Eng-Kean Yeong

Intralesional corticosteroid therapy in proliferating head and neck hemangiomas: A review of 155 cases

PURPOSE The purpose of this paper is to review the effect of intralesional corticosteroid therapy in the treatment of 155 head and neck hemangiomas. METHODS In the past 10 years, we have treated 155 proliferating head and neck hemangiomas with intralesional corticosteroid injections. Three to 6 injections of triamcinolone acetonide (10 mg/mL) in monthly intervals were given. Using slides and chart review, the results were assessed 1 month after completion of the treatment. RESULTS Eighty-five percent of the lesions showed greater than 50% reduction in volume. Varied treatment response was noted in different classes of hemangioma. Eighty percent of the superficial, 75% of the deep, and 60% of the combined hemangiomas show more than 50% reduction in volume. Further growth was not found after treatment. The postinjection complication rate was 6.4% in this series. There were 2 patients with cushingoid appearance, 5 with cutaneous atrophy, and 3 suffered from anaphylactic shock. We found that lesions showing less than 50% reduction in volume were located mostly in the perioral area. CONCLUSIONS Intralesional corticosteroid injections are safe and effective in arresting hemangioma proliferation. Superficial hemangiomas yield the best results.

Treatment of high-flow vascular malformations in the head and neck with arterial ligation followed by sclerotherapy

The traditional treatment of high-flow vascular malformations consists of selective embolization, surgical removal, or a combination of both. Recurrence of the lesion and bleeding control are still the main problems, and the result of treatment is sometimes disappointing. We suggest treatment of these lesions with surgical ligation of the distal major feeding arteries followed by intravascular injection of a sclerosing agent (3% tetradecyl sulfate), and surgical excision and reconstruction when indicated. We have found this to be an effective treatment regimen. We present 14 cases of high-flow vascular malformations of the head and neck area treated with this approach, of which 4 cases developed skin necrosis. Three of these 4 cases of skin necrosis were later treated with skin grafting and, in 1 case, an upper arm skin tube flap was used for nasal tip reconstruction. Three cases underwent delayed reconstruction using tissue expanders. From a symptomatic and aesthetic point of view, preliminary satisfactory results were obtained. We feel that this approach is a good option for treating difficult, high-flow vascular malformations.

Is artificial dermis an effective tool in the treatment of tendon-exposed wounds?

As flap surgery remains the main technique to close wounds with tendon exposure, the application of artificial dermis in these complex soft tissue wounds is seldom reported. The purpose of this article is to review our experiences in the treatment of tendon-exposed wounds with artificial dermis. This retrospective study included 23 patients with 33 tendon-exposed wounds treated with artificial dermis from 2004 to 2009. Data including patient demographics, wound type, duration from artificial dermis implantation to split thickness skin grafting, surgical complications, and clinical outcome were obtained by chart review. Successful treatment was defined as the formation of golden-yellow neodermis followed by successful split thickness skin grafting. Among the 33 tendon-exposed wounds, 11 were secondary to chronic ulcers, 16 to acute wounds, and 6 to surgical wounds after hypertrophic scar excision. The mean patient age was 49 years. The overall success rate with the artificial dermis technique was 82%, including 63% in the chronic ulcer group, 88% in the acute wounds, and 100% in the surgical wounds. In the success group, 11% of the wounds required repeated artificial dermis implantations. Within the failure group, two wounds were closed by below knee amputation, two by local flap surgery, and two were allowed spontaneous healing as a result of graft failure. We have demonstrated an overall success rate of 82% for tendon-exposed wound closure by using artificial dermis. The outcome was better in surgical and acute wounds than in chronic wounds.

Risk factors of tissue-expansion failure in burn-scar reconstruction

BACKGROUND Tissue expansion has become invaluable for burn-scar reconstruction. However, its use is hindered by the complications that often result in expansion failure. This study attempts to identify the risk factors of expansion failure in burn patients, as such factors have not been clearly defined. METHODS This study included 62 tissue expansions in 37 burn patients from January 2001 to June 2009. Factors including patients age, sex, co-morbidities, expander size, implantation site, volume injected at implantation, preinflation volume ratio (PVR=volume injected at implantation/expander size), final inflation volume ratio (FIVR=cumulative volume injected at completion of expansion/expander size) and expansion duration were analysed. Cases were allocated into success (n=53) and failure (n=9) groups. Logistic regression was used in multivariate analysis for identifying predictors of expansion failure. RESULTS The mean age of the patients was 29.6 years. The male to female ratio was 1:1.4. Expansion complication and failure rates were 53% (n=33) and 14.5% (n=9), respectively. The risk factors statistically correlated to expansion failure (p<0.05) were age, expander size, PVR and implantation at lower limb. Expansion of lower limbs carried a risk of failure 43 times greater than other sites. CONCLUSION We conclude that tissue expansion should be avoided in older patients and in lower limbs. The largest possible expander size and inflation at time of implantation should be used to lower the risk of expansion failure.

