CASE REPORT Hemiplegic Syndrome After Chopstick Penetration Injury in the Lateral Soft Palate of a Young Child Syna Daudfar, OMS II; Codee Gorman, OMS II; John T. Pham, DO From the Western University of Health Sciences College of Osteopathic Medicine of the Soft palate penetrating injuries have been reported among children, particularly in children falling with objects in their mouth. The authors present Pacific–Northwest in Lebanon, a case of a healthy 14-month-old child who fell onto a blunt-ended chopstick, Oregon. the subsequent cerebrovascular accident, and the role of the osteopathic Financial Disclosures: tenets thereafter. The child had an acute infarction to the region of his right None reported. middle cerebral artery secondary to right internal carotid artery occlusion. Support: None reported. Physicians should consider the neurologic sequelae of lateral soft palate Address correspondence to injuries and damage to the surrounding anatomical structures. A thorough, John T. Pham, DO, 200 Mullins Dr, Lebanon, OR 97355-3983. whole-patient approach to physical examination is critical. J Am Osteopath Assoc. 2018;118(8):555-559 doi:10.7556/jaoa.2018.124 Email: jtpham@westernu.edu Keywords: hemiplegic syndrome, pediatrics, soft palate penetrating injury Submitted October 30, 2017; revision received December 13, 2017; accepted December 28, 2017. A ccidental falls onto a foreign object resulting in penetrating injuries of the oral mucosa, nares, and orbit are uncommon. Among these injuries, transoral penetration is a rare clinical presentation, particularly in the pediatric population.1 Neurologic sequelae from a blunt-ended object penetrated through the soft palate has not been reported in the literature since the 1960s, to our knowledge.2,3 Because of the good prognosis of intraoral injuries, management has not been well defined.2,3 We report the case of a child in whom hemiplegia developed after a lateral soft palate penetrating injury from a blunt-ended object. We discuss the role of the osteopathic tenets in his evaluation, diagnosis, and treatment, as well as assessment strategies for patients with penetrating injuries, based on our literature search. Report of Case A healthy 14-month-old child presented to the emergency department immediately after falling at home with a chopstick in his mouth (Figure 1). He had no symptoms except for mild bleeding from the roof of his mouth. No imaging was done at that time. The patient was discharged and, according to his medical record, precautionary instructions were provided. The patient continued to perform activities of daily living—he walked, ran, crawled up stairs, pointed to objects, and spoke words for “food,” “mom,” and “dad.” Approximately 40 hours after the incident, his parents noticed a left facial droop and decreased use of his left arm. Twenty hours after noticing the facial droop, the family was urged by the child’s primary care physician to bring him back to the emergency department to undergo further evaluation, including imaging. Quick brain magnetic resonance (MR) imaging without contrast, brain MR angiography without contrast, and carotid MR angiography The Journal of the American Osteopathic Association August 2018 | Vol 118 | No. 8 555 CASE REPORT Figure 1. An illustration of penetrating trauma to the superior pharyngeal constrictor muscle, which caused injury to the internal carotid artery. Source: Randall DA, Kang DR. Current management of penetrating injuries of the soft palate. Otolaryngol Head Neck Surg. Vol 135. 2006/09/05 ed2006:356-360. Reprinted by Permission of SAGE Publications, Inc. Figure 2. Magnetic resonance image of the brain of a 14-month-old child after a lateral soft palate penetrating injury in the (A) coronal view and (B) transverse view showed a right-sided middle cerebral artery infarct. with and without contrast were performed. The MR 556 imaging revealed an acute right middle cerebral artery was discharged to a rehabilitation facility on hospital infarct involving most of its territory (Figure 2). The day 14. MR angiography showed a long segment of occlusion The patient received inpatient physical therapy for in the right internal carotid artery (Figure 3). The 2.5 weeks, with the goal of improving his physical occlusion extended from the carotid sinus to the oph- function to positively affect neurologic structure. At thalmic artery, with partial reconstitution and filling the beginning of therapy, the patient required total through the circle of Willis but narrowing of the right assistance for all mobility, including transitional activ- anterior cerebral artery and middle cerebral artery. He ities, because of his inability to bear weight on the left was subsequently given the diagnosis of a cerebrovas- leg. The patient had left facial weakness and slight cular accident (CVA). Imaging findings suggested that weakness in his left bicep and hip flexors. He had no the patient