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Laryngeal fistula following electrical burn
0 1997 Elsevier ELSEVIER
Pll: SO30541
Bums Vol. 23, No. 3, pp. 265~267,1997 Science Ltd for ISBI. AH rights reserved Printed in Great Britain 0305-4179/97 $17.00 + 0.00
79(96)00125-8
hryngeal
fistula
following
electrical
burn
R. Kumar Sharma and R. Shrikant Department Chandigarh,
of Plastic Surgery and Burns, Postgraduate 16QOl2, India
--
-
A rare case o,f elecfrical buyn resulting presented. The fistula tnan$esfed abouf was successblly managed by using a cufaneous flap. A 1 year follow-up of the 1997 Elsevier Science Lfd for 1SEX Key words:
Institute of Medical Education and Research (I’GIMER),
in laryngeal fisfula is 3 weeks posfburn. This pectoralis major rnyopatient is presented. 0
BUYITS, electrical, laryngeal, fisfula, pecfoyalis major
Pap.
Burns, Vol. 23, No. 3, 265-267,
1997
Discussion Electrical burns constitute approximately 5 per cent of the total burns reporting to a busy unit’. The upper and lower limbs are involved in the majority of cases, as these parts of the body often come into direct contact with a source of electricity. Involvement of the head and neck area is rather infrequent. Although not common, high voltage may cause severe visceral injurieP7. To the best of our knowledge a laryngeal fistula following electrical
Case report VJ, a 20-year-old boy, accidentally touched overhead high tension wires while fixing a TV antenna. He sustained approximately 20 per cent burns involving the front and side of the neck, right upper and right lower limb. The extremity bu.rns were mainly partial-thickness electrical flash burns, however, the front of the neck came into contact with the live wire, leading to full-thickness burns over the laryngeal cartilaginous area (Figure I). The pati’ent was resuscitated and managed conservatively with daily dressings. Two weeks postburn it was noted that he had developed changes m his voice which became increasingly hoarse over the next 3-4 days. At about the same time, a frothy mucous discharge was noted over the larynx” A tentaltive diagnosis of laryngeal fistula was made and confirmed wi.th probing and indirect laryngoscopic examination. This required urgent closure. The neck wound was debrided and a fistula measuring 2 x 2 cm was found (Figure 2). The necrotic part of the cartilage was excised and the mucosal defect was closed primarily by mobilizing the available mucosa. This was then covered with a pectoralis major m:yocutaneous flap (Figure 3). The dimensions of the flap were designed so that it covered the whole aesthetic unit of the neck. The postoperative course was uneventful. The hoarseness of voice gradually improved and returned to near normal. Figure 4 shows the appearance at 12 months postoperation. This patient also developed cataracts in both eyes approximately 4 months postburn antd has been managed accordingly by ophthalmology colleagues.
Figure
1. Exposed
necrotic
laryngeal.
cartilage.
266
Burns:
Vol. 23, No. 3,1997
It was possible to approximate .the mucosa edges by slight undermining of the remnants. The necrotic cartilage needed aggressive debridement because prompt intervention was required for salvage of the exposed non-necrotic cartilages. Moreover, the exbosed cartilage was devoid of any blood supply of its own and therefore needed a well-vascularized cover for its survival. The pectoralis major myocutaneous flap is very useful and very reliable for defects in the head and neck area3. The flap can be used either as a muscle flap, myofascial alone, or as a myocutaneous unit. There is minimal donor site morbidity. It has been conclusively proved both clinically and experimentally that a myocutaneous flap aids in better control of infectiorP. Figure 2. Show:ing
laryngeal
fistula.
References burns has so far not been reported in the English literature, although other fistulae have. The patient suffered fuli-ihickness burns over the anterolateral neck area overlying the larynx. It % probable that the high-tension wires came into direct contact at this site. The burns involved the laryngeal cartilage which began sloughing. The development of the laryngeal fistula was heralded by frothy mucous discharge and progessively increasing hoarseness of voice.
Figure 3. Planning neous (PMC) flap.
of the
pectoralis
major
1 Gupta M, Gupta OK, Yaduvanshi RK et al. Burns epidemiology: the Pink City scene. Burns 1993; 19: 47-51. 2 Haberal M, Ulcar N, Bayraktar U, Oner Z et al. Visceral injuries, wound infection and sepsis following electrical injuries. Burns 1996; 22: 158-161. 3 )4riyan S. The pectoralis major myocutaneous flap: a versatile flap for reconstruction in head and neck area. Nusf .Feconst Surg 1979; 63: 73. 4 Mathes SJ, Alpert BS, Chang N. Use of muscle flap in chronic osteomyelitis: experimental and clinical co-relation. ,?lasf Reconst Surg 1982; 69: 813-828.
musculocuta~Figure 4. One year follow-up.
Sharma
and §hkrikantz Laryngeal
fistula
following
electrical
5 Eshima I, Mathes SJ, Paty I’. Comparison of intracellular killing activity of leukocytes in musculocutaneous and rand’om pattern flaps. PLrsf Recorzsf Surg 1990; 86: 541-547. 6 Khan MK, Raza MK, Igbal J. Extensive bowel injury following electrical burns. Ind 1 Surg 1981; 53: 222-226. 7 Noronha W, Gore MA. Thermal burns with injury to the intestine in a congenital [???I sac. Burns 1995; 21: 550-551.
bum
267
Paper accepted 26 September 1996. Correspondence should be addressed to: Dr Ramesh Kumar Sharma, Additional Professor, Department of Bums and Plastic Surgery, PGIMER, Chandigarh, PIN 160012, India.