The treatment of bone exposure in burns by using artificial dermis.

BackgroundThe treatment of bone-exposed wounds with artificial dermis is not widely accepted in burn patients because of uncertain clinical results. This article aimed to review our clinical experience with this technique. MethodsWe implanted artificial dermis in 11 bone-exposed burns. Implantation was directly performed on bones with periosteum, whereas bones without periosteum were trephinated or burred before implantation. All wounds were closed by secondary skin grafting. ResultsThe mean patient age was 49 years. Lower extremity is the most common site of bone exposure. The mean bone exposed area was 55.6 cm2, whereas the mean Integra-implanted area was 86.7 cm2. The overall implant take rate was 91%, and the skin grafting success rate was 80%. No secondary breakdown was noted after a 2-year follow-up. ConclusionsThis study confirms that artificial dermis can be an alternative treatment tool for burns with exposed bones, especially in patients with limited donor sites.

Serum Bicarbonate as a Marker to Predict Mortality in Toxic Epidermal Necrolysis

Background: Toxic epidermal necrolysis (TEN) is a rare life-threatening disorder characterized by extensive epidermal necrolysis. Its mortality which varies from 20% to 60% is related to risk factors such as age, extent of epidermal detachment, and base deficit. Objectives: The purpose of this study is to investigate the risk factors of mortality in our patients with TEN. Patients and methods: From the year 2000 to 2006, the patients with TEN admitted to the National Taiwan University Hospital Burn Center were studied retrospectively using chart review. Eleven potential risk factors including age, gender, underlying disease, malignancy, extent of epidermal detachment, tachycardia, serum urea, glucose, base deficit, leucopenia, and intravenous infusion of immunoglobulin (IVIG) were analyzed. Patients were grouped into survivors (n = 11) and nonsurvivors (n = 5) after intensive care treatment. Logistic regression was used in multivariate analysis for identifying important predictors of mortality. Results: The mean age of the patients with TEN was 58 years, while the mean total body surface area of epidermal necrolysis was 66.3%. The overall mortality rate was 31.3%. Among the potential risk factors, only serum bicarbonate <20 mmol/L was found to have significant association with mortality (P = .0128) in our patients with TEN. The odds of mortality in the patients with TEN having serum bicarbonate <20 mmol/L was 40 times higher than those without. Conclusion: This study has shown that serum bicarbonate <20 mmol/L is the most important risk factor of mortality in our patients with TEN and it may be used as a marker to predict hospital mortality.

Reconstruction for osteoradionecrosis of the mandible: superiority of free iliac bone flap to fibula flap in postoperative infection and healing.

BackgroundOsteoradionecrosis (ORN) of the mandible is not an uncommon complication after radiotherapy for head and neck cancers. Although definitive treatment has been confirmed as radical excision of the necrotic bone with simultaneous vascularized osteocutaneous flap reconstruction, it remains a unique challenge. In this study, we compare our results of reconstruction with free iliac and fibula flaps in flap survival, bony union, and postoperative complications. Patients and MethodsFrom 1986 to 2011, there were 153 mandibular ORN cases in our center that were treated with radical resection of the necrotic bone and reconstruction with either vascularized iliac (n = 108) or fibula flaps (n = 45). Data collected for analysis included patient demographics, flap survival rate, postoperative infection rate, nonunion/malunion rate, mean hospital stay, and antibiotics use. ResultsAll patients healed eventually without recurrence of ORN. However, we observed difference in the complication rate between the iliac flap group and fibula flap group. In the group with iliac flap reconstruction, patients required less days of hospital stay for intravenous antibiotics treatment postoperatively. The average days required for intravenous antibiotics in the iliac flap group were 10.46 (2.28) versus 16.09 (3.88) days in the fibula group (P < 0.01). In the group with fibula flap reconstruction, 9 (20.0%) patients had subsequent neck infection due to healing problem, compared to 8 (7.4%) patients in the iliac flap group (P = 0.04). In the iliac flap group, the nonunion and malunion rates were 4.6% and 2.8% respectively; whereas in the fibula group, the rates were 15.5% and 6.6%, respectively (P = 0.04 and 0.36, respectively). ConclusionsFor ORN patients, vascularized iliac bone flap provides more reliable results compared to fibula flap. The merits of vascularized iliac flap include the following: (1) its natural curve mimics the shape of mandible and does not need osteotomy; (2) it offers more volume of bone that matches better to the native mandible to allow later osteointegration as well as faster bony union, due to the nature of being a membranous bone; and (3) it carries more abundant soft tissue to obliterate possible dead space. The only disadvantages are short pedicle and requiring special management of skin paddle, which can be overcome by training in microsurgery.