likely had hemiplegic syndrome from a active movement and no increased muscle tone on his carotid dissection due to the internal carotid artery’s left side. He moved his right upper extremity and proximity to the lateral soft palate (superior pharyngeal right lower extremity appropriately. Neurologic exam- constrictor muscle). He was given heparin for anticoa- ination at the start of physical therapy revealed good gulation therapy, then switched to 300 mg/3 mL of visual fixation and tracking and appropriate stranger enoxaparin injections every 12 hours for 3 months. He anxiety. At the end of his therapy, he sat, stood, and The Journal of the American Osteopathic Association August 2018 | Vol 118 | No. 8 CASE REPORT Approximately 2 months after discharge from the hospital, the patient had mild improvement with strength and mobility on his left side but required bracing of his left leg and a support to stand. The multidisciplinary team’s interests of the family, child, and his overall development played an important role in this improvement. The osteopathic tenet of viewing the body as a whole unit and the understanding that structure and function are interrelated were considered when the decision to brace the child’s leg and provide a support to stand was made. The combination of anticoagulation therapy and structural bracing aided the child’s body to self-regulate and self-heal. After the cessation of the enoxaparin injections, the medication prescription was switched to a daily 81 mg aspirin. His treatment continues to include physical therapy, which began as weekly sessions, but the frequency may be altered depending on the patient’s progress. Figure 3. Magnetic resonance angiography images of a 14-month-old child after a lateral soft palate penetrating injury from an (A) anterior-posterior view and (B) posterior-anterior view showed right side occlusion of the internal carotid artery from the carotid sinus to the ophthalmic artery. Discussion To our knowledge, this is the first case report of hemiplegic syndrome caused by blunt trauma from a chopstick that did not penetrate the skull or vertebral bodies. In 1996, Pitner3 hypothesized that an intimal tear could propagate thrombosis in the internal carotid kneeled with minimal assistance. He remained unable artery, resulting in CVA. Imaging findings in the to walk, and no additional words were added to his current case supported Pitner’s hypothesis. Children at vocabulary. the developmental stage of the patient (ie, aged 14 One week after the completion of inpatient physical therapy, neurologic examination revealed grossly intact months) have yet to complete skull elongation, which explains the injury’s proximity to the carotid sinus. cranial nerves II through XII, except for subtle left We identified 24 chopstick-related injuries in the facial droop. He had significant left upper extremity pediatric population since 1995. Of these 24 injuries, hypotonicity, with minimal spontaneous movement 14 were classified as transorbital, 4 were transoral, 2 and mild limited range of motion in the left lower were transnasal, 2 were transbuccal, and 2 were tem- extremity compared with the right lower extremity. poral bone penetrations.4 A series of reports revealed The patient had no spasticity in his extremities and had transoral injury and subsequent hemiparesis caused by appropriate responses to light touch on all extremities. a sharp-ended chopstick.5,6 To our knowledge, no Deep tendon reflexes were 2+ in the right upper and cases of hemiparesis after a penetrating injury from a lower extremities and 1+ in the left upper and lower blunt-ended chopstick have been reported. extremities. His left first toe was upgoing, and his right first toe was downgoing. The Journal of the American Osteopathic Association Management of penetrating injuries is often selflimiting, and current guidelines suggest nonsurgical August 2018 | Vol 118 | No. 8 557 CASE REPORT management.7,8 However, penetrating injuries with palate. Therefore, imposing large health care costs neurologic complications are difficult to assess and onto patients and the health care system may be unwar- require interdisciplinary consultation.9 Research regard- ranted given the low incidence of chopstick penetration ing the management of ischemic CVAs in the pediatric injuries. population has not been evidence-based and is extrapo- The current case highlights the additional costs that lated from treatment recommendations for adults. result from neurologic sequelae of penetrating injuries Randomized trials have shown benefit of intervention involving the soft palate. We propose a method of triag- 10-13 A 2017 randomized ing patients that will minimize the risk of serious seque- trial found that endovascular thrombectomy improved lae after oral penetration injuries but will also keep disability and functional outcomes in adults with ische- health care costs reasonable. This method includes a mic CVA up to 24 hours after becoming symptom- thorough physical examination, including assessment up to 6 hours after CVA onset. 