Oral Burns Research Articles

Bipolar scissor division of tongue-tie under tubeless anesthesia.

Children with tongue-tie are frequently referred to the otolaryngologist. The usual reasons for consultation are associated mechanical problems, speech difficulties, parental concern about the tongue's appearance and, occasionally, suckling problems in infants. Tongue-tie has been accurately defined by Wallace1 as “a condition in which the tip of the tongue cannot be protruded beyond the lower incisor teeth because of a short frenulum linguae.” It may vary in degree from a very mild form in which the tongue is bound only by a thin mucous membrane and an intermediate form, in which both the frenulum and the underlying fibers of the genioglossus muscle are fibrosed, to the rare variety termed “ankyloglossia” in which the tongue is completely fused to the floor of the mouth.2, 3 Data in the literature suggest that the incidence of tongue-tie ranges from 0.03% in newborns to 0.4% in 4-to 5-year-old children presenting to a speech disorders clinic.4, 5 When indicated, tongue-ties are usually divided with the patient under general endotracheal anesthesia and with the use of scissors followed by hemostasis with sutures or diathermy. We introduce a method for tongue-tie division using scissors that cut and induce bipolar coagulation at the same time. The procedure is performed with the patient under tubeless anesthesia because of the complete hemostasis obtained when using these scissors. General anesthesia is induced using intravenous propofol in a dose of 2.5 mg/kg. A McKesson Dental Prop (Wright Health Group, Dundee, Scotland, UK) is used to hold the mouth open, and the tongue is grasped with a surgical swab or toothed forceps. The frenulum is divided with PowerStar Bipolar Scissors (Ethicon, Inc., Somerville, NJ) using a slow cutting movement and the simultaneous current application of 25 W (Fig. 1). The cutting stops short of the genioglossus muscle, which is not divided. Usually, only one snip is required and no bleeding occurs. A face mask supplying 100% oxygen is applied until the child is awake (Fig. 2). The child is discharged later, when able to eat. Division of tongue-tie with bipolar scissors. We have used this technique in six patients without any morbidity. Surprisingly, there was very little discomfort following the procedure and they were all able to go home shortly after surgery. On follow-up a month later, the tongue had gained a good range of mobility, and there were no parental concerns in the intervening period. Child with a face mask applied after the procedure. PowerStar bipolar scissors were introduced in 1997 for use in open surgery. The two blades are insulated from each other to form the active electrodes of the bipolar instrument. The handles and part of the outer surface of the blades are covered with plastic. The pairs we describe are a modification for use in the oral cavity with extended insulation to prevent oral cavity burns (Fig. 3).6 After 30 to 40 operations the blades become blunt; the scissors should then be discarded. Using dual-function scissors provides a completely bloodless operating field and therefore has advantages over the traditional method in many ways. The most important is the ability to perform the procedure with the patient under tubeless anesthesia, which has fewer complications and is associated with a speedy recovery. The operation itself is easier and more precise because of the lack of bleeding during tongue-tie division. Modified bipolar scissors. We have found this technique to be safe, with advantages over other methods. We recommend it to surgeons who perform tongue-tie division.

Electrical injuries: a 30-year review.

Electrical injuries currently remain a world-wide problem. This study determines whether electrical injuries at our institution have changed in the past 30 years, and identifies electrical burn complications and any high-risk groups. From 1967 to 1997, 185 children admitted to our institute were identified with electrical burns. Fifty-five percent of these electrical burns occurred from 1987 to 1997. During the last 10 years of this study, 43% of the electrical injuries (n = 44) were from low voltage (120-240 V) and 57% (n = 58) from high voltage (>1,000 V). In 17 children, serious low-voltage burns were identified as oral commissure burns. These were treated conservatively with one to two reconstructive procedures within 2 years. High-voltage injuries were mainly identified in male children (age 11 to 18 years). Thirty-three percent of high-voltage burns required amputation, 29% had deep muscle involvement, and 24% required either escharotomy or fasciotomy. No mortalities were reported. Although the incidence of low-voltage burns is currently on a steady decline, high-voltage injuries remain a problem, particularly in adolescent males.

Oral commissure burns in children.

