An Adult Case of Pharyngeal Injury Caused by Toothbrush

Abstract

Most toothbrush-induced oral injuries occur in children and are relatively shallow, involving the oral mucous membranes and musculature, but rarely deeper layers. Here, the management of an adult case of pharyngeal injury caused by a toothbrush is discussed. A man fell while brushing his teeth, and his toothbrush stuck in his throat. Contrast-enhanced computed tomography showed a toothbrush stuck in the left parapharyngeal space, reaching the subcutaneous tissue of the posterior neck. The toothbrush was surgically removed because blind removal could damage major cervical arterioles and nerves. In intraoral injuries caused by deep penetrating toothbrushes, there is a risk that the injury extends to the major arterioles and nerves of the neck. The need for imaging studies, methods of removal, and possible complications should all be considered before taking an appropriate removal action.

INTRODUCTION

Oral injuries caused by toothbrushes are common in children who run around with toothbrushes in their mouths and are relatively shallow, involving the oral mucous membranes and musculature, but rarely deeper layers.[1] In severe cases, however, there is concern about serious complications such as damage to major cervical arterioles and nerves. Here, the management of an adult case of pharyngeal injury caused by a toothbrush is discussed.

CASE REPORT

A middle-aged man with depression presented to the emergency department with a toothbrush stuck in his throat. He fell while brushing his teeth and was transported by ambulance to our hospital 30 min later. In the meantime, he did not attempt to pull the toothbrush out himself. Vital signs on arrival were as follows: Glasgow Coma Scale score E4V2M6, blood pressure 107/75 mmHg, pulse rate 91/min, respiratory rate 15/min, and body temperature 36.5°C. No active bleeding was observed. Contrast-enhanced computed tomography (CT) showed a toothbrush stuck in the left parapharyngeal space, reaching the subcutaneous tissue of the posterior neck [Figure 1]. Although the toothbrush needed to be removed as soon as possible, because of the risk of damaging major cervical arterioles and nerves, a surgical procedure was chosen. After preparing for surgical airway clearance, the patient was intubated nasally with a fiberscope. The left posterior neck was incised to expose the bristled head of the toothbrush, which was cut and removed [Figure 2]. The remaining toothbrush handle was removed from the mouth. The patient spent the first 6 postoperative days in the intensive care unit and was discharged from the hospital on day 11, with a week’s supply of the ampicillin–sulbactam combination to prevent infection. Flexion contracture of the left shoulder joint occurred as a sequela of the toothbrush injury, which was not noticed on arrival, but improved 3 months after discharge from the hospital.

Figure 1.

Contrast-enhanced CT image showing that the toothbrush has missed the left internal carotid artery and reached the subcutaneous tissue of the posterior neck (arrowhead). The contrast effect of the internal carotid artery is preserved. CT: Computed tomography

Figure 2.

An image showing the position of the toothbrush in relation to the internal jugular vein and sternocleidomastoid muscle. The handle of the toothbrush was compressing the internal jugular vein

DISCUSSION

To determine which types of pharyngeal injury are more likely to cause complications and require imaging studies, Kumar et al. reviewed 13 cases of toothbrush injury that occurred over a 20-year period and classified them into four types: blunt injury, penetrating injury, impalement injury, and embedded injury. However, the authors noted that this classification does not indicate that some types of injury are more severe than others, or that complications are more strongly associated with certain types of injury.[2] In light of the impact of complication severity, Sasaki et al. stated that if the foreign body has penetrated the pharyngeal wall, a contrast-enhanced CT of the head and neck is indicated to rule out injury to vital organs such as the brainstem, cerebellum, or carotid arteries.[3] Soose et al. stated that any patient with lateral oropharyngeal injury, regardless of wound severity, is at risk of internal carotid artery thrombus formation and the development of neurologic sequelae, and that performing CT angiography is, therefore, a reasonable choice.[4]

Removing the toothbrush stuck in the oral cavity was the next challenge. Blind removal might cause massive bleeding, and since the bristled head is bent backward, the usual removal methods tend to cause greater resistance. Kimura et al. summarized 14 cases of toothbrush trauma in which the toothbrush remained as a foreign body at the time of examination; of these, the toothbrush was removed under general anesthesia in 10 cases and by an external cervical incision in three cases.[5] If removal is performed under general anesthesia, the surgical procedure should be discussed with the surgeon and airway management should be considered. Various approaches for airway clearance have been reported, including oral and nasal intubation, sedation with spontaneous breathing, and no intubation.[2,6,7] In this case, nasal intubation was chosen because an external cervical incision might be too large for airway clearance and an access route from the oral side might be taken during surgery. To remove the toothbrush, the left external neck was incised and the thin handle below the bristled head was cut and removed. This approach was chosen because blindly removing the toothbrush head might increase the resistance of the bristles and could damage the surrounding tissue, as reported previously.[7,8] Since the remainder of the handle tapered toward the punctured tissue, it was removed without resistance.

Caldwell reported a fatal case secondary to a penetrating wound of the soft palate in 1936; autopsy revealed a thrombus and hemorrhagic infarction extending from the internal carotid artery to the middle cerebral artery.[9] Since then, various reports have described complications, including bleeding, infections such as posterior pharyngeal abscess and mediastinitis, mediastinal emphysema, airway obstruction, and thromboembolism.[1,10] Hennelly et al. reported that among 205 well-appearing children with penetrating palatal trauma, the incidence of stroke was 0% and that of infection was 0.9%.[11] While cases with fatal outcomes are of concern to physicians, even if rare, these findings provide some reassurance about the overall risks associated with this type of injury. In this case, flexion contracture of the left shoulder joint occurred postoperatively. This sequela may have been caused by the toothbrush penetrating near the left accessory nerve.

Although penetrating pharyngeal injuries are a rare trauma, if an emergency physician encounters this, they must make an urgent decision to manage it. Even after the toothbrush is removed, in moderate or severe injuries involving the posterior or lateral pharynx, contrast-enhanced CT is the standard of care to rule out the possibility of damage to vital organs such as the brainstem, cerebellum, and carotid arteries. Studies evaluating the risk of infection in intraoral wounds have been inconclusive as to the benefits of antibiotics. However, due to serious infectious complications of pharyngeal trauma,[11] empirical antibiotics are recommended and tetanus prophylaxis should be considered. When removing the toothbrush, refraining from using blind techniques and consulting carefully with surgeons will lead to safe and complication-free results.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Research quality and ethics statement

The authors followed applicable EQUATOR Network (http://www.equator-network.org/) guidelines, notably the CARE guideline, during the conduct of this report.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.