Surgical treatment of distal digit amputation: success in distal digit replantation is not dependent on venous anastomosis.

Background: Although digit amputation at or distal to the distal interphalangeal joint is a common injury, it remains a challenging problem to restore digital length and pulp because of the lack of healthy vessels and the absence of proper vascular size for reanastomosis. The purpose of the present study was to review the authors’ clinical experience with distal digital replantation and to test the hypothesis that success in distal digit replantation is not dependent on venous anastomosis. Methods: Twenty-eight patients with 31 complete distal digit amputations were included in the study. Data regarding patient demographic, replantation technique, and surgical outcome were analyzed. Results: Sixteen digits were replanted with arterial and venous anastomoses (group A). Eleven digits were replanted with only arterial anastomosis (group B). Composite grafting was performed in four digits without vascular anastomosis (group C). The success rates in group A and group B were 81.3 and 81.8 percent, respectively. None of the composite grafts survived. Fisher’s exact test was used for statistical analysis. Although group C has the lowest survival rate (p < 0.05), the differences between the survival rates in group A and group B (p > 0.05) were insignificant. Conclusions: The overall success rate of distal digit replantations in the authors’ series was 81 percent, and there were no differences in the survival rates between replantations with and without venous anastomosis. Finally, the authors conclude that success in distal digit replantation is not dependent on venous anastomosis and suggest that replantation should be encouraged in complete distal digital amputation, even without venous anastomosis. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Prediction of burn healing time using artificial neural networks and reflectance spectrometer

Burn depth assessment is important as early excision and grafting is the treatment of choice for deep dermal burn. Inaccurate assessment causes prolonged hospital stay, increased medical expenses and morbidity. Based on reflected burn spectra, we have developed an artificial neural network to predict the burn healing time. The purpose of our study is to develop a noninvasive objective method to predict burn-healing time. Burn less than 20% TBSA was included. Burn spectra taken on the third postburn day using reflectance spectrometer were analyzed by an artificial neural network system. 41 spectra were collected. With the newly developed method, the predictive accuracy of burns healed in less than 14 days was 96% and that in more than 14 days was 75%. Using reflectance spectrometer, we have developed an artificial neural network to determine the burn healing time with 86% overall predictive accuracy.

Response of a local hospital to a burn disaster: Contributory factors leading to zero mortality outcomes

OBJECTIVE To investigate the outcomes of a local healthcare system in managing a burn mass casualty incident (BMCI). METHODS Thirty-three victims admitted to the National Taiwan University Hospital within 96h of the explosion were included in the study. Data were recorded on: patient demographics, Baux score, laboratory data, management response, treatment strategies, and outcomes. Case notes from June 27, 2015 to November 2015 were reviewed with a focus on fluid resuscitation, ventilation support, nutrition, infection control, sepsis treatment, and wound closure plan. RESULTS Female predominance (mean age: 21.7 years) and lower extremity circumferential flame burns were the characteristics of the burn injury. The mean Baux score was 70±18. The mean burn area was 42% of the total body surface area (TBSA). A total of 79% patients arrived at the hospital within 24h of sustaining injuries. Intensive care unit (ICU) admission criteria were modified to accommodate patients with 40% TBSA of burns, facilities were expanded from 4 ICU beds to 18 beds, and new staff was recruited. A total of 36% patients (n=12/33, 62±13 TBSA of burns) required fluid resuscitation. The mean volume of Lactate Ringer administered in the first 24h of burns was 3.34±2.18ml/kg/%TBSA, while the mean volume of fresh frozen plasma administered was 0.60±0.63ml/kg/h. Forty-two percent patients were intubated on the day of admission, and 71% of the intubated patients had inhalation injuries that were confirmed by diagnostic bronchoscopy. The mean intubation period was 17±9 days. The incidence of pulmonary edema was 58% (n=7/12), possibly due to sub-optimal monitoring. Of these, 57% (n=4/7) patients progressed to adult respiratory distress syndrome, but were successfully treated with early strict fluid restriction, systemic antibiotics, ventilation support, and bronchial lavage. A total of 94% patients received grafting. The mean grafted area was 4432.3±3891cm2. Tube feeding was provided to patients with burns >40% TBSA. All patients tolerated gastric tube feeding without conversion to duodenal switch. On admission, all patients received prophylactic antibiotics. Septic shock was noted in 12 patients, but no mortality occurred. The mean hospital stay was 1.5 days per percent burn. CONCLUSIONS This article highlights the value of precise triage, traffic control, and effective resource allocation in treating a BMCI. Effective supporting systems for facility expansion, staff recruitment, medical supplies and clear-cut treatment strategies for severely burned patients are contributory factors leading to zero mortalities in our series, in addition to young age and minimal inhalation injuries. The need for reevaluation of the safety of cornstarch powder in festival activities is clear.