Paediatric facial paralysis: An overview and insights into management.

The aim of this article is to provide an overview on paediatric facial paralysis, looking into aetiology, epidemiology, assessment and investigation and subsequent treatment options available. Facial paralysis describes the inability to activate the muscles of fascial expression. Overall, it affects 2.7 per 100 000 children under 10 years old and 10.1 per 100 000 children over 10 years old each year. There are many causes of facial paralysis and the outcomes and necessary treatments vary depending on the cause. The mainstays of medical management are corticosteroids and facial therapy; however, when the facial palsy persists, facial deformity surgery is an option to improve the facial symmetry, protect vision and recreate dynamic movement.

Auricular reconstruction.

External ear abnormalities are common. These may affect ear shape, size, prominence and degree of development. They may also be associated with hearing loss. The early identification and management of hearing loss is essential. There are several options for reconstruction of the external ear using both autologous and non-autologous techniques. The aim of this article is to outline the different reconstructive options.

Global variation in cleft palate repairs: an analysis of 352,191 primary cleft repairs in low- to higher-middle-income countries.

Objectives : Resources for repair of cleft lip and palate may be lacking in low- and middle-income countries. The Smile Train is a registered charity that supports cleft repair in resource-poor settings. In the global health care challenge, it has been suggested that many babies born with cleft palates are not repaired. This study aims to determine whether any variation exists in the proportion of cleft lip and cleft palate repairs undertaken in low- and middle-income countries. Methods : Data were obtained from the Smile Train database of 352,191 consecutive cleft operations performed between 2008 and 2011 in low- to higher-middle-income countries. The ratio of cleft lip to palate repair was analyzed as a function of geographic region and by country income (gross national income). Results : A significant correlation exists between both the income of a country and its geographical region to the ratio of lip and palate repair procedures undertaken. Higher-income countries had a higher ratio of cleft palate repairs. Countries in sub-Saharan Africa have the lowest proportion of cleft palate repairs. Conclusion : This study emphasizes that many babies born with cleft palates in resource-poor regions do not have their palates repaired. This finding may be explained by an increased neonatal mortality in cleft palate babies. Furthermore, fewer isolated palatal clefts may present to an appropriate health care facility or there may be a reluctance to treat cleft palate due to concerns regarding higher perioperative risks or the lack of available surgical and anesthetic expertise.

Recovery of functional independence following major burn: A systematic review.

BACKGROUND: Major burn injury, despite advancements in care and prevention, can have a profound impact on long-term morbidity, affecting quality of life and socioeconomic standing. We aim to explore factors predicting recovery of independence, the expected rate and time in majorly burned patients, and the measures of progress used. METHOD: A systematic search of four databases (MEDLINE, EMBASE, COCHRANE, CINAHL) was conducted for studies reporting outcomes pertaining to physical ability indicative of independent function in adult (>15 y) cohorts who had suffered a major burn (>20% TBSA) up to 30 years after treatment in a developed specialised burn service. Data extracted included factors affecting rate of and time to achievement of function in five independence domains, as well as the outcome measures used. RESULTS: 21 eligible studies were included comprising 1298 major burns survivors with a combined mean age of 39.6 y and a mean TBSA of 25.8%. The most significant recurring factors impacting recovery of independent function were older age, female gender, burn severity, prolonged ICU and hospital admission, preceding mental health conditions, and post-acute psychological issues. Exercise-based rehabilitation conferred benefits on major burn patients even over 2 years following injury. Discharge to independent living from hospital occurred in 27% to 97% of patients, while reported return to work rates varied from 52% to 80%. Burns Specific Health Scale-Brief, Functional Independence Measure, and Physical Composite Score (SF-36) were the most widely used outcome scoring systems. CONCLUSION: Major burn survivors have protracted recovery with potential for persistent chronic impairments, remaining consistently below baseline levels of function. Non-modifiable factors such as age and gender, and disease characteristics such as burn size with associated physical, physiological and psychosocial sequelae are contributory. Further research is required to explore achievement of specific milestones of major burn and polytrauma critical care patients, while early targeted rehabilitation addressing physical, psychological, and vocational needs has promising potential benefit.

Quantifying the clinical and economic burden of desquamating dermatological conditions: Implications for a supraregional burns centre.

INTRODUCTION: This study aimed to identify the spectrum of desquamating skin diseases referred for tertiary burns care and quantify the care requirements and expenses associated with caring for these patients within the burns service. METHODS: Patient records were identified with nonburn-induced skin loss between 2016 and 2022. Data was extracted from inpatient records, operative notes, and dressing clinic records. A cost analysis was conducted using figures from the National Schedule of National Health Service Costs and our own unit-specific costs. RESULTS: Twenty patients were identified, with a median age of 46.5 and a median total body surface area of 30%. The mean length of stay was 21.2 days, with 8/20 patients requiring intensive care. Overall mortality was 30%, rising to 50% if patients required intensive treatment unit (ITU) admission. Patients had a mean of 1.5 procedures under general anaesthesia and a mean operative time of 169 min per patient. Postoperatively, a mean of 8.3 dressing changes was required per patient (range 1-21). Of 75% of patients referred as suspected toxic epidermal necrolysis syndrome (TENS), only 32% of patients histologically had TENS (32%), with linear IgA disease, pemphigus vulgaris and bullous lupus comprising the other diagnoses. Cost analysis predicted a total cost to the unit of £1,422,106. CONCLUSION: Desquamating dermatological diseases are life-threatening conditions with exhaustive care requirements. Our experiences highlight the importance of awareness of the range of desquamating skin conditions beyond TENS to enable optimum management and the need to ensure adequate financial provisions to accommodate the care requirements mandated by these patients.

