Neck Burns Research Articles

Postburn head and neck reconstruction using tissue expanders

Background and objective: Tissue expanders are useful adjuvant in reconstruction after burn. The technique provides tissue of similar texture and color to the defect to be covered and has the added advantage of minimal donor site morbidity. The study aimed to assess the outcome and complications of using tissue expansion for head and neck postburn reconstruction. Methods: Thirty patients with head and neck burn scar, treated with thirty eight tissue expanders, were included in this prospective study at the Plastic Surgery Department in Rizgari Teaching Hospital in Erbil from April 2009 to November 2012, with the mean age of 14 years. Statistical package for social sciences (SPSS version 18) was used for data entry and analysis. Results: The commonest use of tissue expander was for treating postburn scar alopecia (18 patients, 60%), followed by postburn cheek scar (six patients 20%). The scar size ranged from 4x10cm to 16x24cm. Complete burn scar excision was possible in 80% of cases with single or multiple sessions of expansion. Early exposure of the expander followed by infection occurred in three cases (10%), which led to interruption of the expansion and expander removal. Satisfactory results were achieved after reconstruction in 90% of cases. Conclusion: Tissue expansion, if carefully planned and conducted, is one of the treatments of choice for post-burn reconstruction of the head and neck, allowing an expanded flap suitable for versatile coverage.

Burns in the head and neck: A national representative analysis of emergency department visits.

Head and neck burns (HNBs) engender serious sequelae including airway edema, speech/swallowing dysfunction, sensory deficits, and scarring/disfigurement, often requiring significant reconstructive surgery. We used a nationally representative resource to estimate the number of visits to emergency departments (EDs), analyze burn types and demographic patterns, and identify specific consumer products involved. The National Electronic Injury Surveillance System was evaluated for the most recent 5-year period available. HNB ED visits were identified, and patient records were evaluated for consumer products facilitating injury, along with other ED visit and patient characteristics. From 2009 to 2013, 6,326 cases extrapolating to 233,431 ED visits nationally were identified. Males were predominantly impacted (64.1%). Although adults overall comprised the majority of patients (59.7%), children between 1 and 2 years of age had the highest incidence (21,544 ED visits nationally). The most common consumer products facilitating HNB included welding equipment, hot water, gasoline, bleaches, and cookware. Most injuries involved the face (55%), whereas the most common etiologies included thermal (40%), chemical (23%), and scald (22%) burns. Consumer products and injury patterns varied by patient age. HNBs significantly impact healthcare delivery, as over 200,000 visits reportedly presented to EDs over the 5-year period studied. Consumer products facilitating visits and associated patient demographics described may guide history, clinical examination, and identification of secondary injuries. In particular, age-specific patterns detailed may be included in consumer education and patient counseling to facilitate injury prevention, as office visits provide an opportunity to counsel patients.

Rescuing the obese or burned airway: are conventional training manikins adequate? A simulation study

Percutaneous tracheal access is required in more than 40% of major airway emergencies, and rates of failure are high among anaesthetists. Supraglottic airway management is more likely to fail in patients with obesity or neck pathology. Commercially available manikins may aid training. In this study, we modified a standard 'front of neck' manikin and evaluated anaesthetists' performance of percutaneous tracheal access. Two cricothyroidotomy training manikins were modified using sections of belly pork to simulate a morbidly obese patient and an obese patient with neck burns. An unmodified manikin was used to simulate a slim patient. Twenty consultant anaesthetists were asked to manage a 'can't intubate, can't ventilate' scenario involving each of the three manikins. Outcome measures were success using their chosen technique and time to first effective breath. Success rates using first-choice equipment were: 'slim' manikin 100%, 'morbidly obese' manikin 60%, and 'burned obese' manikin 77%. All attempts on the 'slim' manikin succeeded within 240 s, the majority within 120 s. In attempts on the 'morbidly obese' manikin, 60% succeeded within 240 s and 20% required more than 720 s. All attempts on the 'burned obese' manikin succeeded within 180 s. Significantly greater technical difficulty was experienced with our 'morbidly obese' manikin compared with the unmodified manikin. Failure rates and times to completion were considerably more consistent with real-life reports. Modifying a standard manikin to simulate an obese patient is likely to better prepare anaesthetists for this challenging situation. Development of a commercial manikin with such properties would be of value.

