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Case

Mouth

The patient in this example is a boy from Nigeria who was adopted by a couple from the Netherlands. Over the past few years, he has been treated by reconstructive surgeons for severe microstomia with extensive scarring in and around the mouth. Between the ages of two and six, five surgical procedures were performed to improve the function of the mouth. 

The aim of this example is to demonstrate that phasing treatment in a challenging reconstructive case can lead to a good outcome. In staging the procedure, less risk was taken, thus avoiding damage to the remaining oral musculature.

Medical history

At just four months old, the infant was discovered by the side of the road with a severely injured mouth. The nature of the injury suggested a chemical burn, although the exact cause remains unknown. Common substances, such as battery acid, are often responsible for such burns in similar cases. Upon discovery, the baby had multiple ulcers in and around the mouth, prompting immediate admission to the neonatal ward of the Obafemi Awolowo University Teaching Hospital Complex. Here, the infant received essential wound care and rehydration for a week.

During the initial recovery period, the baby was fed through a nasogastric tube and later transitioned to syringe feeding (Photos 1 and 2). As the wounds gradually healed, noticeable contractures began to develop. Recognizing the need for specialized surgical intervention, the attending physician emphasized the importance of seeking a dedicated surgical review.

Following the infant's discharge from the hospital, an adoption process commenced. The adoptive parents, determined to provide the best possible care for the child, sought advice on reconstructive surgery from a renowned Burn Center in the Netherlands.

Physical examination

At two years old, the patient underwent a physical examination of the oral cavity under general anesthesia. Due to concerns around intubation, this was performed in a tertiary hospital. A pediatric anesthesiologist, a pediatric ENT surgeon, and reconstructive surgeon were present. 

Laryngoscopy revealed no scarring in the nasopharynx, base of the tongue, epiglottis, or vocal cords. Extensive mucosal scarring was observed inside the mouth, with the left side being more severely affected

Surgery

The journey towards restoring the functionality of the patient's mouth involved a series of five surgeries conducted over a span of five years. These surgical interventions, combined with dedicated physiotherapy and speech therapy, brought significant improvements to the patient's ability to eat, speak, and articulate words.

To begin the transformative process, the oral opening was widened by incising the oral commissures, allowing for further examination (photo 4). Unfortunately, the initial assessment revealed scarce healthy tissue and a notable absence of sulci, underscoring the extent of the challenge (photos 5 and 6). Furthermore, the scarred frenulum, which hindered the mobility of the tongue, had to be released.

The surgeries were meticulously planned, employing a stepwise approach to preserve the remaining oral musculature and gradually reconstruct the functionality of the mouth. The primary focus of the first three surgeries was to increase the oral opening by incising the commissures. The outcome of the third surgery, as depicted in photo 7, demonstrated encouraging progress.

However, despite the positive advancements achieved, the patient still faced significant obstacles. The lower lip remained almost non-existent, impairing essential functions and contributing to excessive drooling (photo 8). Addressing this issue, the fourth procedure involved reconstructing the inner surface of the lower lip. Two sizable mucosal flaps were meticulously harvested from the mouth's floor, skillfully rotated, and advanced medially to create the much-needed inner mucosal lining.

Regrettably, seven months after the fourth surgery, extensive salivation persisted, and scarring in the lateral commissures continued to impede adequate mouth opening. To overcome these challenges, a fifth surgery was performed. This subsequent intervention focused on a second reconstruction of the lower lip and commissures, utilizing multiple mucosal advancements. Additionally, a mucosal V-Y plasty technique was employed to enhance the central part of the lower lip.

Postoperative care

Following surgery, the patient's diet consisted of blended food, with the parents instructed to thicken liquids and rinse the mouth after eating or drinking to prevent aspiration.

A comprehensive postoperative care plan was initiated, including speech therapy and physiotherapy, which continued for approximately five years. The therapies were adapted to the child's age, presented as games, and mostly carried out at home by the parents.

Speech therapy focused on helping the child learn and pronounce words through engaging exercises like blowing on a ball of cotton wool and bulging the cheeks.

Physiotherapy aimed to improve the boy's eating abilities. Initially, contracture massages were performed, and when stiffness in the temporomandibular joints hindered progress, exercises were introduced to increase joint mobility.

To prevent oral opening narrowing due to scar formation, exercises with a splint were started when the child was four years old. The splint was used daily for up to five minutes to stretch the mouth horizontally and vertically.

The diligent implementation of these postoperative care measures, including speech therapy, physiotherapy, and splint use, played a significant role in supporting the patient's recovery and maximizing rehabilitation outcomes.

Outcome

By the age of six, the patient had achieved the ability to eat and drink. However, certain foods like biting into an apple or consuming specific types of ice pops still presented challenges. Drinking using a straw remained difficult due to limited mouth closure, leading to occasional drooling, although the frequency had decreased.

Despite these challenges, the child demonstrated visible improvement over time and did not experience difficulty in speaking, except for a slightly quiet voice.Considering the patient's growth and development, it is possible that additional reconstructive surgeries may be required in the future to further enhance functionality and achieve optimal outcomes.


Lessons learned

Prevention or minimalization of microstomia can be achieved in the acute phase of a burn by using splints or surgical intervention. This is necessary in deep burns, particularly when the burn involves the mucosal lining of the mid-section of the mouth, as it may heal poorly.

Surgical release of the oral commissures in the acute phase of a deep perioral burn allows the wounds in the corners of the mouth to heal while preserving the ability to open and close the mouth or reducing the effects on oral function.

For maximal surgical site exposure, nasal intubation is recommended when correcting microstomia.

In microstomia cases, assessing the extent of scarring beyond the oral opening can be challenging. Using a flexible scope, such as in this patient's case, to verify that the nasopharynx, base of the tongue, epiglottis, and vocal cords were not affected is essential. After this confirmation and subsequent nasal intubation, the surgical release of the commissures can be performed, allowing access to the oral cavity and inspection of the sulci, teeth, underneath the tongue, and rest of the mouth.

In severe microstomia cases, a staged approach with multiple releases of the commissures while preserving the remaining functional oral musculature is the preferred surgical approach. Severe cases of microstomia require such a staged surgical approach, which can only be successful with good aftercare, including supportive caretakers, speech therapy, physiotherapy, and dental care.

Patients and their caretakers should be counseled about potential complications that may arise, such as stiffness in the temporomandibular joints or increased drooling.

Mucosal wounds with healthy surrounding mucosa typically heal quickly and rarely lead to problematic scar formation. This is why releasing incisions in the commissures can often be performed without grafting the subsequent defects. However, in cases where the affected area is large and the availability of healthy mucosa is limited, alternative approaches may be required.


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Mouth

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