Oropharyngeal trauma in children

INTRODUCTION — This review covers the evaluation and management of wounds to the hard and soft palate, tonsils, and posterior pharyngeal walls. Dental and tongue injuries are discussed separately. (See "Evaluation and management of dental injuries in children" and "Evaluation and repair of tongue lacerations".)

EPIDEMIOLOGY — Oropharyngeal injuries account for an estimated 1 percent of all pediatric trauma [1]. A common mechanism involves a young child falling with an object in the mouth or having an item pushed into their mouth by a playmate or caregiver. Typically reported objects include writing instruments (eg, pen, pencil), toothbrushes, Popsicle sticks, lollipops, eating utensils, and drinking straws [2,3]. Infrequently, the trauma may result from a blind finger sweep by a caregiver during a choking episode [3]. Non-accidental trauma should be considered in young infants.

ANATOMY AND PATHOPHYSIOLOGY — The oropharynx consists of the following structures:

●Soft palate, uvula above

●Tongue below

●Dentition and cheeks anterolaterally

●Tonsils and tonsillar pillars posterolaterally

●Posterior pharyngeal wall

The carotid sheath, which contains the internal carotid artery, internal jugular vein, and vagus nerve, lies immediately posterolateral to the tonsils and tonsillar pillars (figure 1).

The retropharyngeal space resides between the vertebral bodies of the cervical spine and the posterior pharynx. The parapharyngeal space describes the region of the neck lateral to the oropharynx and includes the carotid sheath. These potential spaces extend into the mediastinum and, when violated, allow access to air and bacteria.

Internal carotid artery injury (ICA) — Lateral oropharyngeal injury that is posterior to the molars may compress the ICA against the lateral process of a cervical vertebra, creating an arterial intimal tear (figure 1). Thrombus formation at the site of arterial injury can extend up into the anterior and middle cerebral arteries over several hours to several days. During this time period, the patient may remain asymptomatic (ie, lucid interval). With progression of the clot, the patient develops symptoms of stroke (eg, contralateral hemiparesis, ipsilateral facial droop, aphasia, or vomiting). There are at least 30 case reports of stroke from this injury in the literature [4]. In rare cases, hemorrhagic stroke and death have occurred.

Alternatively, injury to the ICA may cause a dissecting aneurysm or pseudoaneurysm with similar neurologic sequelae.

Rarely, ICA injury may cause immediate massive bleeding which requires emergency intubation and neck exploration.

Deep neck space infection — Seeding of bacteria from the oropharynx into the retropharyngeal/parapharyngeal spaces or introduction of organisms from a retained foreign body may cause retropharyngeal infection such as a cellulitis, phlegmon, or abscess. If unrecognized, the infection may extend into the mediastinum. In addition, infection and thrombosis of the internal jugular vein (ie, Lemierres syndrome or jugular vein suppurative thrombophlebitis) may cause severe neck pain and fever. Any of these infections (eg, retropharyngeal abscess, mediastinitis, jugular vein suppurative thrombophlebitis) may cause severe illness with sepsis. (See "Retropharyngeal infections in children".)

CLINICAL FEATURES — Initial evaluation should focus on the mechanism of injury, wound characteristics, and the child's neurologic status. Once these factors are known, then radiographic imaging and management proceed based on the patient's estimated risk of deep structure injury.

History — Mechanism of injury can be graded as mild, moderate, or severe. For example, a 10 kg child who falls slowly from a kneeling position with a rounded object in the mouth is at low risk of serious injury. A 40 kg child who falls while running full speed with a sharpened pencil in the mouth is at higher risk. Oropharyngeal trauma with major sequelae is suggested by the following features:

●Focal neurologic changes (internal carotid artery [ICA] injury)

●Fever, neck pain, torticollis, or drooling in a patient presenting more than 24 hours post oropharyngeal trauma (retropharyngeal or other deep neck infection) (see "Deep neck space infections in adults")

●Chest pain and fever (mediastinitis)

Oropharyngeal injuries resulting from major trauma (eg, air bag deployment when a child has an object in his or her mouth, gunshot wound, or other external penetrating mechanism) warrant management as zone III penetrating neck injuries with an aggressive approach to airway protection and injury identification (eg, angiography, endoscopy, and/or surgical exploration). (See "Penetrating neck injuries: Initial evaluation and management", section on 'Emergency management'.)

