Case Report - Otolaryngology Online Journal (2016) Volume 6, Issue 3
An Unusual Traumatic Injury Leading to Hard Palate Perforation
Virangna Taneja*, Shashidhar, Anish Gupta and Rajesh Bhardwaj
Department of Otolaryngology and Head & Neck Surgery, Artemis Hospital, Gurgaon
- *Corresponding Author:
- Virangna Taneja
Department of Otolaryngology and Head & Neck
Surgery, Artemis Hospital, Gurgaon, B-238, Derawal nagar, Opposite Model Town, Delhi, India,
E-mail: [email protected]
Received date: April 01, 2016; Accepted date: May 18, 2016; Published date: May 21, 2016
Traumatic injuries are very common in oral cavity and involve primarily the soft palate. Traumatic injuries involving the hard palate in adults are rare. Hard palate perforation secondary to animal trauma is a rare entity. This is an unusual case where a 50 yrs old male presented with midline hard palate injury by horn of a bull. The perforation was repaired using palatoplasty and patient had no complication postoperatively. This case report reviews other unusual causes of palatal perforation, mechanism of bull horn injuries and treatment options for such defects.
Palate, Perforation, Traumatic
Palatal perforation either acute or chronic is
rarely caused by trauma. Penetrating trauma to the
head and neck accounts for 1% to 2% of pediatric
trauma admissions. Children have a propensity to
place objects in their mouths, which leaves them
at risk of trauma to the oral cavity. On the contrary
palatal trauma in adults is rare .
Bull-horn wounds are incisive and contusive, they
have special Characteristics 
• The entry opening is usually small and
surrounded by an erosion zone. It also may not
correlate with the gap in the aponeurosis.
• One or more in-depth tracts may be present,
usually with important muscular destruction.
• These wounds are contaminated, and multiple
foreign bodies may found at the bottom of the wound tract, including cloth fragments, dirt,
and horn chips.
This contaminated wound has a high chance of
failure in primary closure. Review of important causes
of palatal fistula indicate Developmental causes
being the most common cause, occur due to failure
of fusion of palatal shelves by 6th week of prenatal
life. Maternal alcohol consumption, cigarette
smoking, deficiency of folic acid, teratogenic drugs
and viruses are some of the known environmental
factors leading to cleft palate  (Figure 1).
Figure 1: No post-operative complication was seen.
Various infectious and chronic granulomatous
conditions are known to cause palatal perforation like
leprosy, tertiary syphilis, tuberculosis, actinomycosis,
histoplasmosis, and blastomycosis. Autoimmune
conditions including sarcoidosis, Wegner’s and
Crohn’s disease also lead to palatal perforation .
Malignancy of minor salivary gland tumor like
adenoid cystic carcinoma also leads to palatal
perforation . Tumors’ from maxilla and nose also
contributes to this either due to rapid spread leading
to bulge in palatal area and later on perforation or
sometimes perforation occur as a part of treatment5.
Cocaine is a proven drug leading to perforation,
other drugs involving the palate includes heroine
and nicotine  (Figure 2).
Figure 2: The large irregular bony defect in preoperative
Perforation might occur following a surgical
procedure done for tumor removal or may be
following intubation. Literature also describes role of
rhinolith leading to perforation . Aim of presenting
this case is to emphasize the rare cause of palatal
injury being animal.
A 50 yrs old male from Nigeria presented to ENT
OPD with a defect in hard palate since 6 months,
which occurred owing to injury by the horns of
bull. Patient also had laceration involving lips and
right side ala of nose. Patient had difficulty while
eating and change in speech. The patient was taking
treatment from the primary health centre in Nigeria,
where he underwent repair for the laceration but
no intervention was done for the palatal wound.
Examination revealed nasal speech, an oval
palatal fistula with irregular margins measuring
3 x 1 cm; extending anteriorly up to the rughae
area and posteriorly up to the canines. No signs of
inflammation noted. CECT oral cavity revealed area
of defect at the anterior part of hard palate.
