Strategies to prevent suppurative chondritis following auricular burns: a systematic review.

OBJECTIVE: Suppurative chondritis is a potentially devastating complication of burns to the ear. The infection and inflammation can liquify cartilage, leading to significant aesthetic deformities which are difficult to treat. This article reviews published measures for preventing post-burn chondritis. METHOD: A comprehensive search of all available literature up to September 2020 was performed, according to PRISMA guidelines, for studies assessing preventive measures for post-burn chondritis. Randomised controlled trials (RCT), cohort studies, case-control studies, case reports and series were eligible for inclusion. RESULTS: A total of 10 studies, including one RCT and nine retrospective observational analyses, were included, incorporating 1369 patients with burns to the ear. The most common interventions were pressure avoidance (70%), daily cleansing (60%), topical mafenide acetate (60%) and targeted debridement (30%). Packages of measures which included pressure avoidance were the most effective, all of which achieved a chondritis incidence of <6%. CONCLUSION: Low-level but strong published evidence suggests that important treatment principles include prevention by pressure relief, targeted debridement, prophylactic local antibiotics, local antisepsis and the avoidance of desiccation.

Neuropathic agents in the management of pruritus in burn injuries: a systematic review and meta-analysis.

OBJECTIVES: Pruritus is a common and often distressing complication after a burn injury. The purpose of this review is to explore the efficacy of drugs classically used to treat neuropathic pain in the management of pruritus after burn injury. METHODS: A systematic literature search of medical databases was conducted to find studies investigating drugs listed in the National Institute for Health and Care Excellence (NICE) guideline (CG173, "neuropathic pain in adults") for the management of pruritus after burn injury in patients of any age. Controlled studies were stratified by the drug class studied and their risk of bias before conducting meta-analysis. A narrative review of case series or observational studies was presented. Severity of pruritus at any time point, with all quantitative and qualitative measures, was included. RESULTS: Fifteen studies were included in the final analysis, 10 investigated the use of gabapentinoids, 4 studied doxepin, and 1 local anesthetic agents. Meta-analysis of three randomized controlled trials (RCTs) demonstrated that the use of gabapentinoids was associated with an improvement in mean VAS (Visual Analog Scale) 0-10 scores of 2.96 (95% confidence interval (95% CI) 1.20 to 4.73, p<0.001) when compared with placebo or antihistamine. A meta-analysis of four RCTs investigating topical doxepin showed an improvement in mean VAS scores of 1.82 (95% CI 0.55 to 3.09, p<0.001). However, when excluding two studies found to be at high risk of bias, no such improvement was found (-0.32, 95% CI -1.64 to -0.99, p=0.83). CONCLUSION: This study suggests that gabapentinoids are beneficial in the management of burn-related pruritus. There is a lack of evidence to suggest that doxepin is an effective treatment. Topical local anesthetic agents may be safe and beneficial, but studies are scarce. LEVEL OF EVIDENCE: Systematic review, level II.

Early experiences using bromelain-based enzymatic debridement in a tertiary burns centre in the United Kingdom: A retrospective case series review.

BACKGROUND: The modern ethos of burn care requires a holistic approach that helps patients to not only survive but also maintain a good quality of life. Bromelain-based enzymatic debridement with Nexobrid™ (NXB) has been shown to selectively debride burnt tissue and allow dermal preservation, which has the potential to reduce surgical burden and improve scarring. In this study, early experience with the use of Nexobrid™ at a tertiary burns centre between July 2016 and December 2019 is presented. In particular, the study assessed whether NXB had changed the acute care delivered to this cohort. METHODS: A retrospective analysis of the patients' records was performed. Results were analysed and presented in the context of current literature. RESULTS: Twenty adult patients (17 male, 3 female) underwent enzymatic debridement with NXB. Median age was 42.5 years. Mean total burn surface area (TBSA) on admission was 20%. Twelve patients were admitted to the intensive care unit, and eight were admitted to the adult burns ward. Mean TBSA treated with NXB was 8.2%, usually within 24 h of admission (mean). All patients had anaesthetist-led analgesia. NXB debridement was successful in 55% of patients, obviating the need for escharotomy in some patients. Sixty percent of all patients required further surgery, and 80% of facial burns treated with NXB required further surgery. Inotrope support was associated with NXB failure (p = 0.015). Mean length of stay was 29 days. DISCUSSION: Current evidence, including our own findings, cannot justify replacing the current surgical standard of care with NXB, but it certainly solidifies enzymatic debridement as a useful adjunct that should form part of the modern burn surgeon's armamentarium.