Physical examination — Victims of major trauma require an initial primary survey for life-threatening injuries before the emergency provider focuses on oropharyngeal injury. Rarely, hemorrhage from a major oral laceration compromises the airway and necessitates emergent endotracheal intubation. (See "Trauma management: Approach to the unstable child" and "The difficult pediatric airway for emergency medicine".)

In the stable patient, the clinician should focus on wound assessment, associated oropharyngeal injury (eg, dentition, jaw), and thorough neurologic examination.

Wound characteristics — Thorough examination of the posterior pharynx in a young child often requires the gentle use of a tongue blade and bite block in conjunction with analgesia as needed. A suction device should be immediately available during the examination. Rarely, sedation or general anesthesia is required to adequately examine the oropharynx in an uncooperative child. (See "Procedural sedation in children: Approach".)

Careful wound assessment includes the following:

●Depth – Small superficial lacerations or scratches (<2 cm long) with clear wound margins and a visible base are of less concern than puncture wounds with a sharp object (eg, pencil). However, depth of a lesion is often difficult to determine. Injury to deeper structures may be present even with apparently minor wounds [5]. Careful exploration with a soft, cotton-tipped applicator may be useful to assess depth.

●Length – Lacerations over two centimeters in length or associated with a hanging flap may need repair, but the location, appearance of the laceration, and whether it seems to "fall back together" is more important than the specific length in deciding whether to close the wound. The decision is important because almost all laceration repairs in this region require general anesthesia.

●Location – Posterior lateral wounds, especially of the tonsillar pillars, have a greater risk of ICA injury than midline wounds [6]. Injuries to the soft palate are more associated with potential complications than wounds to the hard palate.

●Foreign body – A protruding foreign body or concern for a retained foreign body requires additional imaging to demarcate extent of injury and localize involved anatomic structures.

Associated physical findings — Any evidence of focal neurologic deficits on complete neurologic examination should prompt emergency imaging and surgical consultation. Nonspecific findings of vomiting, lethargy, or gait disturbance also warrant aggressive evaluation (table 1).

Neck auscultation over the common carotid artery may demonstrate a bruit on the side associated with the oropharyngeal laceration.

The teeth should be examined for fracture, subluxation, and avulsion. Tongue lacerations may also be present. Malocclusion and pain with motion indicate jaw injury. Other clinical manifestations of these injuries are discussed separately. (See "Evaluation and management of dental injuries in children" and "Evaluation and repair of tongue lacerations" and "Mandibular (jaw) fractures in children".).

Trismus and drooling in association with fever suggests a retropharyngeal abscess. Subcutaneous emphysema with crepitus may accompany retropharyngeal trauma with air dissecting into the mediastinum. (See "Deep neck space infections in adults".)

Oral injuries to the frenulum or unexplained by the history raise suspicion for physical abuse [7,8]. In addition, caregivers have scratched the posterior pharyngeal wall to produce hematemesis as a form of medical child abuse (Munchausen syndrome by proxy) [9,10]. (See "Physical child abuse: Recognition", section on 'Oral or nasal injuries' and "Medical child abuse (Munchausen syndrome by proxy)", section on 'Perpetrator actions'.)

Laboratory evaluation — Immediately after injury, blood testing (complete blood count [CBC], chemistries) is only indicated if there is significant hemorrhage. In these rare situations, the child should receive a hematocrit, platelet count, type and cross, and coagulation studies (prothrombin time, partial thromboplastin time, international normalized ratio).

Patients coming to attention with fever and concern regarding a deep neck infection should undergo a complete blood count with differential and blood culture. Measurement of inflammatory markers (eg, erythrocyte sedimentation rate or C reactive protein) is helpful in suggesting the presence of a serious infection and in monitoring response to treatment in patients with deep neck infections. (See "Retropharyngeal infections in children", section on 'Laboratory evaluation'.)

Radiographic imaging — The goal of imaging is to select those children at increased risk of serious sequelae and to detect foreign bodies. Significant controversy surrounds the approach to radiographic imaging in children with oropharyngeal trauma (algorithm 1). (See 'Approach to diagnosis and management' below.)

