Penetrating injuries are common in young children, particularly boys (1), with falls while holding objects like toothbrushes, toys, writing tools, sticks, or chopsticks being the main cause (2,3). Though often accidental and seemingly minor, these injuries can have life-threatening complications. Children are prone to falling with the items carried in their mouths. Although most cases may be effectively handled in outpatient settings without additional difficulties, some can lead to life-threatening complications. Reported complications include retropharyngeal and mediastinal abscesses, mediastinitis, extensive emphysema, thrombosis of the internal carotid artery, and airway obstruction. Emergency physicians or pediatricians should be aware of these potentially life-threatening problems throughout both the immediate and later stages and be able to manage them.

We report a novel case involving a 5-year-old boy who experienced a traumatic oral injury characterized by the penetration of “miswak,” a wooden stick used for dental hygiene, into the floor of the mouth and discharged without complications. A written informed consent was obtained from his legal guardian for the publication of this report including all clinical images.

A previously healthy 5-year-old boy was brought to the emergency department following an accidental fall while running on stairs with a miswak in his mouth, resulting in the penetration of the miswak into the mouth just below the tongue (Fig. 1). Upon arrival, the initial vital signs were as follows: blood pressure, 100/60 mmHg; heart rate, 90 beats/minute; respiratory rate, 30 breaths/minute; temperature, 37 °C; oxygen saturation, 96% on room air; and a Glasgow Coma Scale of 15/15. The boy was in mild pain, with minimal bleeding from the injury site. He had no history of head trauma, vomiting, loss of consciousness, abnormal movements, or voice hoarseness. On physical examination, we noticed a foreign body protruding from the floor of the mouth with minimal bleeding. He could not fully open or close his mouth. Systemic and neurological examinations were otherwise unremarkable.

Given the penetrating injury in the oral cavity, we administered him a prophylactic cefazolin (20 mg/kg intravenously), 0.9% saline (20 mL/kg bolus), and Tdap (tetanus, diphtheria, and pertussis) vaccine. The findings of basic workups were unremarkable, such as complete blood count, electrolytes, and coagulation profile. Plain chest and neck radiographs showed no signs of complications from the penetrating injury, such as pneumopericardium, pneumomediastinum, or emphysema (Fig. 2). At this point, computed tomography (CT) and CT angiography (CTA) scans of the facial bone were performed to evaluate the precise location and depth of the foreign body, as well as potential injuries involving the soft tissue, bone, or blood vessels. The CT scan showed that the foreign body in the mouth penetrated the floor of the mouth through the left sublingual space and reached the parapharyngeal space near the palatine tonsil (Fig. 3). The CTA revealed the foreign body in close proximity to the tonsillar branch of the facial and lingual arteries, with no signs of active bleeding or vascular injury.

The boy was immediately taken for oral and maxillofacial (OMF) surgery under general anesthesia, and underwent the removal of the foreign body and tissue repair (Fig. 4). He was discharged uneventfully after 24 hours of observation with oral antibiotics and analgesics prescribed, and follow-up to the OMF surgeon arranged.

Here, we report a novel case of oral floor trauma caused by a miswak. Although many accidental oropharyngeal penetrating injuries in children have been documented in the literature, there has been a lack of cases similar to this current case to our best knowledge (2-5). Prompt recognition of the mechanism, thorough assessment, and appropriate intervention can prevent the occurrence of complications. Close monitoring and follow-up are essential to ensure proper wound healing and the resolution of associated issues.

Among the complications, airway obstruction and severe bleeding should be initially stabilized given their potentially life-threatening features. Although uncommon, it is important to promptly address problems that may arise after the first event, such as carotid artery thrombosis, pneumomediastinum, and mediastinal abscesses. Given their close proximity to vital structures, such as the skull base, it is essential to thoroughly assess and appropriately manage injuries to other regions, including the carotid artery, vertebral artery, jugular vein, trachea, esophagus, nerves, and spinal vertebrae and cord. Infectious complications may occur due to the injuries. According to previous reports, it occurs in 4%-8% of wounds inside the mouth (3). Furthermore, prophylactic antibiotics were given in 87%-92% of cases (3). When there is penetration through the mouth floor (4), a study recommends a 24-hour observation in the hospital, along with antibiotic prophylaxis that covers the oral flora. Neurological consequences resulting from the carotid artery injury are rare but have been documented since 1966 (6).

Owing to the rarity of complications, prior research has indicated (1,3) that hospitalization is unnecessary and only provides a misleading sense of reassurance to both guardians and emergency physicians. Hospitalization may be advised for patients at high risk for complications, such as those presenting with retropharyngeal air, hematomas, abscesses, or pneumomediastinum. A lucid interval of up to 60 hours has been observed between the onset of initial trauma and neurological symptoms (7). Therefore, the length of hospital stay should exceed the duration of this latent period. During outpatient follow-ups, patients need close monitoring over a 48 to 72-hour period for the occurrence of any symptoms, such as vomiting, seizures, neck swelling, or bleeding from the mouth.

Recommended screening radiography may vary from no testing to contrast-enhanced CT (4,8). Brietzke and Jones (9) suggested the use of CT or CTA as the initial approach for assessing oropharyngeal injuries. The CTA findings of our patient were normal other than the presence of the foreign body. After total object extraction, the boy responded favorably to supportive therapy without the development of vascular damage or neurological deficits.

It is crucial for emergency physicians or pediatricians to be aware of the potentially perilous complications of penetrating injuries and provide careful management. The injuries require a comprehensive evaluation with attention to the potential high risk of extrication difficulties, referring to a trauma surgeon having appropriate expertise (e.g., OMF surgeons), monitoring the development of neurovascular or infectious complications, and education for guardians about potential symptoms and complications after the injury. Close monitoring and follow-up are essential to ensure proper wound healing and the resolution of associated issues.