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, Pitner
3 hypothesized that an intimal tear could propagate thrombosis in the internal carotid artery, resulting in CVA. Imaging findings in the current case supported Pitner's hypothesis. Children at the developmental stage of the patient (ie, aged 14 months) have yet to complete skull elongation, which explains the injury's proximity to the carotid sinus.
We identified 24 chopstick-related injuries in the pediatric population since 1995. Of these 24 injuries, 14 were classified as transorbital, 4 were transoral, 2 were transnasal, 2 were transbuccal, and 2 were temporal bone penetrations.
4 A series of reports revealed transoral injury and subsequent hemiparesis caused by a sharp-ended chopstick.
5,6 To our knowledge, no cases of hemiparesis after a penetrating injury from a blunt-ended chopstick have been reported.
Management of penetrating injuries is often self-limiting, and current guidelines suggest nonsurgical management.
7,8 However, penetrating injuries with neurologic complications are difficult to assess and require interdisciplinary consultation.
9 Research regarding the management of ischemic CVAs in the pediatric population has not been evidence-based and is extrapolated from treatment recommendations for adults. Randomized trials have shown benefit of intervention up to 6 hours after CVA onset.
10-13 A 2017 randomized trial found that endovascular thrombectomy improved disability and functional outcomes in adults with ischemic CVA up to 24 hours after becoming symptomatic.
14 Data on the efficacy of tissue plasminogen activator administration in children are not available; however, the National Institutes of Health funded a study
15 that evaluated thrombolysis in pediatric CVA. The study
15 recommended preliminary guidelines for treatment of ischemic CVA, but the recommendations were limited to expert consensus and collective experience.
Other recommendations describe the role of a diligent physical examination for adequate triage. For example, tenderness at the mandible angle suggests damage to the peritonsillar musculature and possible neurovascular compromise.
5 Other studies
16,17 have identified that a midline soft palate through-and-through penetration is typically less severe than a lateral penetration. These injuries are associated with a 60-hour lucid interval and, thus, hospitalization for at least 3 days is recommended.
5,16,17 Our literature search identified interval Doppler images and, more recently, computed tomographic scans as being useful in the detection of significant thrombosis and prevention of neurologic sequelae.
5,18-20
These recommendations are rebutted by Randall and Kang,
9 who made an important point regarding the costs associated with the recommended 3-day hospitalization and serial imaging. Their review highlights the lack of supporting evidence for a particular intervention in patients with a penetrating injury to the soft palate. Additionally, they reference Suskind et al,
17 who found a low number of patients with neurologic complications after penetrating injuries involving the soft palate. Therefore, imposing large health care costs onto patients and the health care system may be unwarranted given the low incidence of chopstick penetration injuries.
The current case highlights the additional costs that result from neurologic sequelae of penetrating injuries involving the soft palate. We propose a method of triaging patients that will minimize the risk of serious sequelae after oral penetration injuries but will also keep health care costs reasonable. This method includes a thorough physical examination, including assessment of mandibular angle tenderness. If mandibular angle tenderness is present in the setting of lateral soft palate injury, we recommend consideration for hospitalization up to 60 hours with routine neurologic assessments per hospital protocol. This recommendation is warranted because of the association of mandibular angle tenderness with neurovascular compromise. However, with any oral penetration injury, robust patient and family education on neurologic changes should be provided. To prevent serious sequelae, the importance of prompt return to the physician or emergency department after any changes in symptoms should be emphasized.
The current patient benefited from a whole-person assessment and therapy. However, although his hemiparesis was improving, the effects of the brain injury may remain throughout his life and require comprehensive, whole-person evaluation and treatment of his mind, body, and spirit as he gradually discovers his inability to participate in daily activities for his age group. The progression of the patient's symptoms illustrates how a localized trauma can cause a global impact to the total body unit.