Plain radiographs of the neck and chest — Plain radiographs may detect subcutaneous air, pneumomediastinum, retropharyngeal widening from abscess or hematoma, and radiopaque foreign bodies. Patient cooperation is not necessary to obtain an adequate study. However, plain radiographs lack sensitivity relative to computed tomography angiography (CTA) or contrast enhanced magnetic resonance angiography (MRA) [2]. For this reason, plain radiographs are not generally recommended, except specifically to exclude a radiopaque retained foreign body. Plain radiographs may be used to screen for retropharyngeal infection if the child has presented some time after the initial injury. (See "Retropharyngeal infections in children", section on 'Imaging'.)

Carotid ultrasound with oculoplethysmography — Some specialists have used serial monitoring of carotid flow with ultrasound as a noninvasive method of observing patients while avoiding ionizing radiation. However, this approach warrants patient hospitalization and requires patient cooperation or sedation. In addition, ultrasound findings may not correlate well with blood vessel injury [11].

Computed tomography angiography (CTA) — Observational studies suggest that CTA has good sensitivity for air and subcutaneous foreign bodies and is superior to plain radiographs in patients with oropharyngeal trauma [2,3,11].

Although data does not exist for children with arterial injury after oropharyngeal trauma, systematic reviews have found that CTA has a variable sensitivity and specificity for detecting posttraumatic carotid artery injury in adults with blunt neck trauma. CTA is inferior to contrast enhanced MRA in noninvasive detection of carotid artery defects in adults. (See "Evaluation of carotid artery stenosis".)

Despite questions about its ability to detect ICA injury, CTA is more widely available than contrast enhanced magnetic resonance angiography (MRA) and does not always require general anesthesia. CTA is also noninvasive, although the typical child will require sedation. For these reasons, many otolaryngologists (ear, nose, and throat surgeons) utilize CTA as a primary modality in their diagnostic approach in children with oropharyngeal trauma instead of contrast enhanced MRA. Carotid arterial angiography (CAA) is reserved for patients with neurologic deficit or significant ongoing hemorrhage [2,3,11] or a mechanism of injury so severe that it warrants management as zone III penetrating neck injury. If CTA suggests trauma immediately adjacent to the major vascular structures (eg, when the wound track can be seen to project immediately adjacent to the carotid), CAA should usually be obtained. (See 'Carotid artery angiography (CAA)' below.)

However, the potential for CTA to miss a significant ICA injury remains a concern as does the radiation exposure [12]. Additionally, a large-catheter IV (at least 18-gauge) is needed to inject contrast without infiltration. Thus, the role of CTA versus contrast enhanced MRA in children with oropharyngeal trauma warrants further study [2].

Magnetic resonance angiography (MRA) — Little data exist concerning the use of MRA in children with oropharyngeal trauma. Its use is limited by availability and patient factors, including the need for general anesthesia when used in young children and the inability to image patients with metallic implants.

In adults, contrast enhanced MRA provides good visualization of carotid artery defects with high sensitivity and specificity relative to digital subtraction intraarterial angiography. Contrast enhanced MRA may be preferable to CTA in the older child who can remain still without the need for general anesthesia. Technological advances that shorten MRA test duration to the point that general anesthesia is unnecessary might favor its use for oropharyngeal trauma in children in the future. (See "Evaluation of carotid artery stenosis", section on 'Magnetic resonance angiography'.)

Carotid artery angiography (CAA) — Digital subtraction CAA remains the gold standard for radiologic imaging of children with ICA injury [2]. However, the risk of complications from this procedure is significant. In adults, CAA has a 4 percent risk of embolic stroke and a 1 percent risk of death (see "Evaluation of carotid artery stenosis", section on 'Catheter cerebral angiography'). This risk likely outweighs the risk of internal carotid artery injury in a child with a reassuring exam.

CAA is typically reserved for children with neurologic deficit after oropharyngeal trauma, ongoing hemorrhage, a truly major mechanism of injury, or evidence of ICA injury on other imaging (eg, CTA, contrast enhanced MRA). Given the low frequency of these findings, CAA is rarely performed [2,3]. Although there are no direct data on this point, the risk of CAA in young children or toddlers is probably correlated with the experience of the center in performing angiography in children. If in doubt as to the risk of the study, the ED physician should discuss directly with the radiologist who will be performing the study.

●An observational study over a six year time period from a children's hospital reported that 52 of 107 children with oropharyngeal trauma had a CTA while none had a CAA [3]. No neurologic sequelae were reported.