An unusual case of asymptomatic spontaneous umbilical endometriosis treated with skin-sparing excision.

Spontaneous umbilical endometriosis is a rare extrapelvic manifestation of endometriosis. Very few such cases have been previously reported, almost always associated with a variety of symptoms, usually during menstruation. We present a case of asymptomatic umbilical endometriosis treated with skin-sparing excision. Differential diagnoses relevant to the clinician, as well as treatment options, are also presented. Surgeons should always consider umbilical endometriosis in their diagnostic approach when confronted with atypical umbilical nodules, regardless of whether they are symptomatic or not.

Otoplasty: the case for skin incision by higher volume operators.

Prominent ear correction in the paediatric population is a common and popular procedure, with demonstrable benefit in alleviating psychological distress. Posterior cartilage-sparing techniques for otoplasty have been shown to be consistently safer and better than cartilage-scoring alternatives, however excision of the posterior auricular skin during otoplasty, although a common first step, has not been shown to have any benefits over skin incision alone. In this study, we examined the association between skin excision and recurrence of ear prominence, by examining the collective surgical outcomes of five plastic surgeons, performing 118 otoplasties at the Royal Hospital for Sick Children Edinburgh, between January 2011 and December 2013. Recurrence of prominence at the first follow-up appointment (mean follow-up 3.4 months) was 10.2%. Surgeons with low case volumes had significantly higher recurrence rates than high volume operators. There was no statistically significant association between skin excision and recurrence of prominence. We still favour posterior, cartilage-sparing otoplasties, but based on our findings we do not advocate any skin excision at any stage of the procedure. Surgeons should not include paediatric otoplasty in their portfolio unless they are undertaking significant number of cases each year.

Incisional hernia of the urinary bladder following internal hemipelvectomy.

INTRODUCTION: Hemipelvectomies are uncommon operations, usually performed for primary or metastatic malignant disease and less frequently for benign-aggressive tumours. There are very few reports in literature regarding complications of these procedures and even fewer reports about post hemipelvectomy hernias in particular. PRESENTATION OF CASE: We present the only reported case of an incisional hernia of the urinary bladder following internal hemipelvectomy for aneurysmal bone cyst of the pubic bone. A careful literature review is also performed. DISCUSSION: The development of the incisional hernia in the case of our patient can most likely be explained by the absence of advanced malignant disease of the pelvis that not only reduces the life expectancy but also overshadows other complications post hemipelvectomy. Furthermore, her young age and level of fitness allowed for a full postoperative rehabilitation which, combined with the proven anatomical changes of the internal organs following hemipelvectomies and the weakening of the tissues around the operative site, predisposed to the hernia formation. CONCLUSION: Hemipelvectomies are extensive, anatomically disruptive operations, with significant detriment to the psychosomatic well being of the patients. We presented the only reported case of incisional hernia of the urinary bladder following internal hemipelvectomy and our reconstructive method of choice. We believe that, in the case of our patient, if a mesh had been used to reconstruct the primary defect during the initial surgery, this complication could have been prevented.

Enterobius vermicularis (pinworm) infection of the liver mimicking malignancy: Presentation of a new case and review of current literature.

INTRODUCTION: Enterobius vermicularis or "pinworm" infection of the liver is an extremely rare condition with only five cases previously reported in literature. It is characterized by the presence of granulomas in the liver with a necrotic core, containing adult helminthes or their ova. Because of the relatively mild symptomatology associated with this disease, prior to the arrival of modern imaging methods hepatic enterobiasis was an incidental intra-operative finding during abdominal surgery for other conditions. In recent years however, with high-resolution abdominal imaging readily available and the improved safety of hepatic resection, a lower threshold for treating suspicious hepatic nodules aggressively with surgery is being adopted. PRESENTATION OF CASE: We present the second case in international literature, where E. vermicularis of the liver was mistaken for malignancy and led to hepatic resection and perform a literature review of the five previously documented cases of hepatic enterobiasis. DISCUSSION: Our report identifies certain trends in this condition's aetiology and clinical behaviour, but due to its rarity definitive answers cannot yet be established. CONCLUSION: We do not advocate a change in the current approach of suspicious hepatic nodules, but we do feel that better understanding of the mechanisms involved with hepatic enterobiasis could, in the future, prevent unnecessary surgery.