Neck
When deep burn wounds on the neck aren't treated properly in the early stages, they can lead to severe contractures. The way these injuries are cared for can have a significant impact on the scars that develop and the long-term outcome. This case study examines a patient who sustained burns on their face, neck, and left shoulder. The surgical treatment used in this case from Tanzania involved excision and grafting, and the scars healed without the need for additional cosmetic treatment. The progression of the scars over time is also documented, with a 2-year follow-up period.
Medical history
This case study is about a 21-year old epileptic Iraqw woman who fell in the fire at home during a seizure. Her mother brought her immediately to a nearby health facility where an ambulance was arranged to bring her to Haydom Lutheran Hospital the same day.
Physical examination
During the physical examination, burn wounds were observed on the left neck, face, ear and shoulder area of the patient. The patient had no difficulties with breathing and no soot was found in the nose or mouth. The oropharynx was not inflamed and no abnormalities were detected during chest auscultation. The total body surface area (TBSA) burned was 6%. As shown in the picture, it can be difficult to determine the depth of a burn wound by inspection alone. Using palpation, doctors identified the burn on the left upper neck area as a full thickness burn with hard, leathery skin and no sensation.
Conservative management
The patient was initially treated with silver sulphadiazine cream and daily soaking. The doctors chose a delayed grafting strategy for the face, in the hopes that the deeper second-degree burn wound would re-epithelialize on its own. Due to financial constraints, a staged grafting strategy was not an option. After two weeks of soaking, the wound on the neck was cleaned, but the shoulder was still covered with eschar.
Surgery
Two weeks after being admitted to the hospital, the patient underwent an escharectomy of the shoulder under general anesthesia, along with split skin grafting of all wounds. Skin was harvested from the thigh and meshed using a scalpel.
Postoperative care
Both the donor and acceptor sites were treated with a combination of tetracycline ointment and Vaseline gauzes, and then covered with dry gauzes and secured with a bandage. The patient was advised to avoid friction on the grafted areas to prevent loss of the skin grafts
After three days, the first wound inspection showed that the grafts were healing well, with the exception of the graft on the ear, which had partly failed. The patient was discharged from the hospital 10 days after the surgery.
Outcome
During follow-up visits, it was observed that the wounds healed without contractures, but scars had become hypertrophic, particularly at the edges of the grafted areas, especially on the cheek. In higher resource settings, there are many treatment options that could have potentially benefited the patient, such as silicone sheets or gels and pressure garments, or more advanced options like dermabrasion and laser therapy. Corticosteroids could also have been used to reduce the scarring, but they may also cause changes in skin color. The patient was offered these options but she had no complaints and was very satisfied with the outcome and did not want any additional treatment.
Lessons learned
This case served as a reminder to local doctors that sometimes, with burns, less is more. The face healed well without surgery and the scars improved over time without any treatment. It also highlighted that the patient is the ultimate decision maker and factors such as cultural, psychological, and financial considerations must also be taken into account when making treatment decisions.