Electrical burns of the mouth are relatively common in young children. Early intervention to prevent complications remains controversial. A chart review was conducted of 24 patients with oral commissure burns who were treated at the University of Iowa from 1975 to 1988. All of these patients were treated conservatively without splinting or early surgery. Only one patient underwent oral splinting before receiving care at the University of Iowa Hospitals and Clinics. While under our care, no patients suffered significant hemorrhage at eschar separation. Commissuroplasty and/or reconstructive lip surgery were performed at various times after the burn injury was healed and the functional or aesthetic impairment was established. Long-term follow-up was from 5 to 17 years, allowing for longitudinal evaluation of the postburn scars and their influence on facial growth. Our review revealed that (1) younger children with more severe burns have a less favorable outcome; (2) no hemorrhage was observed immediately after the burn or at eschar separation; and (3) conservative surgical treatment after scar maturation- and in some cases following steroid injections- resulted in a successful functional and esthetic outcome.

Ingestion of caustic cosmetic products

Twelve children over a 6-year period (1985 to 1991) underwent aerodigestive tract endoscopy after ingestion of lye-containing cosmetic products. All children were less than 2 years of age and had facial and/or oral cavity burns. Eleven of these patients ingested alkaline hair products such as "activators" or "relaxers." Endoscopy revealed pharyngeal burns in five patients but no laryngeal or esophageal burns in any patient. Erythema of the esophageal mucosa was seen in one patient. One patient ingested a solution used in fingernail decorating. This patient sustained extensive superficial burns of the pharynx, larynx, and esophagus and required intubation and admission to the intensive care unit. No long-term sequelae developed. Cosmetic products containing caustic chemicals represent a significant health risk to small children, especially because child-proof packaging is not standard for these products.

Hair Relaxer Ingestion: A New Trend

Although the health care system has done much to reduce the incidence of ingestion of such alkalis as drain and oven cleaners, in recent years we have seen an overwhelming increase in the incidence of hair relaxer ingestion. In a 5-year review (1987 to 1992) of 48 cases of caustic ingestion, 15 cases involved alkaline hair-relaxing agents. This retrospective study was undertaken to evaluate the agents ingested, the presenting signs and symptoms, the diagnostic procedures, and the outcomes in those 15 cases. Oral cavity and lip burns were common in these children, but none of the 15 had significant esophageal burns. Education of the medical and lay community about the risk of hair relaxer ingestion should be undertaken to reverse this worrisome trend.

Oral Electrical Burns: Etiology, Histopathology, and Prosthontic Treatment

Oral electrical burns occur predominantly in young children and may lead to permanent disfigurement. The etiology and histopathology of oral electrical burns are discussed. Prosthodontic treatment options are presented to provide clinical guidelines for the practitioner.

Burns of the oral mucosa: Report of 6 cases

Burns of the oral cavity may be caused by prolonged use of certain drugs by the patient or by incorrect use of caustics by the dentist. Unwillingly-acquired self-inflicted injuries are also encountered, such as caustic ingestion (out of curiosity or by accident), excessive consumption of fresh fruit and fresh fruit juice, and wrong oral hygiene practice. Our experience with six infrequent and unfamiliar types of oral burns, caused by various components and material, is described and discussed.

Management of injuries from liquid lye ingestion.

The simultaneous admission of nine youths to our institution following their ingestion of concentrated sodium hydroxide (which had been mistaken for wine) provided us with a unique opportunity to manage corrosive esophageal injuries ranging in severity from second-degree oral mucosal injury alone to full-thickness hypopharyngeal, esophageal, and gastric injury. The severity of injury was graded first on the basis of symptoms and physical examination of the mouth, and then in the operating room by rigid esophagoscopy. This procedure provided a logical approach to management. Three patients with second-degree oral burns required no surgery. Six patients required laparotomy with gastrostomy and/or chimney feeding jejunostomy, one required immediate esophagogastrectomy, and three required immediate total or subtotal gastrectomy. There were no deaths. Three patients have subsequently required esophageal replacement and three others have required repeated dilatations. At 2-year followup, all nine maintain their nutritional status orally, and all except for the previously mute patient can phonate. Ingestion of liquid lye requires a much more aggressive diagnostic and therapeutic approach than is currently recommended for ingestion of caustics in general. On the basis of our experience with these nine patients, we suggest the following for esophageal liquid lye injury: 1) early evaluation of the esophagus by esophagoscopy; 2) with esophageal burns, urgent laparotomy to assess gastric damage and gastrostomy to pass a string for subsequent retrograde dilatations; 3) adequate resection of stomach for gastric burns; 4) with deep esophageal burns, early esophagectomy.

Oral Splint Therapy to Manage Electrical Burns of the Mouth in Children

Oral electrical burns to the lip commissure are disfiguring injuries for a child. Current treatment includes the use of an orally anchored splint to hold the lip commissures at their correct positions during healing. After wearing an appliance for a period of one year, the burn site is evaluated for the need for corrective surgery (Fig. 9). It has been found that the use of a commissure appliance decreases the need for reconstructive surgery.