Surgical simulation training for escharotomy: A novel course, improving candidate's confidence in a time critical procedure.

BACKGROUND: Circumferential deep burns on the limb lead to a constrictive, tourniquet-like effect causing critical limb ischaemia. The treatment, escharotomy, is a time-critical procedure that sometimes is required before the patient arrives at a burn centre. At present, no practical method of teaching this procedure is incorporated into formal educational courses. METHODS: The feasibility of a comprehensive education package to teach upper limb escharotomy was assessed in a group of plastic and general surgery trainees in Wales. Small group workshops focused on the clinical presentation of patients requiring escharotomy. Participants then executed this on a custom-made high-fidelity simulation upper limb model. The articulated limb has subcutaneous silicone fat which bulges upon decompression and a finger-tip which turns pink indicating satisfactory reperfusion. A before and after five-point Likert scale was used to evaluate changes in participants' self-assessed confidence in the surgical management of escharotomy. Statistical significance between scores was assessed using the Wilcoxon signed-rank test. RESULTS: A total of 34 participants took part. Following completion of the course, general surgery trainees' confidence in executing the procedure increased from a median score of 1.00 "not confident at all" (IQR 1.00-2.00) to 4.00 "fairly confident" (IQR 4.00-5.00, p < 0.01). Plastic surgery trainees' confidence increased from a median score of was 3.00 "somewhat confident" (IQR 1.75-4.00) to 4.00 "fairly confident" (IQR 3.00-4.25, p < 0.01). DISCUSSION: We developed a comprehensive simulator course that has been demonstrated to improve candidate's confidence in performing escharotomy. The next stage in the course development is to confirm the results in a larger cohort. By developing this simulator course we aim to improve emergency burn care education in the UK and globally.

Cyanoacrylate Nail Glue and the Pajama Catalyst.

Nail glues are routinely used for the application of false nails and are readily available for unrestricted purchase from highstreet and online retailers. We present the case of a young lady who accidentally spilled her nail glue on to her cotton pajama trouser leg setting off a violent exothermic reaction that resulted in a full-thickness burn injury to her foot. She ultimately went on to require surgical debridement and skin grafting. We intend to remind both healthcare workers and members of the public that while nail glue alone in contact with the skin is relatively harmless, contact together with natural fibers such as cotton clothing produces a dangerous chemical reaction, which is too often underestimated and can lead to serious burn injuries. Our patient and the surgical team agree that more must be done to raise awareness of the risks these products pose, and retailers must ensure consumers are responsibly informed.

Can intralesional cryotherapy reshape the management of difficult keloid scars?

Keloid scars are notoriously difficult to treat with very high recurrence rates despite a range of treatment options. We present a case report of a 43-year-old man with a resistant keloid scar on his left ear from a piercing. After 15 years of multimodal treatments including surgery, steroid and 5-fluorourcil injections, the keloid persisted. It has responded very well to a single treatment of intralesional cryotherapy (trademark: CryoShape, Etgar Group International Ltd). The authors would now consider intralesional cryotherapy as a useful tool in their armamentarium for prominent, resistant or recurrent keloids. Future experience will guide its clinical applications.

Intensive care unit-acquired weakness in the burn population.

Intensive care unit-acquired weakness is an evolving problem in the burn population. As patients are surviving injuries that previously would have been fatal, the focus of treatment is shifting from survival to long-term outcome. The rehabilitation of burn patients can be challenging; however, a certain subgroup of patients have worse outcomes than others. These patients may suffer from intensive care unit-acquired weakness, and their treatment, physiotherapy and expectations need to be adjusted accordingly. This study investigates the condition of intensive care unit-acquired weakness in our burn centre. We conducted a retrospective analysis of all the admissions to our burn centre between 2008 and 2012 and identified 22 patients who suffered from intensive care unit-acquired weakness. These patients were significantly younger with significantly larger burns than those without intensive care unit-acquired weakness. The known risk factors for intensive care unit-acquired weakness are commonplace in the burn population. The recovery of these patients is significantly affected by their weakness.

Evaluating an outreach service for paediatric burns follow up.

Complications following paediatric burns are well documented and care needs to be taken to ensure the appropriate follow up of these patients. Historically this has meant follow up into adulthood however this is often not necessary. The centralisation of burns services in the UK means that patients and their parents may have to travel significant distances to receive this follow up care. To optimise our burns service we have introduced a burns outreach service to enable the patients to be treated closer to home. The aim of this study is to investigate the impact of the introduction of the burns outreach service and within this environment define the optimum length of time needed to follow up these patients. A retrospective analysis was carried out of 100 consecutive paediatric burns patients who underwent surgical management of their burn. During the follow up period there were 43 complications in 32 patients (32%). These included adverse scarring (either hypertrophic or keloid), delayed healing (taking >1 month to heal) and contractures (utilising either splinting or surgical correction). Fifty-nine percent of these complications occurred within 6 months of injury and all occurred within 18 months. Size of burn was directly correlated to the risk of developing a complication. The outreach service reduced the distance the patient needs to travel for follow up by more than 50%. There was also a significant financial benefit for the service as the follow up clinics were on average 50% cheaper with burns outreach than burns physician. Burns outreach is a feasible service that not only benefits the patients but also is cheaper for the burns service. The optimum length of follow up for paediatric burns in 18 months, after which if there have not been any complications they can be discharged.