A Case of Severe Head and Neck Post-Burn Contractures: Fiberoptic Intubation through an I-Gel Laryngeal Mask Maintaining Spontaneous Ventilation

Airway management in patients with head and neck contractures can be very challenging. Severe facial and neck scars may predict difficult mask ventilation. Difficult intubation should also be expected. We analyzed the airway management in an adolescent with severe post burn head and neck contractures. The challenges during airway approach are discussed and a comprehensive analysis regarding the option for fiberoptic intubation using an I-gel laryngeal mask as a conduit is also performed. Considering the scarce literature in this topic, the techniques described here represent an important contribute to the process of decision-making when planning the airway approach in these patients.

English

English

49. Neurophysiological monitoring in surgery of cervical subependimomas

Subependymomas are lesions that typically arise in the fourth and lateral ventricles. Subependymomas of the spinal cord are rare and only 33 cases have been described. These lesions are subpial, and eccentrical in location and present an exophytic component. We report the case of a 54-years old woman who came to our attention complaining for a five months history of neck pain and burning paresthesia in her right upper limb. Neurological examination revealed severe hyperreflexia and a grade 3/5 power in her right upper and lower limb. MRI with gad revealed a hyperintense intramedullary lesion on T2-weighted images at the level of C2–C3 and C4, with minimal post-contrast enhancement. The lesion was removed through a C2 to C4 laminectomy. A cleavage plane was evident and the lesion was removed in a peacemeal manner. The entire procedure was performed under neurophysiological monitoring (PES, PEM, D-wave, EMG free-run); at the end of the removal, there was an improvement in the motor evoked potentials of the right upper limb. The patient was able to ambulate from the second postoperative day and her right upper strength slightly improved; MRI with gad revealed a gross total removal of the lesion. Histological examination revealed a subependymoma.

Neck burn reconstruction with pre-expanded scapular free flaps

BackgroundThe reconstruction of neck contracture deformities after severe burns is challenging. This is due to insufficient tissue to resurface the large defect after local flap transfer as well as the poor functional and cosmetic results after traditional methods such as skin grafting. We employed free transfer of pre-expanded scapular flaps to reconstruct postburn neck deformities. MethodsIn the first stage, skin expansion was performed with tissue expanders ranging from 400 to 800mL according to the neck defect size and expanders were filled to their end volumes. In the second stage, the contracture in the neck was released and the unstable scar was resected. The pre-expanded scapular flap was then harvested and transferred to the neck defect. Flap revisions were performed 3–12 months after flap transfer. ResultsA total of 12 flaps (100%) were successful. The contour, colour, and texture of flaps matched well to the nearby skin. The range of motion of the neck was significantly improved. The donor defects were closed directly except for one case, which required skin grafting. ConclusionsThe free tissue transfer of pre-expanded scapular flap is a valuable tool in neck burn reconstruction. It can be used safely and effectively with minimal morbidity in selected patients.

Tracheal intubation difficulties in the setting of face and neck burns: myth or reality?

IntroductionFace and/or neck burn (FNB) exposes patients to the double respiratory risk of obstruction and hypoxia, and these risks may require a tracheal intubation. This study aims to describe the incidence and the characteristics of difficult intubation in FNB patients. MethodsWe conducted a 5-year retrospective, single-center study including all patients meeting the following criteria: 18 years of age or older, an FNB at least 1% of burned surface area with a severity equal to or greater than the superficial second degree, and intubation and a burn center admission within the first 24 hours after the burn. Patients were compared according to the difficulty of their intubation. ResultsBetween January 2007 and December 2011, we included 134 patients. The incidence of difficult intubation was 11.2% but was greater in the burn center than in the pre–burn center: 16.9% vs 3.5% (P = .02). The most important difference between patients with or without difficult intubation was the time between the burn injury and the intubation: 210 (105-290) vs 120 (60-180) minutes (P = .047). After multivariate analysis, an intubation performed at a burn center was independently associated with difficult intubation: odds ratio = 3.2; 95% confidence interval, 1.1-528. ConclusionsThis study underlines the high incidence of difficult intubation in FNB patients, greater than 11.2%, and demonstrates that intubation is more difficult when realized at a burn center, probably because it is performed later, allowing for development of cervical and laryngeal edema.

Difficult endotracheal intubation caused by head and neck burn

Difficult endotracheal intubation caused by head and neck burn

Post burn contracture neck: clinical profile and management.