Dynamic orthoses for the management of microstomia.

Oral wounds and burns may result in microstomia with significant management problems. An important early management decision involves the selection of an appliance capable of applying forces that will halt and reverse the condition. A selection appropriate to the patient may be based on the need for teeth suitably placed to retain and position a particular device. Limited access to the patient's mouth because of recent trauma, surgery, wiring, inability to tolerate anesthetic, etc., may further restrict choices. Thus, the process of selection involves a weighing of the specific patient's condition and program of treatment against an understanding of the unique features, including complexity of fabrication and durability, of the range of prostheses available. This article provides an overview of the structural and clinical characteristics of seven dynamic intraoral and extraoral microstomia appliances. The need for interdisciplinary management of microstomia with appliances has been noted, and opportunities for research have been pointed out.

Splinting of oral commissure electrical burns in children.

traditional culture technique for detection of group A betahemolytic streptococci. J Clin Microbiol 20:824, 1984. 8. Gerber MA, Spadaccini L J, Wright LL, Deutsch L: Latex agglutination tests for rapid identification of group A streptococci directly from throat swabs. J PEDIATR 105:702, 1984. 9. Otero JR, Reyes S, Noriega AR: Rapid diagnosis of group A streptococcal antigen extracted directly from swabs by an enzymatic procedure and used to detect pharyngitis. J Clin Microbiol 18:318, 1983. 10. Petts DN: Early detection of streptococci in swabs by latex agglutination before culture. J Clin Microbiol 19:432, 1984. 11. Halfon ST, Davies AM, Kaplan O, et al: Primary prevention of rheumatic fever in Jerusalem school children. II. Identification of beta-hemolytic streptococci. Isr J Med Sci 4:809, 1968. 12. Kaplan EL, Top FH Jr, Dudding BA, Wannamaker LW: Diagnosis of streptococcal pharyngitis: Differentiation of active infection from the carrier state in the symptomatic child. J Infect Dis 123:490, t971. 13. Kaplan EL, Couser R, Huwe BB, McKay C, Wannamaker LW: Significance of quantitative salivary cultures for group A and non-group A/3-hemolytic streptococci in patients with pharyngitis and in their family contacts. Pediatrics 64:904, 1979. 14. Stillerman M, Bernstein SH: Streptococcal pharyngitis: Evaluation of clinical syndromes in diagnosis. Am J Dis Child 101:476, 1961. 15. Bresse BB, Disney FA, Talpey WB, et al: Beta-hemolytic streptococcal infection: The clinical and epidemiologic importance of the number of organisms found in cultures. Am J Dis Child 119:18, 1970.

Caustic ingestions. Pathophysiology, diagnosis, and treatment.

More than 5,000 caustic ingestions are estimated to occur each year. Liquid lye is associated with the greatest morbidity. Endoscopy is the only method for evaluating the extent of the injury; clinical signs and symptoms (e.g., vomiting, dysphagia, abdominal pain, oral burns, leukocytosis) are not reliable. In less severe burns (involving only mucosal irritation or ulceration), current therapy with antibiotics and steroids results in a very favorable prognosis. Circumferential or very deep burns have a much poorer outcome, with a greatly increased risk of stricture formation and/or perforation. The risk of developing esophageal carcinoma may be 1,000 times greater for individuals who have had a lye burn than in the general population. It cannot be overemphasized that prevention is still the key to decreasing this morbidity.

