Jessica A. Ching

The evaluation of physical exam findings in patients assessed for suspected burn inhalation injury.

The purpose of this investigation was to evaluate the utility of singed nasal hair (SN), carbonaceous sputum (CS), and facial burns (FB) as indicators of burn inhalation injury, when compared to the accepted standard of bronchoscopic diagnosis of inhalation injury. An institutional review board approved, retrospective review was conducted. All patients were suspected to have burn inhalation injury and subsequently underwent bronchoscopic evaluation. Data collected included: percent burn TBSA, burn injury mechanism, admission physical exam findings (SN, CS, FB), and bronchoscopy findings. Thirty-five males and twelve females met inclusion criteria (n = 47). Bronchoscopy was normal in 31 patients (66%). Data were analyzed as all patients and in subgroups according to burn TBSA and an enclosed space mechanism of injury. Physical exam findings (SN, CS, FB) were evaluated individually and in combination. Overall, the sensitivities, specificities, positive predictive values, and negative predictive values calculated were poor and inconsistent, and they did not improve within subgroup analysis or when physical findings were combined. Further statistical analysis suggested the physical findings, whether in isolation or in combination, have poor discrimination between patients that have and do not have inhalation injury (AUC < 0.7, P > .05) and poor agreement with the diagnosis made by bronchoscopy (&kgr; < 0.4, P > .05). This remained true in the subgroup analysis as well. Our data demonstrated the findings of SN, CS, and FB are unreliable evidence for inhalation injury, even in the context of an enclosed space mechanism of injury. Thus, these physical findings are not absolute indicators for intubation and should be interpreted as one component of the history and physical.

An Analysis of Inhalation Injury Diagnostic Methods and Patient Outcomes.

The purpose of this study was to compare patient outcomes according to the method of diagnosing burn inhalation injury. After approval from the American Burn Association, the National Burn Repository Dataset Version 8.0 was queried for patients with a diagnosis of burn inhalation injury. Subgroups were analyzed by diagnostic method as defined by the National Burn Repository. All diagnostic methods listed for each patient were included, comparing mortality, hospital days, intensive care unit (ICU) days, and ventilator days (VDs). Z-tests, t-tests, and linear regression were used with a statistical significance of P value of less than .05. The database query yielded 9775 patients diagnosed with inhalation injury. The greatest increase in mortality was associated with diagnosis by bronchoscopy or carbon monoxide poisoning. A relative increase in hospital days was noted with diagnosis by bronchoscopy (9 days) or history (2 days). A relative increase in ICU days was associated with diagnosis according to bronchoscopy (8 days), clinical findings (2 days), or history (2 days). A relative increase in VDs was associated with diagnosis by bronchoscopy (6 days) or carbon monoxide poisoning (3 days). The combination of diagnosis by bronchoscopy and clinical findings increased the relative difference across all comparison measures. The combination of diagnosis by bronchoscopy and carbon monoxide poisoning exhibited decreased relative differences when compared with bronchoscopy alone. Diagnosis by laryngoscopy showed no mortality or association with poor outcomes. Bronchoscopic evidence of inhalation injury proved most useful, predicting increased mortality, hospital, ICU, and VDs. A combined diagnosis determined by clinical findings and bronchoscopy should be considered for clinical practice.

A Simple Mandibular Distraction Protocol to Avoid Tracheostomy in Patients With Pierre Robin Sequence

Objective Recent treatment goals for Pierre Robin sequence (PRS) focus on avoiding tracheostomy through modalities such as mandibular distraction osteogenesis (MDO). We primarily evaluated the efficacy of our straightforward MDO treatment protocol for resolution of PRS-associated airway obstruction while secondarily analyzing patient characteristics associated with success or failure of MDO. Design A retrospective chart review before and after treatment. Setting Tertiary institutional center and private practice setting. Patients All patients were diagnosed with PRS and treated with MDO, according to the MDO treatment protocol, by a single surgeon with the same operative technique from 1999 to 2013. A sample size of n = 38 met the inclusion criteria. Data assessed included tracheostomy status (pre-MDO, post-MDO, or none), microlaryngoscopy and bronchoscopy (MLB) findings, multipositional airway study results, clinical resolution of airway obstruction following MDO, and patient characteristics. Main Outcome Measure Resolution of airway obstruction with avoidance of a tracheostomy. Results Prior to referral for MDO, five patients required urgent tracheostomy. Of patients without a pre-MDO tracheostomy (n = 33), two patients required tracheostomy post-MDO, while 94% avoided tracheostomy with clinical resolution of airway obstruction (n = 31). On secondary analysis, anatomic abnormalities diagnosed by MLB were associated with a higher rate of tracheostomy (P = .037), confirming the utility of preoperative evaluation with MLB; otherwise, no patient characteristics demonstrated significance in patient selection. Follow-up ranged from 6 months to 10 years (mean = 6.45 years, median = 7.61 years). Conclusions Our treatment protocol demonstrates MDO is highly effective for resolving severe airway obstruction related to PRS. Based on secondary analysis, our simplified protocol does not require amendment.

The impact of neoadjuvant hedgehog inhibitor therapy on the surgical treatment of extensive basal cell carcinoma.

