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BMJ Case Reports 2012; doi:10.1136/bcr.10.2011.5006 1 of 3
BACKGROUND
Foreign bodies implamental injuries to the palate are quite
rare with 32 cases reported in the English literature.
1 Most
cases occur in infants and children, and are usually accom-
panied by a poor and confusing history. Due to its rarity,
it is not usually considered among the diffential diagno-
sis of palatal lesions. Although these injuries usually heal
wiithout treatment, thrombosis of the internal carotid
artery is a rare complication.
2
CASE PRESENTATION
A 6-year-old girl who claimed to have fallen while play-
ing with a metal rod was brought to our ENT emergency
unit 16 h after by the father. Neither of the parents was
around when the incidence happened. She was brought
to the hospital because of pain, bleeding from the mouth,
drooling of saliva mixed with blood and inability to feed or
phonate appropriately.
General examination reveal temperature (T°) of 37.0; pulse
rate of 118 bpm; respiratory rate of 22 cpm. Examination of
the oral cavity revealed a triangular area of avulsion in the
posterior aspect of the hard palate extending to the soft pal-
ate with its fl ap of skin over hanging the uvula posteriorly
( fi gure 1 ). Other systems were essentially normal.
INVESTIGATIONS
Urgent packed cell volume (36%), full blood count (within
normal limit) and x-ray soft tissue neck (reveal no abnor-
mality) were done.
TREATMENT
The patient was admitted, commenced on intravenous fl u-
ids and augmentin and metronidazole injections. She had
examination under anaesthesia and had wound repaired
with 3-0 vicryl interrupted sutures under general anaesthe-
sia after thorough wound debridement ( fi gures 2 and 3 ).
Reminder of important clinical lesson
Palatal avulsion injury by a foreign body in a child
Sulyman Biodun Alabi, 1 Shuaib Kayode Aremu, 2 A Y Abdulkadir, 3 J N Legbo, 4 Halima J Akande 5
1 ENT Department, UITH, Ilorin, Nigeria ;
2 ENT Department, FMC Azare, Bauchi State, Nigeria ;
3 Radiology Department, FMC Gusau, Gusau, Zamfara, Nigeria ;
4 Surgery Department, UDUTH, Sokoto, Nigeria ;
5 Radiology Department, UITH, Ilorin, Kwara, Nigeria
Correspondence to Dr Shuaib Kayode Aremu, shuaib.aremu@gmail.com
Summary
A 6-year-old girl who claimed to have fallen while playing with metal rod that resulted in palatal avulsion injuries was presented. Neither of
the parents was around when the incidence happened. She was brought to the hospital because of pain, bleeding from the mouth, drooling
of saliva mixed with blood and inability to feed or phonate appropriately. Examinations of the oral cavity revealed a triangular area of avulsion
in the posterior aspect of the hard palate extending to the soft palate. She had examination under anaesthesia and wound repaired with 3-0
vicryl interrupted sutures after thorough wound debridement. She did well and was discharged from the clinic.
Figure 1 Preoperative photograph showing lacerated palate.
Note the fl ap of skin and and the exposed palatine. Figure 2 Immediately postsuturing: the wound is well apposed.
BMJ Case Reports 2012; doi:10.1136/bcr.10.2011.5006
2 of 3
She was place on nil per oral for 8 h and thereafter com-
menced on straw feeding over 72 h.
OUTCOME AND FOLLOW-UP
The patient did well and was discharged home on the 5th
post operation day in a stable condition and outpatient
clinic visits has been uneventful since over 3 months and
she has been discharged from the clinic.
DISCUSSION
Foreign bodies implamental injuries to the palate are quite
rare with 32 cases reported in the English literature.
1
The possibility of children inserting objects into their
oral cavity is the main reason why palatal foreign bodies
and injuries are most common in this age group.
3 Objects
tend to adhere to the hard palate due to the anatomical
differences in the paediatric palate. The natural position of
the tongue, thumb sucking and feeding patterns further led
to the adherence of a foreign body to the roof of the oral
cavity by producing a constant force on the foreign body
up against the palate. Foreign bodies of the hard palate can
present in a variety of ways.
3
–
7 In the group of children
under 6 years of age as in the case presented, injuries to the
mouth and oropharynx are usually caused by objects, such
as pens, pipes and cylindrical toys.
