Burns to the ear and face

A burn is tissue damage caused by local exposure to high temperature, electric current, aggressive substances and radioactive radiation. Thermal burns are the most common; the pathomorphological and pathoanatomical changes that occur with them are very typical and, at the first degree of damage, are similar to chemical and radiation burns; structural and clinical differences occur only at severe degrees of damage by these factors. Burns are divided into industrial, domestic and combat. In peacetime, burns make up 1.5-4.5% of all surgical patients and about 5% of all injured victims in different regions of Russia.

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Causes of burns of the auricle and face

Thermal burns occur as a result of exposure to flame, radiant heat, contact with hot and molten metals, hot gases and liquids.

The classification of burns is based on signs of the depth of damage and pathological changes in the burned tissues.

• First degree burns - erythema;
• II degree - formation of blisters;
• Grade IIIA - skin necrosis with partial involvement of its germinal layer;
• IIIB degree - complete necrosis of the skin throughout its entire thickness;
• IV degree - necrosis extends beyond the skin to varying depths with complete or partial charring of the affected tissues.

From a clinical point of view, all burns are conveniently divided into superficial (I and II degrees) and deep (III and IV degrees), since most often superficial burns combine the first two degrees, and deep burns combine all four.

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Pathogenesis and pathological anatomy of burns of the auricle and face

First-degree burns develop aseptic inflammation, which manifests itself in dilation of skin capillaries and moderate swelling of the burned area due to plasma exudation into the skin. These phenomena disappear within a few days. First-degree burns end with peeling of the epidermis and in some cases leave behind pigmented areas, which also disappear after a few months.

In case of second-degree burns, inflammatory phenomena are expressed more sharply. There is abundant plasma effusion from sharply dilated capillaries, which accumulates under the stratum corneum of the epidermis with the formation of blisters. Some blisters form immediately after the burn, some may appear after several hours. The bottom of the blister is formed by the germinative layer of the epidermis. The contents of the blister are initially transparent, then become cloudy due to fibrin loss; with secondary infection, it becomes purulent. With an uncomplicated course, the dead layers of the epidermis regenerate in 7-14 days without scarring. With secondary infection, part of the germinal layer of the epidermis dies. In this case, healing is delayed for 3-4 weeks, with the formation of granulation tissue and thin superficial scars.

General phenomena characteristic of burn disease are not observed with limited lesions of the face or isolated lesions of the auricle in burns I and II.

In III and IV burns, necrosis phenomena come to the fore, arising as a result of thermal coagulation of cell and tissue protein. In milder cases, necrosis only partially affects the papillary layer (grade IIIA), which creates the possibility of not only marginal but also insular epithelialization. In grade IIIB, total skin necrosis occurs, and in grade IV, necrosis of deeper tissues occurs (in facial burns - subcutaneous tissue, facial muscles, branches of the facial and trigeminal nerves; in auricle burns - perichondrium and cartilage).

First degree burns occur upon direct contact with a liquid or solid heated to a temperature of 70-75°C, second degree burns - 75-100°C, third and fourth degree burns - upon contact with hot or molten metal or flame.

It is not possible to differentiate the depth and extent of necrosis by clinical signs in the first hours and even days after injury, since pathological processes associated with thermal destruction of tissues continue for some time, up to the formation of demarcation boundaries between tissues that have retained their physiological state and tissues that have been subjected to burns of various degrees. In case of grade 3B burns, the affected areas of the skin are dense to the touch (formation of a scab), acquire a dark or grayish-marbled color, and lose all types of sensitivity (necrosis of nerve endings). In case of burns of deeper tissues, the scab acquires a black color and all types of sensitivity of the affected area of the skin are lost from the very beginning. In case of deep burns of the face and auricle, a suppurative process often develops, accompanied by melting and rejection of necrotic tissues and ending according to the type of healing by secondary intention with the formation of granulation and epithelialization. After this, coarse, disfiguring scars often form, with areas of impaired sensitivity, and if the lesion affected the face, then also the facial function.

The diagnosis of thermal injuries to the face and auricle is not difficult and is based on the anamnesis and characteristic pathological signs of the burn. It is much more difficult to establish the depth and extent of the injury in the first hours. Determining the area of the burn and its degree is of great importance. According to the "rule of nines", the surface of the head and neck is 9% of the surface of the entire body. This rule is used to determine extensive burns of the trunk and extremities; as for the face and outer ear, the specific anatomical structure that was damaged is indicated, for example, "superficial burn of the right half of the face and right auricle (I-II degree)".

Symptoms of burns of the face and auricle are determined by the degree of damage, its size and possible concomitant types of damage (burns of the eyes, scalp). In case of local and limited thermal damage of the face and auricle and burns of the first and second degree, general clinical symptoms are not observed. In case of more widespread burns of the third and fourth degree, signs of burn disease may occur, manifested by periods of shock, toxemia, septiotoxemia and convalescence. Each of the specified periods is characterized by its own clinical picture and corresponding pathogenesis, which are considered in the course of general surgery. As for local damage of the face and auricle, here the clinical picture is formed from the dynamics of the burn process and subjective and objective symptoms, which were mentioned above.

Treatment of burns of the auricle and face

Treatment of burns consists of general and local measures.

General treatment

Victims with burns of the face and auricle are hospitalized either in a surgical hospital or in a specialized department of maxillofacial surgery or ENT. First aid to a burn victim at the scene consists of extinguishing clothing (removing burning headgear) and covering the burnt surface with a dry aseptic bandage. Nothing should be done to clean the burnt area, just as there is no need to remove the remains of burnt clothing stuck to the skin. When providing assistance before evacuation, the victim must be injected subcutaneously with 1-2 ml of a 1% solution of morphine hydrochloride or pantothenic acid (promedol). Evacuation should be carried out carefully, without unnecessary trauma to the damaged areas of the body; in case of a burn of the head (auricle or the corresponding half of the face), the head should be fixed with hands. During transportation of the victim, do not allow him to cool down. The air temperature in the ward should be within 22-24 ° C.

