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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