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consistent with exposure to such pressure changes. The treatment for sinus
barotrauma is supportive, with pain control and antimicrobials.

TRAUMA TO THE ORAL CAVITY AND PHARYNX
Goals of Treatment
The emergent goal in oral and pharyngeal injuries is to evaluate and protect the
airway when at risk for compromise or obstruction. In addition, the emergency
clinician must identify serious injuries that may involve vascular structures or
wounds that may lead to infection. Oral and pharyngeal foreign bodies should be
removed promptly due to risk of aspiration. Ingestion and aspiration is covered in
detail in Chapter 32 Foreign Body: Ingestion and Aspiration , Chapter 91
Gastrointestinal Emergencies , and Chapter 124 Thoracic Emergencies .
CLINICAL PEARLS AND PITFALLS
Falls with objects in the mouth may result in injuries to the vascular
structures, potentially resulting in CNS complications.
Foreign bodies may be retained in the oral cavity.

Current Evidence
A common etiology of oral cavity injury is biting of the cheek causing a
laceration or hematoma. Palatal injuries are usually caused by a foreign body,
often as a result of falling with something in or around the patient’s mouth. Risk
of associated injury can be stratified based on location of the trauma within the
oral cavity. Central hard or soft palate injuries are not likely to be associated with
neurovascular injury. Lateral palate, especially soft palate or tonsillar fossa is
associated with vascular injury given the close proximity to the carotid sheath.
Posterior pharyngeal wall injuries may be associated with vascular injuries
resulting in hematoma and risk of infection.

Clinical Considerations
Clinical Recognition
Oral or pharyngeal injuries in children often result from a fall, foreign body,

ingestion, or blow from a projectile object such as a ball.
Triage


Children with severe intraoral injuries or punctures can be acutely ill on
presentation or deteriorate quickly. These patients should be seen emergently. For
patients with injury to the oral pharynx who appear stable and are awaiting
evaluation, careful and frequent reassessment for change in condition is prudent.
Initial Assessment
A history of objects in the mouth, possible foreign bodies, or bleeding from the
oral cavity should raise concern for intraoral injuries. A thorough oral
examination for lacerations, hematomas, and foreign objects should be
performed. Expanding neck hematoma, persistent oral bleeding, or diminished
pulses in the neck are signs of vascular injury and require immediate attention.
Management
Oral lacerations rarely require suturing unless a large flap (or defect greater than 1
to 2 cm) exists. For nonoperative injuries, oral hygiene with warm saline rinses
can keep the area clean (see Chapter 105 Dental Trauma ). Antibiotics are not
routinely indicated. If concern exists for a retained foreign body, imaging with CT
is warranted. Superficial foreign bodies can usually be removed in the ED.
Deeper foreign bodies are most safely removed in the OR which is better suited
for management of potential complications and allows wound exploration
following removal. Children with suspected vascular injury should undergo CT or
MRI with angiography. Children with isolated oral injuries may be safely
discharged home. Those suspected to have retained foreign body or vascular
injury should be definitively imaged and admitted for further treatment if
indicated (see Fig. 106.2 ).

Caustic Injuries
Injuries resulting from ingestion of caustic substances such as lye or acid may

cause burns to the oral mucosa, pharynx, proximal esophagus, or as far distally as
the stomach. Injuries caused by basic chemicals are far more serious than those
caused by acidic ones. The former creates a liquefactive necrosis that is often
deeper and causes more damage than the coagulative necrosis caused by acids.
Identifying the ingested agent is critical in managing the patient with caustic
burns.
Skip lesions are possible, with no injuries initially visible on examination.
Patients with definite ingestion of known caustic substances should undergo
endoscopy within 12 to 24 hours to assess the extent of injuries (see Chapter 102
Toxicologic Emergencies ). The role of steroids has been debated; some data
suggest benefit in reducing the risk of strictures while other studies had not


shown improvement and raise concerns for impaired wound healing. No antidotes
are available. Vomiting should not be induced as the resulting emesis can cause
additional injuries or aspiration. Laryngeal involvement can cause edema and
respiratory distress or compromise.


FIGURE 106.2 Lateral neck radiograph of a straight pin lodged in posterior pharyngeal wall.