If the victim is in a state of shock, he is placed in the intensive care unit and, before proceeding to the examination of the affected areas, anti-shock measures are taken. However, before they are taken, it is necessary to make sure that the victim is not poisoned by carbon monoxide or toxic combustion products. At the same time, by analogy with the case novocaine blockade, carried out for burns of the extremities, a similar blockade of the periauricular area or unaffected areas of the face around the lesion is permissible. Novocaine blockade, being a pathogenetic treatment, has a beneficial effect on the reflex-trophic functions of the nervous system, in particular, it reduces the increased permeability of capillaries during a burn. In case of extensive burns of the head, the patient is treated as a victim with significant burns of the trunk and extremities. It is advisable to hospitalize such patients in burn centers.

To prevent or combat secondary infection, broad-spectrum antibiotics are used in combination with sulfonamides. To combat intoxication, anemia and hypoproteinemia, as well as to maintain water-salt balance, transfusions of single-group fresh citrate blood, plasma, protein hydrolysates, 5% glucose solution, and saline solutions are administered. Analgesics, tranquilizers, cardioprotectors, and vitamin mixtures are administered as indicated.

In case of deep burns of the face and mouth area and the impossibility of independent food intake, tube feeding with parenteral administration of nutritional mixtures is established. Care for burn patients and protective regimen are of great importance in the treatment of burn patients. Victims with fresh burns should not be placed in the wards of the purulent department.

Local treatment of burns of the auricle and face

The burn surface in case of second- and third-degree burns should be considered as a wound, which is first and foremost an entry point for infection, therefore it is subject to primary surgical treatment in all cases. If there is no need for emergency anti-shock measures, this treatment should be performed as soon as possible. The volume of primary surgical treatment is determined by the degree and extent of the burn. It begins with the introduction of 1-2 ml of a 1% morphine solution under the skin or into a vein. The most gentle and pathogenetically substantiated method of primary surgical treatment of burns was proposed by A.A. Vishnevsky (1952). With this method, after removing the upper layers of the primary dressing, the lower layers of gauze adhering to the burnt surface are separated by irrigation with a warm weak solution of potassium permanganate. After this, the burnt surface is irrigated with a weak stream of a warm solution of furacilin to clean the affected area of the skin. Then the skin around the burn is wiped first with balls soaked in a 0.5% aqueous solution of ammonia, then in 70% ethyl alcohol. Scraps of epidermis are cut off from the burnt surface. Large blisters are incised at the base and emptied, medium-sized and small blisters are preserved. Finally, the burnt surface is irrigated with a warm isotonic solution of sodium chloride and carefully dried with sterile cotton or gauze balls.

Subsequent treatment is carried out in an open or, much more often, closed manner by applying a bandage.

In the 1950s and 1960s, the oil-balsamic emulsion of A.V. Vishnevsky and A.A. Vishnevsky, consisting of 1.0 liquid tar; 3.0 anesthesin and xeroform; 100.0 castor oil, proved itself to be effective against fresh burns. They try to keep such a dressing on for 8-12 days, i.e., practically for the period of complete healing of second-degree burns.

Later, for second-degree burns, the D.P. Nikolsky-Bettman method was used: the skin around the blisters is wiped with an aqueous solution of ammonia; the burnt surface is lubricated with a freshly prepared 5% aqueous solution of tannin and then with a 10% solution of silver nitrate. The resulting crust is preserved until self-rejection.

S.S. Avadisov proposed a novocaine-rivanol emulsion consisting of 100 ml of a 1% aqueous solution of novocaine in a 1:500 solution of rivanol and 100 ml of fish oil. Such a dressing is changed only when the burnt surface becomes suppurated. In this case, they resort to lubricating the affected areas with alcohol solutions of aniline dyes.

There are also methods of covering burns with various anti-burn films, autografts or preserved heterotransplants of skin, etc. Modern liniments, ointments and pastes containing antibiotics, corticosteroids, proteolytic enzymes, etc. are also used, accelerating the rejection of dead tissue, wound healing without coarse scarring and preventing secondary infection.

In deep burns, accompanied by necrosis of the skin throughout its entire thickness, after the rejection of dead tissue, defects arise; when they heal by secondary intention, scars are formed that not only disfigure the face, but also often disrupt facial expression and articulation functions.

To prevent these complications, early skin grafting with autografts is often used.

Skin grafting for burns accelerates the wound healing process and provides better functional and cosmetic results.

Prognosis for burns of the face and auricle

The prognosis for burns of the face and auricle concerns mainly cosmetic and functional aspects. Often, with a burn of the auricle, the external auditory canal is also affected, which is fraught with its stenosis or atresia. The auricle itself is significantly deformed with deep burns, which requires plastic restoration of its shape in the future. With burns of the face of the first and second degree, as a rule, complete epidermization of the skin occurs without scarring. With extensive burns of the third and fourth degree, the face is contracted by deep disfiguring scars, becomes mask-like, immobile; the eyelids are deformed by scar tissue, their function is limited. The pyramid of the nose is reduced, the nostrils look like shapeless openings. The lips lose their outlines, the mouth is barely mobile, and sometimes because of this, difficulties arise in eating and articulation. Such victims require long-term functional and cosmetic treatment.

Only burns of the face complicated by secondary infection pose a danger to life, which can spread through emissaries and venous anastomoses (for example, through the angular vein) into the cranial cavity, causing intracranial purulent-inflammatory processes.

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