●An observational study of 23 children seen over six years at a children's hospital reported that 21 had one or more imaging studies; CTA was performed in 18 children, plain neck radiographs in 9, and CAA in 3 [2]. CAA followed an abnormal CTA (air near the carotid sheath) in one case and showed vessel spasm without thrombus. CAA was normal in the remaining two children; one was performed despite a normal CTA because of a carotid bruit on examination and the other study was the only imaging performed. No neurologic sequelae were seen.

EVALUATION AND MANAGEMENT — Although every emergency clinician encounters oropharyngeal trauma, major complications are rare enough that prospective studies have not been feasible. Recommendations are therefore based on observational studies and expert opinion [2].

Initial stabilization — Victims of major trauma require an initial primary survey for life-threatening injuries before the emergency provider focuses on oropharyngeal injury. Rarely, hemorrhage from a major oral laceration compromises the airway and necessitates emergency endotracheal intubation, cricothyroidotomy, or tracheostomy. (See "Trauma management: Approach to the unstable child" and "The difficult pediatric airway for emergency medicine".)

Children with significant facial injury sustained during major trauma warrant cervical spine immobilization until appropriate assessment and diagnostic imaging of the neck are performed. (See "Pediatric cervical spinal motion restriction".)

Protruding oropharyngeal foreign bodies should be left in place until they can be fully assessed, imaged, and removed under controlled conditions in the operating room.

Approach to diagnosis and management — The algorithm provides an approach to evaluation and management of oropharyngeal trauma in children (algorithm 1). These injuries pose a significant diagnostic challenge because the vast majority will heal spontaneously without complications [2,13-16], but a small minority will develop deep neck infections or carotid artery injuries that cause major morbidity and mortality [17-25]. The approach to oropharyngeal blunt trauma relies on an assessment of the oropharyngeal wound, a rational use of diagnostic tools, primarily noninvasive radiologic techniques, and surgical intervention in selected patients.

High risk injury — Patients who have suffered high-force penetrating trauma (motor vehicle accident, gunshot wound to the neck, stabbing victim) or who manifest neurologic deficit, profuse bleeding, or carotid bruit on exam after isolated oropharyngeal trauma have a high risk for vascular injury and should undergo emergency imaging, either CTA or CAA. These patients should be treated as zone III penetrating neck injuries and require an aggressive approach to airway protection, and injury identification (eg, angiography, endoscopy, and/or surgical exploration). (See "Penetrating neck injuries: Initial evaluation and management", section on 'Emergency management'.)

In addition, these patients warrant immediate consultation of an otolaryngologist (ear, nose, and throat surgeon) with pediatric expertise in concert with neurosurgical or vascular surgeons. If capability to manage these patients does not exist at the admitting hospital, then the patient should be stabilized and transferred expeditiously to an appropriate institution. Further treatment in consultation with surgical specialists is guided by CAA results and may include anticoagulation, surgical exploration of the neck, or carotid thrombus endarterectomy. (See "Penetrating neck injuries: Initial evaluation and management", section on 'Emergency management'.)

Moderate risk injury — Children who have a retained or protruding foreign body, a deep wound, or a wound of indeterminate depth with a concerning mechanism should undergo CTA or contrast enhanced MRA, particularly if the wound is lateral in the oropharynx (overlying the carotid sheath). Concerning findings on CTA include ICA abnormality, subcutaneous air near the carotid sheath, or significant tissue disruption adjacent to the carotid sheath. MRA shows similar findings but may also have the ability to show ICA injury with greater sensitivity and specificity. Patients with an abnormal CTA or MRA should have otolaryngology and neurosurgical consultation, and likely a digital subtraction CAA. We recommend that these children undergo hospital admission.

In addition, these patients warrant immediate consultation of an otolaryngologist (ear, nose, and throat surgeon) with pediatric expertise. If capability to manage these patients does not exist at the admitting hospital, then the patient should be transferred expeditiously to an appropriate institution. Further treatment may include anticoagulation, surgical exploration of the neck, or carotid endarterectomy.

If CTA or MRA suggests limited penetration, not adjacent to the carotid (eg, mid-line), we suggest that the child be discharged home to a reliable caregiver who can closely monitor for symptoms of ICA occlusion or deep neck infection and who can return promptly for reevaluation should symptoms develop (table 1). The child should be re-examined by their physician in 24 to 48 hours to repeat a careful neurologic exam.

