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Burn of nasal septum — Clinical Guidelines

Overview

Burn injuries to the nasal septum represent a complex and challenging subset of facial burns, often resulting from thermal, chemical, or electrical exposures. These injuries can lead to significant functional impairment, affecting breathing and potentially causing chronic respiratory distress, alongside profound aesthetic and psychological consequences. The intricate anatomy of the nasal septum, crucial for maintaining proper airflow and structural integrity of the nose, makes reconstruction particularly demanding. Successful management requires a multidisciplinary approach, integrating plastic surgery, otolaryngology, and psychological support to address both physical and emotional recovery needs.

Clinical Presentation

Symptoms and Signs

Patients with burns affecting the nasal septum typically present with a constellation of symptoms reflecting the severity and extent of the injury. Immediate complaints often include pain, nasal bleeding, and difficulty breathing through the affected nostril(s). As healing progresses, patients may exhibit deformities such as saddle nose deformity, septal perforation, or collapse, leading to significant asymmetry and impaired nasal function. Visually, there can be noticeable swelling, discoloration, and scarring that becomes more apparent as the acute phase resolves. Psychosocially, these changes can profoundly impact self-esteem and social interactions, necessitating early psychological evaluation and support [PMID:28336256].

Differential Diagnosis

Differentiating burn injuries of the nasal septum from other nasal pathologies is crucial for appropriate management. Conditions such as traumatic nasal fractures, chronic sinusitis, or allergic rhinitis may present with similar symptoms but require distinct therapeutic approaches. Key distinguishing factors include the history of thermal exposure, characteristic burn patterns (e.g., concentric circles in chemical burns), and the presence of associated burns on other parts of the face or body. Imaging studies like CT scans can help delineate structural damage and rule out concurrent fractures or other internal injuries, aiding in a precise diagnosis [PMID:28336256].

Diagnosis

Initial Assessment

The initial clinical assessment involves a thorough history taking to identify the cause and extent of the burn injury. Physical examination focuses on evaluating the integrity of the nasal septum, assessing for signs of airway compromise, and noting any associated injuries. Vital signs, including respiratory rate and oxygen saturation, are closely monitored to detect early signs of respiratory distress.

Diagnostic Imaging and Tests

CT Scan: Essential for detailed visualization of the nasal structures, identifying septal defects, bone damage, and assessing the extent of soft tissue injury.

Endoscopy: Useful for direct visualization of the nasal cavity and septum, helping to diagnose perforations, stenosis, and other internal deformities.

Laboratory Tests: Basic blood tests (CBC, electrolytes) to assess overall health status and guide fluid management, particularly in severe burns.

Management

Acute Phase Management

During the acute phase, the primary goals are to stabilize the patient, manage pain, and prevent complications such as infection and airway obstruction. This includes:

Pain Control: Administering analgesics as needed, often starting with opioids for severe pain.

Airway Management: Monitoring for and addressing any airway compromise, potentially requiring intubation or advanced airway interventions.

Infection Prevention: Prophylactic antibiotics may be considered, especially in extensive burns, to prevent nosocomial infections.

Surgical Reconstruction

Successful reconstruction of the nasal septum post-burn injury demands meticulous surgical planning and execution:

Timing: Initial reconstruction is typically deferred until the acute inflammatory phase subsides, often 6-12 weeks post-injury, to allow for adequate healing and scar maturation.

Techniques: Utilization of local flaps (e.g., septal mucosal flap), grafts (autogenous skin grafts, cartilage grafts), and in complex cases, free flaps to restore both form and function.

Multidisciplinary Approach: Collaboration between plastic surgeons and otolaryngologists is crucial for optimal outcomes, ensuring preservation of symmetry, contour, and respiratory function.

#### Innovative Approaches

Stent Placement: For non-compliant patients, such as those with autism, innovative solutions like self-expandable metallic esophageal stents have shown promise in maintaining patency of the nasal cavity and nostrils with minimal postoperative intervention [PMID:25748514]. This approach can reduce the need for frequent retainer placement or gauze packing, common in conventional treatments for burn-induced nasal stenosis.

Postoperative Care

Monitoring: Regular follow-up visits to monitor healing progress, manage potential complications (e.g., infection, dehiscence), and adjust rehabilitation plans as needed.

Rehabilitation: Incorporating physiotherapy to maintain nasal patency and prevent restenosis, including saline irrigation and gentle nasal exercises.

Psychological Support: Ongoing psychological counseling to address the emotional impact of disfigurement and functional limitations.

Complications

Common Complications

Restenosis: A frequent issue following burn injuries, often necessitating prolonged postoperative measures such as retainer placement or continuous gauze packing to maintain patency.

Infection: Increased risk due to compromised skin integrity and potential for deep tissue involvement.

Scarring and Contractures: Can lead to functional impairment and aesthetic concerns, requiring meticulous surgical management and possibly skin grafting.

Management of Complications

Restenosis: Aggressive use of stents, regular endoscopic evaluations, and timely surgical interventions to dilate narrowed passages.

Infection: Prompt administration of appropriate antibiotics based on culture and sensitivity results, along with wound care adjustments.

Scar Management: Early intervention with silicone sheets, pressure therapy, and possibly laser treatments to minimize hypertrophic scarring.

Prognosis & Follow-up

Long-term Prognosis

Recovery to a socially acceptable state often involves extensive follow-up and multiple surgical interventions over several years. The prognosis varies widely depending on the initial severity of the burn, the timeliness and effectiveness of initial management, and the patient's overall health. Psychological resilience and social support play critical roles in achieving a positive outcome.

Follow-up Schedule

Short-term (1-3 months post-injury): Frequent visits (weekly to biweekly) to monitor healing, manage acute complications, and adjust rehabilitation protocols.

Intermediate (3-12 months): Monthly follow-ups to assess progress, address any emerging issues, and plan subsequent surgical interventions if necessary.

Long-term (1 year+): Quarterly evaluations to ensure sustained function and aesthetics, with adjustments made based on individual recovery trajectories.

Special Populations

Patients with Autism

Children and adults with autism spectrum disorder (ASD) present unique challenges due to potential non-compliance with postoperative care routines. Innovative approaches, such as the use of self-expandable metallic stents, have shown efficacy in maintaining nasal patency with minimal need for patient intervention. Tailored psychological support and clear, structured communication strategies are essential to enhance adherence to rehabilitation protocols and improve overall outcomes [PMID:25748514].

Key Recommendations

Early Multidisciplinary Involvement: Engage plastic surgeons, otolaryngologists, and psychologists early in the treatment plan.

Patient-Specific Care Plans: Tailor surgical and rehabilitative strategies to individual patient needs, especially considering psychological and compliance factors.

Innovative Solutions: Explore advanced techniques like stent placement for patients who may not adhere to conventional postoperative care.

Comprehensive Follow-up: Establish a rigorous follow-up schedule to monitor healing, manage complications, and adjust treatments as necessary.

References

1 Bouguila J, Ho Quoc C, Viard R, Brun A, Voulliaume D, Comparin JP et al.. Nose burns: 4-dimensional analysis. European annals of otorhinolaryngology, head and neck diseases 2017. link 2 Sekine K, Matsune S, Shiiba K, Kimura M, Okubo K, Kaneshiro T et al.. Treatment of nostril and nasal stenosis due to facial burn using a self-expandable metallic esophageal stent. Auris, nasus, larynx 2015. link

2 papers cited of 3 indexed.

Burn of nasal septum