A Rare Complication: Perioral Burn Related to Electrocautery Use during Adenotonsillectomy

doi:10.4236/mps.2013.32013

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Modern Plastic Surgery, 2013, 3, 68-70

http://dx.doi.org/10.4236/mps.2013.32013 Published Online April 2013 (http://www.scirp.org/journal/mps)

A Rare Complication: Perioral Burn Related to

Electrocautery Use during Adenotonsillectomy

Erkun Tuncer1, Sadık Şentürk2

1Department of Otolaryngology—Head and Neck Surgery, Mevlana (Rumi) University Hospital, Konya, Turkey; 2Department of

Plastic and Reconstructive Surgery, Mevlana (Rumi) University Hospital, Konya, Turkey.

Email: [email protected], [email protected]

Received February 22nd, 2013; revised March 25th, 2013; accepted April 1st, 2013

License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Electrocautery is frequently used for incisions and bleeding control during adenotonsillectomy which is one of the most

commonly performed pediatric surgical procedures. Although cases of perioral burn related to electrocautery use are

rarely reported complications in literature, they account for a significant portion of malpractice lawsuits. The use of

insulated surgical tools and lip protective equipment, careful surgery, and the frequent control of surgical equipment

may decrease the number of this complication. This study examines whether a rarely reported complication related to

perioral burn is indeed rarely seen or whether there are problems in reporting the real rates because it is evaluated to be

a case of malpractice, and the protective factors that will prevent this problem. Consequently, it is underlined that this

complication, which is more frequently seen than it is reported, should be a part of preoperative information process and

the consent form.

Keywords: Burn; Adenotonsillectomy; Tonsillectomy; Malpractice; Perioral Burn

1. Introduction

The most frequently reported complications related to

adenotonsillectomy, which is one of the most commonly

performed pediatric surgical procedures, include bleed-

ing, pain, dehydration, fever, airway obstruction related

to edema, nasopharyngeal stenosis, voice change, and

velopharyngeal insufficiency [1,2-4]. The rate of perioral

burns after adenotonsillectomy is between 0.01% and

0.04% according to literature [5-7]. Although cases of

perioral burn related to electrocautery use are rarely re-

ported complications in literature, they account for a sig-

nificant portion of malpractice lawsuits [1]. The use of

insulated surgical tools and lip protective equipment,

careful surgery, and the frequent control of surgical

equipment may decrease the number of this complication

[7,8]. Although perioral burn cases have been rarely re-

ported, different stages of this complication is frequently

seen and therefore we believe that perioral burn as a

complication should be included in the preoperative in-

formation process and in the content of the consent form.

2. