Accepted Manuscript

Management of Head and Neck Burns – a 15 year review

Travis J. Hamilton, DMD, MD, Jeromy Patterson, MD, Rachael Y. Williams, MD,
MHS, Walter L. Ingram, MD, Juvonda S. Hodge, MD, Shelly Abramowicz, DMD, MPH

PII: S0278-2391(17)31165-5
DOI: 10.1016/j.joms.2017.09.001
Reference: YJOMS 57977

To appear in: Journal of Oral and Maxillofacial Surgery

Received Date: 28 June 2017

Revised Date: 29 August 2017
Accepted Date: 1 September 2017

Please cite this article as: Hamilton TJ, Patterson J, Williams RY, Ingram WL, Hodge JS, Abramowicz
S, Management of Head and Neck Burns – a 15 year review, Journal of Oral and Maxillofacial Surgery
(2017), doi: 10.1016/j.joms.2017.09.001.

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 ACCEPTED MANUSCRIPT
Management of Head and Neck Burns – a 15 year review

Travis J. Hamilton DMD, MD1, Jeromy Patterson, MD2, Rachael Y. Williams, MD, MHS3, Walter L. In-
gram, MD4, Juvonda S. Hodge,MD5, Shelly Abramowicz DMD, MPH6

1
Chief resident, Division of Oral and Maxillofacial Surgery, Department of Surgery, Emory University

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School of Medicine
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Previously, Burn Surgery Fellow, Grady Memorial Hospital Burn Unit, Department of Surgery, Emory
University School of Medicine
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Assistant Professor, Trauma/Surgical Critical Care at Grady Memorial Hospital, Department of Sur-

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gery, Emory University School of Medicine
4
Associate Professor Trauma/Surgical Critical Care at Grady Memorial Hospital, Department of Sur-
gery, Emory University School of Medicine and Medical Director, Grady Memorial Hospital Burn Unit

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5
Assistant Professor, Trauma/Surgical Critical Care at Grady Memorial Hospital, Department of Sur-
gery, Emory University School of Medicine and Assistant Medical Director, Grady Memorial Hospital
Burn Unit
6

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Assistant Professor, Division of Oral and Maxillofacial Surgery, Department of Surgery, Emory Uni-
versity School of Medicine and Associate Chief, Section of Dentistry/Oral and Maxillofacial Surgery,
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Children’s Healthcare of Atlanta, Atlanta, GA

Presented at Annual Meeting of the American Association of Oral and Maxillofacial Surgeons; Las
Vegas, Nevada; September 22, 2016 and Southern Regional Medical Association Burn Conference;
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Atlanta, Georgia; November 06, 2016

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Address correspondence and reprint requests:

Shelly Abramowicz DMD, MPH
Division of Oral and Maxillofacial Surgery
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Department of Surgery
Emory University
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1365 Clifton Road, NE

Building B, Suite 2300
Atlanta, GA 30306
404-778-4500 office
404-778-5879 fax
sabram5@emory.edu
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ABSTRACT

PURPOSE: The purpose of this project was to characterize isolated head and neck burns admitted to

Grady Memorial Hospital (GMH) Burn Center.

MATERIALS AND METHODS: This was a retrospective case series of patients admitted to GMH

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Burn Center with primary diagnosis of head and neck burns from 2000-2015. Demographic data

(gender and age) were recorded. Burn details (etiology, mechanism, percent of burned total body sur-

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face area [TBSA], depth, and associated injuries) was summarized. Patient management and hospital

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course were documented. The data were collected using a standardized collection form. Descriptive

statistics were computed.

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RESULTS: There were 5,938 patients admitted to burn unit at GMH during the study period. Of them,
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2,547 patients had head and neck burns. 205 patients met inclusion criteria. Majority (n=136, 66%)

were male with a mean age of 40 years old. The most common burn depth was superficial partial
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thickness. Flame burns were the most likely mechanism related to full thickness injury. About a quar-
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ter of patients had an associated injury such as inhalation or ocular injury. Surgical interventions con-
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sisted of tangential excision and split thickness skin grafting, contracture release, excision of hyper-

trophic scars, and rotational flaps. The mean LOS for isolated head and neck burns was 4.4 days.
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Overall mortality was 2%.

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CONCLUSION: The results of this study show that superficial partial thickness head and neck burns
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were more likely to occur due to accidental exposure to flames in men older than 55 years. Due to an

increase in risk and mortality of inhalation injury associated with head and neck burns, airway protec-

tion and respiratory management are critical considerations of head and neck burn management.
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INTRODUCTION

Burns are responsible for more than 300,000 deaths annually, with 11 million people worldwide

requiring medical attention1. An estimated 3 to 4% of these patients will require special care. Im-

provements in burn care have caused a reduction in morbidity. In the United States (US) the majority

of burn injuries are considered preventable injury and a public health issue2,3. Head and neck burns

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vary in severity and may result in disfigurement. Since the face is often considered the center of

one’s identity, any disfigurement can lead to significant psychosocial consequences2,4. In addition, the

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initial burn trauma and resultant scarring/contracture can lead to functional deficits in visual and olfac-

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tory senses, and motor dysfunction such as difficulty eating, moving and talking5.

There is limited data in oral and maxillofacial surgery (OMS) literature characterizing head and

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neck burns in the US. The purpose of this project was to characterize isolated head and neck burns
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admitted to Grady Memorial Hospital (GMH) Burn Center. This would allow development of a treat-
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ment algorithm for burn patients upon presentation to emergency department (ED) and throughout

their hospital course.

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MATERIALS AND METHODS

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This was a retrospective case series (Institutional Review Board # 00080359) of patients ad-
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mitted to GMH Burn Center with primary diagnosis of head and neck burns from 2000-2015. Inclusion

criteria consisted of (1) head and neck burn, (2) admission to inpatient Burn Unit, (3) no history of pri-
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or burns, and (4) complete medical records. Exclusion criteria consisted of (1) presence of burns be-
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yond the head and neck, (2) burns not requiring hospital admission, or (3) incomplete medical rec-

ords.

Medical records were reviewed. Demographic data (gender and age) were recorded. Burn de-

tails (etiology, mechanism, percent of burned total body surface area [TBSA], depth, and associated

injuries) was summarized. Patient management (need for intubation/tracheostomy, ventilator days,
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surgical intervention) and hospital course (number of days from admission to surgical management,

length of stay [LOS], mortality/discharge) were documented. The data were collected using a stand-

ardized collection form. Descriptive statistics were computed.

RESULTS

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There were 5,938 patients admitted to burn unit at GMH during the study period. Of them,

2,547 patients had head and neck burns. 205 patients met inclusion criteria. The majority (n=136,

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66%) were male with a mean age of 40 years old (range 2 months to 88 years). Patients older than

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55 years was the largest group (n=69, 34%), followed by 35 to 55 year old group (n=50, 24%), less

than 15 year old age group (n=47, 23%), and 15 to 34 year old age group (n=39, 19%).

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Burn details were analyzed. Etiology consisted of accidental (n=196, 96%), assault (n=5, 2%),
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chemical (n=3) or flame (n=2). One case reported self-harm via contact burn with a hot iron. The

most common mechanism was by flame (n=136, 66.3%), scald burns (n=32, 15.6%), chemical burns
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(n=20, 9.7%), contact burns (n=12, 5.8%) and electrical burns (n=5, 2.4%). Mean TBSA was 3%
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(range 1 to 8%). The most common burn depth was superficial partial thickness (n=166, 80%), deep
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partial thickness burns (n=26, 12%) and full thickness burns (n=13, 6%). Flame burns were the most

likely mechanism related to full thickness injury (accounting for 67% of full thickness burns). About a
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quarter of patients (42, 21%) had an associated injury such as inhalation (n=32, 16%) or ocular injury

(n=10, 5%) (Figure 1).

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Hospital course was reviewed. Airway management consisted of intubation as part of initial

stabilization in 29 patients (14%) (Figure 2). Of them, 14 (7%) were intubated for one day or less.

Nine (4%) received a tracheostomy during their hospital course. On average, patients received venti-

lator assistance for 8.35 days (range 1-85 days). Surgical interventions, defined as any management

in the operating room requiring general anesthesia, was required in 9.7% (n=20) patients. Of the 20

operative cases, 15 (75%) were tangential excision and split thickness skin grafting. Remaining pro-
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cedures consisted of contracture release (n=2), excision of hypertrophic scars (n=1), and rotational

flaps (n=2). All patients required daily dressing changes and wound care consisting of local debride-

ment and ointment application.

On average, the number of days from ED admission to surgical management was 12.4 (range

0 to 240 days). The mean LOS for isolated head and neck burns was 4.4 days (range 1 to 112 days).

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Inhalation injury was the most common associated injury in 32 patients. Overall mortality was 2%

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(n=4). Inhalational injury accounted for half (n=2) of the deaths.

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DISCUSSION

TBSA is a primary determinant of severity and risk of mortality; it guides patient resuscitation

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and the decision to refer patient to a burn center. There are two tools that incorporate this information
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in order to summarize severity of a burn. The Rule of Nines divides body into areas of 9 percent to

estimate surface area of a burn6. It has traditionally been used to estimate TBSA involved in a burn
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injury but does not allow for differences in proportion of body surface in children. Lund and Browder
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developed a method incorporating changes in the percentage of body surface of certain body parts
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that occur during different stages of growth and development. For example, surface area of the head

of a child contributes a greater proportion to the total body surface area than an adult7. Only partial or
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full thickness depth burns are included in these calculations.

Despite the importance of head and neck burns, there are limited studies in OMS literature.
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The aim of this study was to characterize isolated head and neck burns admitted to GMH Burn Cen-
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ter. In our population, head and neck burns are most common in patients older than 55 years who

are male. Majority of burns took place because of an accidental and unintentional flame exposure

(96%). In some studies from developed countries, scalding- related burns, had a high prevalence in

the <15-year-old age group3.In our population, scald burns (n=16) were almost as common as flame

burns (n =17). It can be expected that scalds will remain a significant cause of unintentional injury
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among young children because toddlers have an increase in mobility but lack insight into cause-and-

effect of dangerous situations8.

Recent studies have shown a plateauing incidence of scald burns in developing countries

where flames from cooking fires have been reported to be the main etiology9,10. Conversely, in devel-

oped countries, there is an increase in incidence in head and neck burns2,3. Unfortunately, this study

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did not specifically investigate the physical setting (e.g. kitchen, nursing homes, place of work, etc.).

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In our study, the number of head and neck flame burns to the face is congruent with other studies in

relation to demographics and mechanism10.

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In our population, the rate of intentional burns from assault/homicide or self-harm was 2%

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(n=5) and <1% (n=1), respectively. In comparison to the previously published report8, there was a
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similar incidence with attempted homicide/assault at 1.98% (n=16). However, there was a greater

number of self-harm/suicide attempts 1.98% (n=16). Overall mortality in this study was 2% compared
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to 1.6% in previous work10.

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When a patient sustains flame injury to the head and neck, health care providers should care-
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fully assess inhalation injury10,11. In these cases, the particulate components of the smoke cause se-

vere inflammation. They should be examined for carbon monoxide toxicity. Thus, in our unit, these
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patients are placed in a monitored room in order to assess vital signs and airway in more frequent in-

tervals than other burn patients. If there is suspicion for significant airway embarrassment, intubation
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for airway protection should take place,11. In our cohort, patients were intubated upon arrival to ED
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because of risk of inhalation injury. This likely explains the high proportion of extubation on hospital

day one (48% of intubated patients). This probably occurs because GMH ED has a low threshold for

intubation prior to transport to the burn unit.