In situations where social concerns do not allow discharge, or the managing physician is concerned about the risk of possible neurologic sequelae, the patient may be admitted for 24 to 48 hours for neurologic checks, recognizing that neurologic sequelae may rarely occur 48 hours or longer after injury.

Low risk injury — Patients with minor trauma associated with superficial laceration (eg, a toddler tips over from a sitting position with a pencil in his or her mouth), especially midline wounds, do not require imaging or subspecialty consultation. These children can be discharged home to reliable caregivers who can closely monitor for symptoms of internal carotid artery occlusion or deep neck infection and who can return promptly for reevaluation should symptoms develop (table 1).

Wound management

Laceration repair — Puncture wounds and lacerations <2 cm long usually heal well and do not need surgical closure. Children with hanging palatal flaps, tonsillar avulsion, retained or protruding foreign body, or gross contamination warrant repair by an otolaryngologist in the operating room. The frequency of operative care is approximately 6 to 11 percent of children with oropharyngeal trauma based on three observational studies [3,14,15].

Tetanus prophylaxis — Oropharyngeal wounds are considered tetanus prone and require tetanus prophylaxis, as needed (table 2).

Empiric antibiotic therapy — For children with oropharyngeal lacerations with mucosal penetration, we suggest prophylactic antibiotics. Children who require admission should receive intravenous clindamycin (10 mg/kg every 6 hours, maximum dose: 4.8 g per 24 hours) or intravenous ampicillin with sulbactam (50 to 100 mg/kg every 6 hours: maximum dose 8 g ampicillin per 24 hours) to cover infection caused by oral flora (anaerobic species, coagulase-negative Staphylococcus, Streptococcal species, and S. aureus) (algorithm 1).

Oral clindamycin (10 mg/kg three times daily, maximum dose 1.8 g per 24 hours) or amoxicillin with clavulanate (20 mg/kg twice daily, maximum dose 875 mg amoxicillin) are reasonable alternatives for children who are discharged home.

Duration of therapy is not standardized, although a minimum of five to seven days would coincide with wound healing in most instances.

Preliminary evidence suggests that the infection rate is low following oropharyngeal trauma. As an example, in an observational study of 116 children with isolated penetrating palate trauma of whom 67 were prescribed antibiotics, one patient developed an infection within seven days of the injury (infection rate 1 percent [95% CI 0-5 percent]) [4]. However, no trials have evaluated the benefit of prophylactic antibiotics in children with penetrating oropharyngeal trauma, and deep neck infection (eg, retropharyngeal or parapharyngeal abscess) remains a concerning complication for deep wounds. Thus, we suggest that patients with oropharyngeal lacerations with mucosal penetration receive antibiotics [3,11].

Child protection — In cases where child abuse is suspected, involvement of an experienced child protection team is crucial and in many parts of the world (including the United States, United Kingdom, and Australia) reporting to a governmental agency is mandatory. The safety of other children in the home must be ensured by local Child Protective Services. (See "Child abuse: Social and medicolegal issues", section on 'Reporting suspected abuse' and "Physical child abuse: Diagnostic evaluation and management".)

FOLLOW-UP — Prior to discharge, the emergency clinician or otolaryngologist (ear, nose, and throat surgeon) should counsel the caregiver to closely monitor their child for 48 to 72 hours after injury. Caregivers should be instructed about the specific symptoms of neurologic sequelae or deep neck infection and advised to seek medical attention immediately if they appear (table 1) [26].

Otolaryngologists usually reevaluate children who sustain oropharyngeal trauma with mucosal penetration one to two weeks after injury. The purpose of this visit is to ensure proper healing and to assess for any unrecognized neurologic or infectious complications. Most children with superficial wounds may follow up with their primary care provider rather than a specialist.

Deep neck infection — Children with new onset of infectious symptoms several days after a penetrating oropharyngeal injury need emergency computed tomography (CT) of the neck with intravenous (IV) contrast. Those patients with a proven neck abscess should receive intravenous antibiotics, otolaryngology consultation, and hospital admission. In addition, surgical intervention may be required. (See 'Empiric antibiotic therapy' above and "Retropharyngeal infections in children", section on 'Management'.)

Cerebral vascular thrombosis — Children who develop focal neurologic finding or mental status change after an oropharyngeal injury should undergo emergency carotid angiography and consultation with a vascular surgeon or neurosurgeon. (See 'High risk injury' above.)