Patient was taken up for V-Y Palatoplasty and intra
operatively the bony defect was found to be 5 x 5
cm. The defect was then repaired in 3 layers using
PDS suture for nasal layer and 4.0 vicryl for muscle
and mucosa, and patient was allowed liquids orally
next morning. Due to the large irregular bony defect
in pre-operative CT, consent for bone grafting was
also taken but intra operatively the closure was
Palate contributes to an important part of oral
cavity, the defect of which leads to nasal regurgitation
of food, recurrent nose and ear infections and nasal
It comprises of the palatine part of palatine
process of maxilla covered by palatine muscles and
Pathologies affecting palate can be congenital or acquired. Acquired causes include idiopathic or
due to traumatic, infectious, malignancy related,
Case presented here is of interest as it is caused
by trauma by horns of animal (bull). It is important
to understand the complex mechanism causing the
wound, as the result of the interaction of various
distinct forces. The depth is dependent on the force
of penetration of the bull´s horn into the body (which
is the result of the animal´s weight and speed).
There is an additional force because of the effect
of the bull´s strong neck muscles when it raises its
horns. This force causes upward tears at right angles
to the ground. If the injured person is lifted, his body
weight exerts an opposite force. Finally, when the
patient´s body is lifted and suspended by the bull´s
horns, it is in an unstable balance, which, depending
on the location of the center of gravity relating to the
horn, causes a rotational movement (with ensuing
tears of arteries, veins, and nerves), combined with
the animal´s efforts to disengage the person´s body .
Cases of traumatic perforation have been
reported in literature. Hwang and Kim reported a
case of submucosal cleft palate in 27 yr old women
because of ingestion of hot food (Thermal injury).
Perforation and midline notching at the posterior
edge of the hard palate was seen noted . A case
of 69 years male patient was reported by Macleod
in which perforation of the hard palate secondary
to pressure atrophy was noted . Ozul et al. 
reported a case in which perforation of hard and
soft palate is seen after a long intubation period. A
case of palatal perforation in a 36-year-old female
patient treated for empyema of maxillary sinus was
reported by Pegler . Other non-traumatic acquired
causes presenting as palatal perforation should
include infections (syphilis, leprosy, tuberculosis, diphtheria, mucormycosis, actinomycosis) tantrum
oris, mechanical trauma, intranasal cocaine abuse,
malignancies (especially nasal T cell lymphomas,
carcinoma, melanoma), collagen vascular diseases
(Wegener’s granulumatosis, systemic lupus
erythematosus), sarcoidosis and idiopathic cause
such as midline non-healing granuloma . This
patient was operated 6 months after the injury.
This was sufficient time for optimal wound healing
and contraction of fistula and union of adjacent
maxilla facial bones. Pre-operative CT scan helps in
determining the extent of surgery required and to
consent the patient for possible bone grafting.
The treatment options comprise sealing of
the defect, either surgically or with a removable
obturator, once the lesion has been seen to remain
stable. The surgical technique is chosen according
to the location and dimension of the lesion, the
presence of infections and the general patient
For reconstruction of the defect, the literature
describes surgical techniques like primary closure,
use of local pedicled flaps, lingual grafts, temporal
muscle flaps, oral adipose tissue grafting, von
Langenbeck technique, Furlow double opposing Z
palatoplasty, Veau-Wardill-Kilner or VY pushback
palatoplasty. In case of extensive lesions, free
microvascular flap ie. radial forearm free flap 15
is indicated, with or without simultaneous bone
The literature also describes the resolution of small
or medium-sized defects using a Le Fort I osteotomy and bilateral adipose flap of the Bichat bulla, in those
cases where a temporal or microvascularized flap is
contraindicated . Anterior hard palate perforation
are better dealt with von lagenbeck technique or
its modifications , V Y pushback palatoplasty and
posterior soft palate ones by furlow double opposing
Z palatoplasty. Each of these techniques has their
advantages and different failure rates depending on
site of perforation and extent of perforation. This
case was done by VY pushback palatoplasty without
complications of VPI or fistula.