In our unit, surgical intervention for burns consisted of any procedure which takes place in op-

erating room and requires general anesthesia. Furthermore, patients had daily wound care and

‘dressing’ changes. Patients with facial burns generally do not need dressings, however they require
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frequent application of antibiotic ointment. Facial burn patients are often admitted to allow for the

‘declaration’ of the extent of the burn beyond the acute phase12-14. The GMH burn unit’s preferred

ointment for facial burns is bacitracin (gentamycin ointment if allergic). Once daily, the ointment is re-

moved. Removal of the ointment assists with debridement of burn eschar and allows for evaluation of

the burn depth and healing process. Silver sulfadiazine is not used on the face because it inhibits re-

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epithelization and delays wound healing15. All burn patients are monitored closely for burn cellulitis. If

burn cellulitis is suspected, intravenous antibiotics are initiated. In our cohort, small proportion of iso-

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lated head and neck burns required skin grafting (n=15, 7.3%). In comparison, Hoogewerf et al. re-

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ported 20.5% of the Dutch population requiring primary facial surgeries.3 This difference is likely be-

cause at our institution, we perform daily wound care (e.g. daily debridement, dressing changes,

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ointment application) which decreases overall wound contracture and need for skin grafts.
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Our center uses a specific treatment algorithm for management of head and neck burns (Fig-
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ure 3). Upon presentation to the ED, a patient with head and neck burn undergoes an airway as-

sessment. Specifically, the patient is intubated upon arrival if there is a possibility of impending res-
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piratory failure. Intubation criteria are: (1) respiratory failure (hypoxic or hypercarbic), (2) carbon mon-
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oxide poisoning, (3) burn great than 20% TBSA (intubated for pain control), (4) deep partial and full

thickness burns involving the entire face and neck, and (5) stridor/hoarseness on exam. It is important
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to note that isolated finding of singed nasal hairs is not an indication for intubation since this physical

finding does not correlate with true vocal cord edema16. During the time of assessment, the burn
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mechanism and initial depth is determined. This helps guide acute management. A fluorescein eye
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exam is completed to assess for corneal damage. If it is positive, ophthalmology consultation is re-

quested. Superficial head and neck burns have clinical signs of erythema and pain, without evidence

of blistering. These burns can usually be managed in an outpatient setting after the initial assess-

ment. Superficial partial thickness and partial thickness head and neck burns benefit from admission

and observation in the burn unit. This allows for daily airway monitoring, pain control, wound deb-

ridement and infection control. Patients with full thickness head and neck burns should be intubated
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and admitted to the burn unit. Surgical treatment in the operating room will likely be required for full

thickness burns for skin grafting, and possible tracheotomy.

There were several limitations of this study. This study investigated isolated head and neck

burns, so patients with additional burns on other anatomical regions were eliminated. Thus, a large

subset of data for facial burns was not reviewed. The retrospective nature of data collection did not

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allow for further statistical analysis. Lastly, outpatient follow up for these burns was not included.

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Thus, surgical outcomes of current algorithm could not be evaluated.

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The present study showed that in our cohort, superficial partial thickness head and neck burns

were more likely to occur in men older than 55 years and due to accidental exposure to flame,. There-

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fore, preventive healthcare resources can be focused on this group of patients. The majority of head
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and neck burns are managed outside of the operating room via local wound debridement and dress-

ing changes. Due to an increase in risk and mortality of inhalation injury, airway protection and respir-
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atory management are critical considerations of head and neck burn management. This study may

help to better stratify risk and improve management protocols.

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FIGURES

Figure 1: Mechanism and burn depth (n)

Figure 2: Airway management

Figure 3: Burn treatment algorithm

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