14 Data on the efficacy of tissue plasminogen of mandibular angle tenderness. If mandibular angle activator administration in children are not available; tenderness is present in the setting of lateral soft palate however, the National Institutes of Health funded a injury, we recommend consideration for hospitalization study15 that evaluated thrombolysis in pediatric CVA. up to 60 hours with routine neurologic assessments per atic. 15 recommended preliminary guidelines for hospital protocol. This recommendation is warranted treatment of ischemic CVA, but the recommendations because of the association of mandibular angle tender- were limited to expert consensus and collective ness with neurovascular compromise. However, with experience. any oral penetration injury, robust patient and family The study Other recommendations describe the role of a education on neurologic changes should be provided. diligent physical examination for adequate triage. To prevent serious sequelae, the importance of prompt For example, tenderness at the mandible angle return to the physician or emergency department after suggests damage to the peritonsillar musculature any changes in symptoms should be emphasized. 5 Other The current patient benefited from a whole-person studies16,17 have identified that a midline soft palate assessment and therapy. However, although his hemi- through-and-through penetration is typically less paresis was improving, the effects of the brain injury severe than a lateral penetration. These injuries are may remain throughout his life and require comprehen- associated with a 60-hour lucid interval and, thus, hos- sive, whole-person evaluation and treatment of his pitalization for at least 3 days is recommended.5,16,17 mind, body, and spirit as he gradually discovers his and possible neurovascular compromise. Our literature search identified interval Doppler images inability to participate in daily activities for his age and, more recently, computed tomographic scans as group. The progression of the patient’s symptoms illus- being useful in the detection of significant thrombosis trates how a localized trauma can cause a global impact and prevention of neurologic sequelae.5,18-20 to the total body unit. These recommendations are rebutted by Randall and Kang,9 who made an important point regarding the costs associated with the recommended 3-day hospital- Conclusion ization and serial imaging. Their review highlights the Lateral soft palate penetration injuries in children may lack of supporting evidence for a particular intervention result in lifelong deficits. Currently, there is a lack of in patients with a penetrating injury to the soft palate. consensus regarding the best management strategy for Additionally, they reference Suskind et al, 558 17 who soft palate penetration injuries because of the limited found a low number of patients with neurologic compli- number of cases reported. We recommend prompt cations after penetrating injuries involving the soft physical examination and risk stratification and stress The Journal of the American Osteopathic Association August 2018 | Vol 118 | No. 8 CASE REPORT that patients with lateral soft palate impalement and lateral mandible tenderness are at high risk and should 9. Randall DA, Kang DR. Current management of penetrating injuries of the soft palate. Otolaryngol Head Neck Surg. 2006;135(3):356-360. doi:10.1016/j.otohns.2005.12.003 be monitored closely. We also encourage physicians to 10. Saver JL, Goyal M, Bonafe A, et al. Stent-retriever thrombectomy after consider the osteopathic tenets in the evaluation and intravenous t-PA vs. t-PA alone in stroke. N Engl J Med. 2015;372 treatment of these patients. (24):2285-2295. doi:10.1056/NEJMoa1415061 11. Berkhemer OA, Fransen PSS, Beumer D, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015;372(1):11-20. doi:10.1056/NEJMoa1411587 Acknowledgments We express our sincerest gratitude to Paul Evans, DO; Paul Aversano, DO; William Merbs, PhD, ABD; Edward Goering, DO; and David Clark, DO, for their guidance, edits, and recommendations. 12. Campbell BCV, Mitchell PJ, Kleinig TJ, et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med. 2015;372(11):1009-1018. doi:10.1056/NEJMoa1414792 13. Goyal M, Demchuk AM, Menon BK, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015;372(11):1019-1030. doi:10.1056/NEJMoa1414905 References 1. 14. Nogueira RG, Jadhav AP, Haussen DC, et al. Thrombectomy 6 to 24 Chauhan N, Guillemaud J, El-Hakim H. Two patterns of impalement injury to the oral cavity: report of four cases and review of literature. Int J Pediatr Otorhinolaryngol. 2006;70(8):1479-1483. doi:10.1016/j. ijporl.2006.02.002 Bickerstaff ER. Aetiology of acute hemiplegia in childhood. 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