4 A metal rod was the
agent in our case. The most common types of impalement
injuries in the paediatric age group result from falls sus-
tained while holding objects intraorally as in our patient.
5
6
The resultant injuries, can result in several complications
requiring active management, some of which are poten-
tially life threatening.
7
8 Due to the paucity of such events
there is no evidence base or clear consensus on a particular
management plan.
Surgical anatomy
The skull base forms the fl oor of the cranial cavity and
separates the brain from other facial structures. This ana-
tomic region is complex and poses surgical challenges
for otolaryngologists and neurosurgeons alike. Working
knowledge of the normal and variant anatomy of the skull
base is essential for effective surgical treatment of disease
in this area.
The fi ve bones that make up the skull base are the eth-
moid, sphenoid, occipital, paired frontal and paired pari-
etal bones. The skull base can be subdivided into three
regions: the anterior, middle and posterior cranial fossae.
The petro-occipital fi ssure subdivides the middle cranial
fossa into one central component and two lateral compo-
nents. This article discusses each region, with attention
to the surrounding structures, nerves, vascular supply and
clinically relevant surgical landmarks.
9
10
The most important anatomic structures below the ante-
rior cranial fossa are the orbits and the paranasal sinuses.
A thorough description is beyond the scope of this article,
but important anatomy and relationships are discussed.
The bony orbit is often a route for intracranial and
extracranial spread of infection and tumours because of its
direct proximity to the anterior fossa. The posterior wall is
thin and adjacent to the superior sagittal sinus and frontal
lobe dura. The posterior aspect includes the optic canal, the
superior orbital fi ssure (SOF) and the inferior orbital fi ssure
(IOF). The SOF conveys the oculomotor, trochlear, abdu-
cens and ophthalmic nerves (cranial nerves (CN) III, IV, VI
and V1, respectively), as well as the ophthalmic veins.
The IOF transmits the maxillary nerve (CN V2) and
infraorbital vessels, and it communicates with the infratem-
poral and pterygomaxillary fossae. The lateral portion of
the IOF is an important surgical landmark for positioning
lateral orbital osteotomies during anterior skull base resec-
tions. The optic canal transmits the optic nerve (CN II) and
the ophthalmic artery.
9
10
Management
Management of trauma to the palate and lateral pharyngeal
wall will initially include hospitalisation, mucosal repair and
antibiotic prophylaxis and also diagnostic studies as well
as treatment if thrombosis or neurologic changes develop.
Shanon et al in 1972 and Hengerer in 1984 both recom-
mended hospitalisation for 48 to 72 h, due to the devastat-
ing nature of carotid and cerebral vascular thrombosis hence
angiography and surgical management if indicated.
11
12 The
patient presented was hospitalised for 5 days due to unre-
liable home situations and distance from the hospital in
order to ensure proper healing of the wounds.
13
Our patient did not show any evidence of vascular
thrombosis that would have necessitated angiography.
The reported indication for laceration repair of pala-
tal injury varies from 7% to 72%.
14
–
18 Domarus et al and
Hellman et al
14
15 suggested repair for for gross contami-
nation, large, avulsed, or hanging fl aps as in the case pre-
sented. The need for antibiotics remains unclear, however
some authors empirically recommend antibiotic prophy-
laxis in all patients.
14 especially in large avulsed wound to
be sutured as in our case coupled with the tropical climate
in our environment which encourages infection.
CONCLUSION
Most lacerations heal if left alone, however repair should
be undertaken for large, gaping injuries, with foreign bod-
ies, and when perforating with empirical antibiotics cover
as in our case, also hospitalisation is quite important in an
environment with poor health facilities that are not readily
assessed by the populace.
Figure 3 Third postoperative day.
BMJ Case Reports 2012; doi:10.1136/bcr.10.2011.5006 3 of 3
Learning points
▶ The possibility of children inserting objects into their
oral cavity is the main reason why palatal foreign
bodies and injuries are most common in this age
group.
The most common types of impalement injuries in the
▶
paediatric age group result from falls sustained while
holding objects intraorally.
The need for antibiotics remains unclear, however
▶
some authors empirically recommend antibiotic
prophylaxis in all patients.
Competing interests None.
Patient consent Obtained.
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Alabi SB, Aremu SK, Abdulkadir AY, Legbo JN, Akande HJ. Palatal avulsion injury by a foreign body in a child.
BMJ Case Reports 2012;10.1136/bcr.10.2011.5006, Published XXX
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