BackgroundAlthough hedgehog inhibitor therapy (HHIT) is offered as isolated medical treatment for extensive basal cell carcinoma (BCC), there is little evidence on the use of HHIT before definitive surgical intervention. In order to better define the utilization of HHIT for extensive BCC, we evaluated the impact of neoadjuvant HHIT on the subsequent surgical resection and reconstruction. MethodsAn IRB-approved, retrospective chart review was performed of patients who received HHIT as initial treatment for extensive BCC. Patients who discontinued HHIT and underwent surgical resection were included. Evaluation included BCC tumor response to HHIT, operative data, pathological data, radiation requirements, and evidence of tumor recurrence. ResultsSix patients were identified with tumors of the face/scalp (n = 4), trunk (n = 1) and upper extremity (n = 1). Hedgehog inhibitor therapy continued until tumors became unresponsive (n = 3, mean = 71 weeks) or side effects became intolerable (n = 3, mean = 31 weeks). In each case, a less extensive surgery was performed than estimated before HHIT. In 3 cases, significant bone resection was avoided. All resected specimens contained BCC. Four specimens exhibited clear margins. Postoperative radiation was performed in cases with positive margins (n = 2), and 1 patient experienced local recurrence. Length of follow-up was 5.7 to 11.8 months (mean = 8.23 months). ConclusionsAlthough HHIT was not curative for extensive BCC, HHIT can decrease the morbidity of surgical treatment and increase the likelihood of curative resection. For patients with extensive BCC, a combined neoadjuvant use of HHIT and surgical treatment should be considered.

The stylet technique for inframammary fold definition in breast reconstruction

After three weeks, the base of the flap was sectioned and adapted to the posterior face of the pinna. The secondary surgical defect was repaired using a full skin graft taken from the left supraclavicular area. After 12 months a good esthetic result was observed. Given the morphological peculiarities of the pinna, reconstruction is not simple. Various techniques are employed for the surgical reconstruction of the helix. Direct closure will always be the technique of choice, but this is only possible in small defects, usually smaller than 1 cm. If the defect is larger, or affects the cartilage, a wedge resection can be used, combining different folding techniques in order to adapt the edges to the anatomical concavity of the helical rim (stellate closure, or the creation of notches along the helical rim) for better esthetic results. Above a certain size the resulting microtia may present a significant aesthetic issue. However, this patient presented a large, full thickness, surgical defect (3 1.5 cm) located on the junction of the upper and middle thirds of the helix. The most appropriate reconstruction options for this defect would be the rotation-transposition flap, the bipedicle flap from the post-auricular groove with cartilage graft, or the retroauricular U advancement flap similar to the technique chosen, but without the cartilage. The first option is a dual flap, consisting of a transposition flap from the post-auricular glabrous region, which then is moved to cover the defect (reconstructive flap), assisted by a rotation flap from the pilous area (transportation flap). A cartilage graft is first inserted in order to support the flap correctly. The disadvantages of this technique are that it requires considerable movement of tissue in comparison with the defect being repaired, and the distortion of the hairline. The latter issue is of less importance, as it is hidden in the area behind the ear. A bipedicle flap could be used, which would be taken from the post-auricular area. This procedure starts with the extraction of cartilage from the post-auricular groove, which is then sutured to the defect to provide support. A flap of post-auricular skin and subcutaneous tissue is then dissected. This process uses two parallel incisions with a sufficient width to cover the skin defect, taking the previously made incision as the anterior edge. The anterior edge of the flap is sutured to the anterior edge of the defect. Blood will be supplied to the flap through its upper and lower ends. Three weeks later, both ends are sectioned and the flap is adapted to the defect. Finally, it is important to mention retroauricular U advancement flaps. These may be exclusively cutaneous, or use a free cartilage graft. The method used for these flaps is the same as that described in the above clinical case, except for the use of cartilage, which we did in the form of a compound flap. We opted for this compound retroauricular advancement flap because it allows the repair of total thickness defects, as it is supported by the advancement cartilage. Scarring is barely visible in a shaded area. This case presents an original auricular reconstruction, with favorable aesthetic results, the only drawback of which is the need for two surgical interventions. Funding sources

Estrogen treatment of acetic acid burns to the vagina, cervix, and perineum: a case report and review of the literature.

In colposcopic evaluation of the cervix, acetic acid of 3 to 5% is commonly used for identification of preneoplastic and neoplastic cells. Acetic acid is a known caustic substance and has the potential to cause irritation and chemical burns when there is sufficient concentration or duration of contact. The authors present a unique case of a woman who inadvertently received undiluted acetic acid during a routine colposcopy, resulting in significant chemical burns of the vagina, cervix, and perineum. Her burns were treated with topical estrogen cream of 1 g twice daily applied directly to the wounds. The burn wounds were fully healed within 8 weeks without complication or additional treatment. At 6 months after the injury, the patient was allowed to engage in sexual activity, and vaginal dilation and pelvic floor therapy were initiated. At 12 months postinjury, her only symptomatic scarring at the left vaginal wall continues to improve. Thus, topical estrogen treatment of 1 g applied twice daily should be continued until burn scar maturation is complete and treatment improvement plateaus in cases of burns to the vagina, cervix, and perineum. This case is further clinical evidence of estrogens positive effect on wound healing and its potential role in burn treatment.