Morbidity related to hypertrophic scars and contractures which are well known sequel after burns remains high and in fact has increased as more severely burned patients are surviving. This study was undertaken in order to assess the varied clinical presentation, precipitating factors, preventive measures, treatment modalities of neck contractures and evaluate the results after surgical procedures. This hospital based study was conducted on patients admitted in our institution with proven cases of Post burn neck contracture from 1st August 2009 to 31st July 2011. Twenty two patients of post burn neck contracture who underwent operative treatment were included. 10 of 22 cases were in the middle age group i.e. between 21-30 years. There were 5 males and 17 females. Accidental flame burn was the commonest aetiology. Fourteen patients were treated within 1 year of burns for functional disability. Excisional release was performed in 13 and incisional release in 9 of our patients. Resurfacing with STSG (split thickness skin graft) was carried out in 19 cases and a local or regional flap with or without a graft in 3 patients. Hypertrophy and recontracture were the commonest late complications and occurred in 3 cases. Good to fair results were obtained in 19 patients Local flaps have many advantages and are to be used whenever possible. It is preferable to place the grafts if used in the area surrounding the neck (donor site of flap) or at least in the non-visible area of the neck (submental area). When a combination of flap & graft is used, it's preferable to place the flap in a horizontal intersecting fashion in between the two patches of the graft. A follow up program for reasonable period is highly desired.

Anaesthetic management of a patient with severe post-burn mento-sternal and circumoral scar contractures -a challenging airway

The anaesthetic management of patients with severe post-burn contracture presents many difficult problems ranging from scarce venous access to a difficult airway. Airway management is a challenge to anaesthesiologist owing to contractures and deformity resulting in nonalignment of oral, pharyngeal and laryngeal planes for intubations. Severe post burn neck contracture results in difficult intubation, which can be life threatening and can result in multiple serious complications and sequels. We present the successful anaesthetic management of a patient with severely limited neck extension, fixed flexion deformity and microstomia by awake nasal fibreoptic intubation.

Percutaneous dilational and surgical tracheostomy in burn patients: Incidence of complications and dysphagia

The aim of this study is to evaluate the incidence of complications and dysphagia in relation to the timing of tracheostomy and tracheostomy technique in 49 consecutive adult burn patients. We analysed prospectively collected data. Bronchoscopy was used to diagnose tracheal stenosis and a modified Evans blue dye test was used to diagnose dysphagia. Eighteen patients received a percutaneous dilatational tracheostomy (PDT) and thirty-one patients received an open surgical tracheostomy (OST). Eight patients developed significant complications (16%) following tracheostomy, there is no difference in the incidence of complications; post op infection, stoma infection or tracheal stenosis between PDT and OST groups. Patients with full thickness neck burn who developed complications had a tracheostomy significantly earlier following autografting (p=0.05). Failed extubation is associated with dysphagia (p=0.02) whereas prolonged intubation and ventilation prior to tracheostomy independently predicts dysphagia (p=0.03).We conclude that there is no difference in the complication rates for PDT and OST in our burn patients. We recommend early closure of neck burns and tracheostomy through fully adherent autograft or at least 10 days after grafting to reduce stomal infections. For patients with no neck burn, we support early tracheostomy to reduce the likelihood of dysphagia.

Early onset pneumonia in patients with severely burned face and neck: A 5-year retrospective study

Patients with face and neck burns (FNBs) often undergo prehospital intubation, or sustain inhalation injury which are risk factors for pneumonia in specific populations. Early onset pneumonia (EOP) might be caused by initial management. The primary goal of this study was to find risk factors for EOP in FNB patients.This is a retrospective, single-center trial. We screened all FNB patients for EOP with the Clinical Pulmonary Infection Score. Pneumonia diagnosis was with culture from a mini broncho-alveolar lavage. Potential risk factors for EOP were recorded.We included 152 patients, EOP was diagnosed in 58 (38.2%). EOP patients had a greater burned surface area median (20±17% vs. 10±17%; p<0.001), were more frequently intubated during prehospital care (65.5% vs. 21.3%; p<0.001), had more abnormal fiberoptic bronchoscopy at admission (58.6% vs. 19.1%; p=0.002) and a lower initial PaO2/FiO2 ratio (median 314±118.6 vs. 365±105.7; p=0.01). Multivariate analysis showed that only prehospital intubation was independently associated with EOP (odds ratio 3.6; 95% confidence interval, 1.34–10).Prehospital intubation appears to be an independent risk factor for EOP in severe burn patients. Assessments of the risk–benefit ratios of intubating and of not intubating those patients are indicated.