The use of prosthetic obturators as a solution to
situations that pose social problems for the patient
is often indicated in cases characterized by palatal
communications secondary to highly mutilating
surgery. These obturators may be offered as an
alternative for patients with palatal perforations
who do not wish to undergo surgery, in those cases
where the cost/benefit ratio is not favorable, in
patients who cannot or do not wish to abandon the
habit, or as a temporary measure before surgical
Such obturators avoid nasal reflux, facilitating
correct swallowing and sufficient speech
performance. The only contraindication to such
devices is patient tolerance of the obturator, since in
some cases the obturator size required to fully seal
the defect can cause nausea .
Traumatic injuries to maxillofacial region are quite
common but this report presents a unique type of
traumatic injury causing perforation of palate.
- Cooper A, Barlow B, Niemirska M, Gandhi R (1987) Fifteen years’ experience with penetrating trauma to the head and neck in children. JPediatr Surg 22: 24-27
- Bull- Horn injuries: a nine year experience ( article in Spanish) Our Surgical Diseases Around the World column, guest edited by Walter J. Burdette, M.D., Ph. D., of Houston, Texas, examines the geographic distribution of disease and the varying treatment modalities around the world.
- Amaratunga NA (1989) A study of etiologic factors for cleft lip and palate in Sri Lanka. J Oral Maxillofac Surg 47: 7-10.
- Karabulut AB, Kabakas F, Berköz O, Karakas Z, Kesim SN (2005) Hard palate perforation due to invasive aspergillosis in a patient with acute lymphoblastic leukemia. Int J PediatrOtorhinolaryngol 69: 1395-1398.
- Ferrazzo KL, Schneider PP, Shinohara EH (2011) An unusual case of adenoid cystic carcinoma with hard palate perforation. Minerva Stomatol 60: 83-86.
- Chaudhary SV, Karnik ND, Sabnis GR, Patil MV, Bradoo RA (2011) Extranodal NK/T cell lymphoma presenting as palatal perforation with oronasal fistula. J Assoc Physicians India 59: 112-114.
- Silvestre FJ, Perez-Herbera A, Puente-Sandoval A, Bagán JV (2010) Hard palate perforation in cocaine abusers: a systematic review. Clin Oral Investig 14: 621-628.
- Pinto LS, Campagnoli EB, de Souza Azevedo R, Lopes MA, Jorge J (2007) Rhinoliths causing palatal perforation: case report and literature review. Oral Surg Oral Med Oral Pathol Oral RadiolEndod 104: e42-e46.
- Herranz F, Hernandez C (1987) Heridas genitourinarias por asta de toro: A propósito de tres casos.ActasUrolEsp 11:214-217
- Hwang K, Kim YS (2010) Perforation in submucous cleft palate due to thermal injury. J Craniofac Surg 21: 280-281.
- Macleod AL (1927) Perforation of hard palate. Proc R Soc Med 20: 1096.
- Ozgul S, Tezel E, Numanoglu A (2005) Palatal perforation after long intubation period. Eur J Plast Surg 27: 335-337.
- Pegler LH (1910) Traumatic (post-operative) Perforation through the Hard Palate, communicating with the Floor of Left Nasal Fossa and Maxillary Antrum. Proc R Soc Med 3: 146.
- Goodger NM, Wang J, Pogrel MA (2005) Palatal and nasal necrosis resulting from cocaine misuse. Br Dent J 198:333-334.
- Di Cosola M, Turco M, Acero J, Navarro-Vila C, Cortelazzi R (2007) Cocaine-related syndrome and palatal reconstruction: report of a series of cases. Int J Oral Maxillofac Surg 36:721-727.
- Pelo S, Gasparini G, Di Petrillo A, Tassiello S, Longobardi G, Boniello R (2008) Le Fort I osteotomy and the use of bilateral bichat bulla adipose flap: an effective new technique for reconstructing oronasal communications due to cocaine abuse. Ann Plast Surg 60: 49-52.
- Genden EM, Wallace DI, Okay D, UrkenML (2004) Reconstruction of the hard palate using the radial forearm free flap: indications and outcomes. Head Neck 26: 808-814.