Pll: SO30541
Bums Vol. 23, No. 3, pp. 265~267,1997 Science Ltd for ISBI. AH rights reserved Printed in Great Britain 0305-4179/97 $17.00 + 0.00
79(96)00125-8
hryngeal
fistula
following
electrical
burn
R. Kumar Sharma and R. Shrikant Department Chandigarh,
of Plastic Surgery and Burns, Postgraduate 16QOl2, India
--
-
A rare case o,f elecfrical buyn resulting presented. The fistula tnan$esfed abouf was successblly managed by using a cufaneous flap. A 1 year follow-up of the 1997 Elsevier Science Lfd for 1SEX Key words:
Institute of Medical Education and Research (I’GIMER),
in laryngeal fisfula is 3 weeks posfburn. This pectoralis major rnyopatient is presented. 0
BUYITS, electrical, laryngeal, fisfula, pecfoyalis major
Pap.
Burns, Vol. 23, No. 3, 265-267,
1997
Discussion Electrical burns constitute approximately 5 per cent of the total burns reporting to a busy unit’. The upper and lower limbs are involved in the majority of cases, as these parts of the body often come into direct contact with a source of electricity. Involvement of the head and neck area is rather infrequent. Although not common, high voltage may cause severe visceral injurieP7. To the best of our knowledge a laryngeal fistula following electrical
Case report VJ, a 20-year-old boy, accidentally touched overhead high tension wires while fixing a TV antenna. He sustained approximately 20 per cent burns involving the front and side of the neck, right upper and right lower limb. The extremity bu.rns were mainly partial-thickness electrical flash burns, however, the front of the neck came into contact with the live wire, leading to full-thickness burns over the laryngeal cartilaginous area (Figure I). The pati’ent was resuscitated and managed conservatively with daily dressings. Two weeks postburn it was noted that he had developed changes m his voice which became increasingly hoarse over the next 3-4 days. At about the same time, a frothy mucous discharge was noted over the larynx” A tentaltive diagnosis of laryngeal fistula was made and confirmed wi.th probing and indirect laryngoscopic examination. This required urgent closure. The neck wound was debrided and a fistula measuring 2 x 2 cm was found (Figure 2). The necrotic part of the cartilage was excised and the mucosal defect was closed primarily by mobilizing the available mucosa. This was then covered with a pectoralis major m:yocutaneous flap (Figure 3). The dimensions of the flap were designed so that it covered the whole aesthetic unit of the neck. The postoperative course was uneventful. The hoarseness of voice gradually improved and returned to near normal. Figure 4 shows the appearance at 12 months postoperation. This patient also developed cataracts in both eyes approximately 4 months postburn antd has been managed accordingly by ophthalmology colleagues.
Figure
1. Exposed
necrotic
laryngeal.
cartilage.
266
Burns:
Vol. 23, No. 3,1997
It was possible to approximate .the mucosa edges by slight undermining of the remnants. The necrotic cartilage needed aggressive debridement because prompt intervention was required for salvage of the exposed non-necrotic cartilages. Moreover, the exbosed cartilage was devoid of any blood supply of its own and therefore needed a well-vascularized cover for its survival. The pectoralis major myocutaneous flap is very useful and very reliable for defects in the head and neck area3. The flap can be used either as a muscle flap, myofascial alone, or as a myocutaneous unit. There is minimal donor site morbidity. It has been conclusively proved both clinically and experimentally that a myocutaneous flap aids in better control of infectiorP. Figure 2. Show:ing
laryngeal
fistula.
References burns has so far not been reported in the English literature, although other fistulae have. The patient suffered fuli-ihickness burns over the anterolateral neck area overlying the larynx. It % probable that the high-tension wires came into direct contact at this site. The burns involved the laryngeal cartilage which began sloughing. The development of the laryngeal fistula was heralded by frothy mucous discharge and progessively increasing hoarseness of voice.
Figure 3. Planning neous (PMC) flap.
of the
pectoralis
major
1 Gupta M, Gupta OK, Yaduvanshi RK et al. Burns epidemiology: the Pink City scene. Burns 1993; 19: 47-51. 2 Haberal M, Ulcar N, Bayraktar U, Oner Z et al. Visceral injuries, wound infection and sepsis following electrical injuries. Burns 1996; 22: 158-161. 3 )4riyan S. The pectoralis major myocutaneous flap: a versatile flap for reconstruction in head and neck area. Nusf .Feconst Surg 1979; 63: 73. 4 Mathes SJ, Alpert BS, Chang N. Use of muscle flap in chronic osteomyelitis: experimental and clinical co-relation. ,?lasf Reconst Surg 1982; 69: 813-828.
musculocuta~Figure 4. One year follow-up.
Sharma
and §hkrikantz Laryngeal
fistula
following
electrical
5 Eshima I, Mathes SJ, Paty I’. Comparison of intracellular killing activity of leukocytes in musculocutaneous and rand’om pattern flaps. PLrsf Recorzsf Surg 1990; 86: 541-547. 6 Khan MK, Raza MK, Igbal J. Extensive bowel injury following electrical burns. Ind 1 Surg 1981; 53: 222-226. 7 Noronha W, Gore MA. Thermal burns with injury to the intestine in a congenital [???I sac. Burns 1995; 21: 550-551.
bum
267
Paper accepted 26 September 1996. Correspondence should be addressed to: Dr Ramesh Kumar Sharma, Additional Professor, Department of Bums and Plastic Surgery, PGIMER, Chandigarh, PIN 160012, India.