Our experience in reconstructing the burn neck contracture with free flaps: Are free flaps an optimum approach?

Introduction: The aim of the reconstructive burn surgeon is to remove all the scar tissue in the affected area and resurface the area with supple tissue, which allows proper movement of the neck and is esthetically pleasing. We present our series of 10 patients of burn neck contracture, primary and recurrent, who were treated with free flap reconstruction. Patients and Methods: A retrospective review of all the data of the patients was done and the demographic data, preoperative and postoperative examination findings, surgery offered, results and follow-up details were tabulated and analyzed. Results: All the flaps survived completely. Two flaps showed postoperative congestion on day 1 and were taken to the operating room to be reexplored. All patients showed marked improvement in the degree of neck extension, lateral flexion, and rotation which remained unchanged with successive follow-ups. Conclusion: The results of free flap reconstruction of the burn neck contracture area appear to be better than other methods in terms of functional and esthetic restoration of the normal anatomy. The postoperative morbidities for the patient are also reduced and patient comfort is enhanced. The authors feel that in centers where microsurgical expertise is available, the patients of burn neck contractures may be offered the option of complete scar excision and free flap reconstruction as a primary option instead of scar release and split skin grafting.

Elective cesarean section in a parturient with post burn neck contracture: An anesthetic challenge!

The incidence of failed intubation in the pregnant population is 1 in 250-300 patients, which is 8 times higher than non-pregnant patients. Regional anesthesia is the technique of choice in a parturient with recognized potentially difficult airway for cesarean section; however, it may be controversial in the presence of anticipated intraoperative hemodynamic instability. We describe anesthetic management of 23-year-old female, gravida 2, para 1 admitted in the labor ward with central placenta previa and severe post burn contracture of neck for elective cesarean delivery.

Airway management of recovered pediatric patients with severe head and neck burns: a review

There are approximately 10,000 pediatric burn survivors in the United States each year, many of whom will present for reconstructive surgery after severe burns in the head and neck (1). These recovered burn victims, who are beyond the acute phase of injury, often have significant scarring and contractures in the face, mouth, nares, neck, and chest, which can make airway management challenging and potentially lead to a 'cannot intubate, cannot ventilate' scenario (2). Although numerous cases have been presented in the literature on this topic (3-17), there are no comprehensive review articles on the unique challenges of airway management in the recovered pediatric burn patient with distorted airway anatomy. This article aims to provide a comprehensive review of airway management in such patients, focusing on challenges encountered during mask ventilation and tracheal intubation, as well as the role of surgical release of neck contractures to facilitate tracheal intubation. Lessons learned from all reported cases identified in a thorough literature search are incorporated into this review.

Randomized crossover comparison of the laryngeal mask airway classic with i-gel laryngeal mask airway in the management of difficult airway in post burn neck contracture patients.

Purpose:The objective of the study was to compare the performance of i-gel supraglottic airway with cLMA in difficult airway management in post burn neck contracture patients and assess the feasibility of i-gel use for emergency airway management in difficult airway situation with reduced neck movement and limited mouth opening.Methods:Prospective, crossover, randomized controlled trial was performed amongst forty eight post burn neck contracture patients with limited mouth opening and neck movement. i-gel and cLMA were placed in random order in each patient. Primary outcome was overall success rate. Other measurements were time to successful ventilation, airway leak pressure, fiberoptic glottic view, visualization of square wave pattern.Results:Success rate for the i-gel was 91.7% versus 79.2% for the cLMA. i-gel required shorter insertion time (19.3 seconds vs. 23.5 seconds, P=0.000). Airway leak pressure difference was statistically significant (i-gel 21.2 cm H20; cLMA 16.9 cm H20; P=0.00). Fiberoptic view through the i-gel showed there were less epiglottic downfolding and better fiberoptic view of the glottis than cLMA. Overall agreement in insertion outcome for i-gel was 22/24 (91.7%) successes and 2/24(8.3%) failure and for cLMA, 19/24 (79.16%) successes and 5/24 (16.7%) failure in the first attempt.Conclusion:The i-gel is cheap, effective airway device which is easier to insert and has better clinical performance in the difficult airway management of the airway in the post burn contracture of the neck. Our study shows that i-gel is feasible for emergency airway management in difficult airway situation with reduced neck movement and limited mouth opening in post burn neck.