OUTCOME — Most children fully recover after experiencing oropharyngeal trauma. Based on observational studies, from 1 to 5 percent of patients develop an infectious complication (wound infection, retropharyngeal abscess, mediastinitis, or suppurative jugular venous thrombosis) and <1 percent of patients sustain an internal carotid artery injury or neurologic sequelae [1,3,4].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Pediatric trauma" and "Society guideline links: Child abuse and neglect".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)

●Basics topic (see "Patient education: Mouth and dental injuries in children (The Basics)")

●Beyond the Basics topic (see "Patient education: Mouth and dental injuries in children (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Clinical features – Penetrating oropharyngeal wounds in children typically result from low force mechanisms and usually heal spontaneously with no sequelae. Rarely, internal carotid artery (ICA) injury or deep space neck infection may complicate oropharyngeal trauma. (See 'Clinical features' above.)

●Initial stabilization – Victims of major trauma require an initial primary survey for life-threatening injuries before the emergency provider focuses on oropharyngeal injury. Those children with major facial trauma should be placed in cervical spine immobilization until cervical spine injury is excluded. (See 'Initial stabilization' above and "Trauma management: Approach to the unstable child" and "Pediatric cervical spinal motion restriction".)

●Approach – Once the patient is stabilized, initial evaluation should focus on the mechanism of injury, location of injury (midline versus lateral), wound characteristics, and the child's neurologic status. Key physical findings help categorize oropharyngeal trauma as minor, moderate, or severe (table 3). Once these factors are known, then radiograph imaging and management proceed based on the patient's estimated risk of deep structure injury (algorithm 1) (see 'Approach to diagnosis and management' above):

•High risk injury – Patients who have suffered high-force penetrating oropharyngeal trauma should be managed as zone III penetrating neck injuries and require an aggressive approach to airway protection and injury identification (eg, angiography, endoscopy, and/or surgical exploration). (See 'High risk injury' above and "Penetrating neck injuries: Initial evaluation and management", section on 'Emergency management'.)

Protruding oropharyngeal foreign bodies should be left in place until they can be fully assessed, imaged, and removed under controlled conditions in the operating room.

•Moderate risk injury – Children with a moderate mechanism of injury and a wound with concerning features (deep, lateral, or associated with a foreign body) should undergo CTA or contrast enhanced MRA. Those patients, whose imaging confirms a deep oropharyngeal wound adjacent to the ICA with abnormal CTA or MRA, should have immediate otolaryngology (ear, nose, and throat) consultation undergo digital subtraction carotid artery angiography (CAA) and hospital admission. Further management is based on the results of the CAA. (See 'Moderate risk injury' above and 'Radiographic imaging' above.)

If CTA or MRA suggests limited penetration not immediately adjacent to the carotid in a child with moderate risk of injury, then this patient may be discharged home, assuming the caregivers can closely monitor for symptoms of ICA occlusion or deep neck infection and can return promptly for reevaluation should symptoms develop (table 1). (See 'Moderate risk injury' above.)

•Low risk injury – Patients with a minor mechanism of injury associated with superficial laceration, especially midline wounds, may be discharged home without imaging or subspecialty consultation. The caregiver should be counseled regarding the symptoms of ICA occlusion or deep neck infection and instructed to return promptly for reevaluation should symptoms develop (table 1). (See 'Low risk injury' above.)

●Wound management – Puncture wounds and lacerations <2 cm long usually heal well and do not need surgical closure. Children with hanging palatal flaps, tonsillar avulsion, retained or protruding foreign body, or gross contamination require repair by an otolaryngologist in the operating room. All oropharyngeal wounds are considered tetanus prone and require tetanus prophylaxis, as needed (table 2). (See 'Wound management' above.)

We suggest that patients with oropharyngeal lacerations with mucosal penetration receive antibiotics that provide adequate coverage for oral pathogens (eg, Staphylococcus species, Streptococcal species, and anaerobes) (Grade 2C). (See 'Empiric antibiotic therapy' above.)

●Follow-up – Prior to discharge, the caregiver should be instructed to closely monitor their child for 48 to 72 hours after injury. Caregivers should be advised to seek medical attention immediately if symptoms of neurologic sequelae or deep neck infection appear. (See 'Follow-up' above.)