Electrical oral burns in Danish children with special reference to prevention

Electrical oral burns in Danish children with special reference to prevention

Splinting of oral commissure electrical burns in children

traditional culture technique for detection of group A betahemolytic streptococci. J Clin Microbiol 20:824, 1984. 8. Gerber MA, Spadaccini L J, Wright LL, Deutsch L: Latex agglutination tests for rapid identification of group A streptococci directly from throat swabs. J PEDIATR 105:702, 1984. 9. Otero JR, Reyes S, Noriega AR: Rapid diagnosis of group A streptococcal antigen extracted directly from swabs by an enzymatic procedure and used to detect pharyngitis. J Clin Microbiol 18:318, 1983. 10. Petts DN: Early detection of streptococci in swabs by latex agglutination before culture. J Clin Microbiol 19:432, 1984. 11. Halfon ST, Davies AM, Kaplan O, et al: Primary prevention of rheumatic fever in Jerusalem school children. II. Identification of beta-hemolytic streptococci. Isr J Med Sci 4:809, 1968. 12. Kaplan EL, Top FH Jr, Dudding BA, Wannamaker LW: Diagnosis of streptococcal pharyngitis: Differentiation of active infection from the carrier state in the symptomatic child. J Infect Dis 123:490, t971. 13. Kaplan EL, Couser R, Huwe BB, McKay C, Wannamaker LW: Significance of quantitative salivary cultures for group A and non-group A/3-hemolytic streptococci in patients with pharyngitis and in their family contacts. Pediatrics 64:904, 1979. 14. Stillerman M, Bernstein SH: Streptococcal pharyngitis: Evaluation of clinical syndromes in diagnosis. Am J Dis Child 101:476, 1961. 15. Bresse BB, Disney FA, Talpey WB, et al: Beta-hemolytic streptococcal infection: The clinical and epidemiologic importance of the number of organisms found in cultures. Am J Dis Child 119:18, 1970.

The emergency management of caustic ingestions

Controversial therapeutic issues in patients with caustic ingestions concern the reliability of symptoms and signs in predicting esophageal injury, the appropriate use of endoscopy in evaluating esophageal damage, and the use of steroids in preventing late strictures. The conclusions of this review are: 1. (1) The majority of pediatric caustic ingestions involve a “lick and taste” whereas adolescents and adults often ingest substantial quantities. 2. (2) Oral burns and dysphagia are sensitive predictors of esophageal injury; however, esophageal injury may occur in the absence of the findings. 3. (3) Household bleach and nonphosphate detergents represent a low risk of injury whereas button batteries greater than 20 mm in diameter and Clinitest tables® represent high risk. 4. (4) Endoscopy should be an elective rather than emergency procedure and should be undertaken in all symptomatic patients, and in asymptomatic patients when history indicates substantial ingestion. 5. (5) Steroid therapy should be considered only for patients who have deep or circumferential esophageal burns.

Oral Splint Therapy to Manage Electrical Burns of the Mouth in Children

Oral electrical burns to the lip commissure are disfiguring injuries for a child. Current treatment includes the use of an orally anchored splint to hold the lip commissures at their correct positions during healing. After wearing an appliance for a period of one year, the burn site is evaluated for the need for corrective surgery (Fig. 9). It has been found that the use of a commissure appliance decreases the need for reconstructive surgery.

Improved splinting of oral commissure burns

Improved splinting of oral commissure burns

Electric oral burns in Danish children with special reference to prevention.

68 children, most of them 1-3 years old, with electric burns of the mouth from slight cases to severe burns with extensive necroses were treated over a 30-year period. Principles of primary conservative treatment and secondary reconstructive surgery are mentioned. A Stein- Abbe flap procedure, single or double, has been the method-of-choice in severe defect of the lower lip. In the majority of the cases the accident was caused by a defective bakelite plug from the detachable cord of a popular electric vacuum cleaner of Danish origin. In 1968 a plea was made for a change of this kind of plug to a better type made of an unbreakable plastic material. As a prophylactic measure this intervention seems to have been very useful in so far as the number of these senseless accidents has decreased dramatically in Denmark during the last 15 years.

The prosthetic management of oral commissure burns.

The complications of electrical burn to the oral cavity include microstomia and cosmetic deformity. Surgical burn excision and repair by primary closure, skin grafts, or tongue flaps have recognized disadvantages. The use of intraoral fixed or removable appliances, or the extraoral facemask prosthesis, serves to maintain adequate commissure spacing and allows normal skin and mucosal healing to occur. Secondary commissuroplasties may be required after prosthetic management of the burn.

Liquid Caustic Ingestion Spectrum of Injury

Seventeen patients who ingested liquid caustics were reviewed for location, extent, severity, and outcome of the mucosal injury. Although many complained of glossopharyngeal pains and dysphagia (12 patients), and most had some oral mucosal burns (15 patients), the absence of severe oral burns or pharyngoesophageal symptoms did not exclude esophageal or gastric injury as determined by endoscopy. The location of the most severe mucosal injury was unpredictable by symptoms alone; seven of the 17 patients demonstrated gastric mucosal injury greater than esophageal. One patient died of extensive esophageal, gastric, and duodenal injury; esophageal strictures developed in three patients. Caustic ingestion is a serious medical condition whose severity can best be gauged by endoscopic findings and not by patient symptoms alone. Outcome is variable, ranging from an asymptomatic state to stricture formation or even death.