Incidence and Predictive Factors for Dysphagia After Thermal Burn Injury: A Prospective Cohort Study

The objective of this study is to determine dysphagia incidence for a consecutively admitted population of thermal burn injury patients and to determine admitting characteristics that can be used to reliably predict patients at risk of developing dysphagia after thermal burn. Four hundred thirty-eight patients with thermal burns, with or without inhalation injury, who were consecutively admitted to and received management at a state-wide burn center over a 2-year period (2007-2009) were included. All patients meeting the project's inclusion criteria underwent clinical swallowing assessment to determine the presence or absence of dysphagia. Dysphagia incidence was found to be 11.18% (n = 49) in the admitted population. Dysphagia severity at initial assessment was classified as severe for 40.82%, moderate for 30.61%, and mild for 28.57%. Statistical analysis revealed a core set of statistically significant parameters known within the first 24 hours postinjury that showed strong sensitivity and specificity for detection of dysphagia risk. These include, in isolation or in combination, with the consideration of increasing age, TBSA burnt ≥18%, head and neck burns, need for escharotomy, inhalation injury, need for intensive care admission, and need for mechanical ventilation. This is the first large, prospective cohort study to document dysphagia incidence within the thermal burn population and to validate key predictors for dysphagia risk in this population. These data will assist the allocation and planning of speech pathology services and provide an evidence-based pathway for ensuring early identification and management of patients at high risk of dysphagia after thermal burn injury.

Aesthetic and functional restoration of anterior neck scar contracture using a bipedicled expanded forehead flap

Objective The study aimed to explore a new method to restore functional and cosmetic outcomes for anterior neck burn scar contracture. Methods Tissue expanders were implanted subcutaneously under the muscle of the forehead. Tissue expansion started 1 week postoperatively. When the skin expansion finished, a bilateral pedicled expanded skin flap was created on the basis of the superficial temporal artery and transferred to the anterior neck. Both the range of motion of cervical spine and the mental cervical angle were measured before and after operation. Data were analysed by Statistical Package for Social Sciences (SPSS) 13.0 and t-test. Results From September 2006 to May 2010, six male patients were treated by this method. The active range of motion of the neck of patients improved, the postoperative ranges of active flexion, extension, left flexion, right flexion and left and right rotation of cervical spine increased respectively. The mental cervical angle was 152.7 ± 1.9° preoperatively and 90.7 ± 2.2° postoperatively; the physiological angle was recovered. Patients were followed up from 5 months to 3 years, they were satisfied with the results and no recurrence of contracture was found. Conclusion The bipedicled expanded forehead flap, which provided good blood supply, repaired anterior contracture in the neck and created both aesthetic and functional results; it also diminished donor morbidity.

Prevention-oriented epidemiology of burns in Ardabil Provincial Burn Centre, Iran

In preventing burns, it is essential to know how they occur and which population groups, environments and heating appliances can be targeted for prevention work. The aim of this study was to determine the epidemiological characteristics of burns leading to hospitalisation in the northwest of Iran with a focus on the pre-event phase of injury. Between 2007 and 2008, 237 burn victims hospitalised in Ardabil provincial burn centre were enrolled into a descriptive study. A questionnaire was filled in during hospital stay for all patients, with a focus on obtaining information necessary for prevention purposes. Males constituted 56% of victims. Mean age was 22 years. The most severe burns occurred between the ages of 18 and 32 years, and were mainly flame related. Both in case of flame and non-flame burns, women suffered more severe burns and mortality than men. However, with respect to non-flame burns of which most were scalds, the majority of the severe cases involved children under the age of 5 years. More than 80% of burns occurred at home. The kitchen was the main place of injury in 47% of cases, followed by living rooms in 28%. Nearly 45% of burns were scalds and 47% were flame burns. The main container was the samovar in 37%, followed by kettles in 32% and pots in 22%. The overturning of a container was the major mechanism of contact with hot liquids in 86%. Bumping into a container was the main scenario of a scald injury, constituting nearly 70% of the cases. The difference between flame and non-flame burns in the distribution of burns in extremities was not statistically significant, but head and neck burns were 3.7 times more likely to be caused by flame. The two most important injury patterns, more common among women, were getting burned while using a camping gas stove or while refilling the chamber of kerosene-burning appliances without first extinguishing them. Domestic burns among children and young women are a priority in injury-prevention programmes. Camping gas stoves, valors (traditional dual-purpose heating and cooking appliances) and samovars can be considered as target appliances for burn-specific home-safety-promotion efforts in this area or in similar settings.