, India 760004.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Demetriades D, Theodorou D, Cornwell E, Berne TV, Asensio J, Belzberg H, et al. Evaluation of penetrating injuries of the neck: Prospective study of 223 patients. World J Surg 1997;21:41-7.  Back to cited text no. 1
    
2.
Burgess CA, Dale OT, Almeyda R, Corbridge RJ. An evidence based review of the assessment and management of penetrating neck trauma. Clin Otolaryngol 2012;37:44-52.  Back to cited text no. 2
    
3.
ATLS Subcommittee; American College of Surgeons' Committee on Trauma; International ATLS Working Group. Advanced trauma life support (ATLS®): The ninth edition. J Trauma Acute Care Surg 2013;74:1363-6.  Back to cited text no. 3
    
4.
Huang J, Li D, Chen H. Successful management of a penetrating iron-rod injury through the oral cavity involving the posterior cranial fossa. Neurol India 2017;65:666-8.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Kummer C, Netto FS, Rizoli S, Yee D. A review of traumatic airway injuries: Potential implications for airway assessment and management. Injury 2007;38:27-33.  Back to cited text no. 5
    
6.
Choi KJ, Cheng T, Cobb MI, Sajisevi MB, Gonzalez LF, Ryan MA. Recurrent post-tonsillectomy bleeding due to an iatrogenic facial artery pseudoaneurysm. Acta Otolaryngol Case Rep 2017;2:103-6.  Back to cited text no. 6
    
7.
Tiwari T, Singh A, Rawat J, Chaudhary J. Difficult airway caused by retained iron rod penetrating through floor of mouth and base of tongue following road traffic accident: A case report. Airway 2019;2:96-9.  Back to cited text no. 7
  [Full text]  
8.
de Geus JJ, Maisels DO. A traumatic fistula of the submandibular gland. Br J Plast Surg 1976;29:196-8.  Back to cited text no. 8
    
9.
Traiger J. Laceration of a minor salivary gland. A complicating factor in a fracture of the mandible in a child. Oral Surg Oral Med Oral Pathol 1963;16:783-5.  Back to cited text no. 9
    
10.
Lazaridou M, Iliopoulos C, Antoniades K, Tilaveridis I, Dimitrakopoulos I, Lazaridis N. Salivary gland trauma: A review of diagnosis and treatment. Craniomaxillofac Trauma Reconstr 2012;5:189-96.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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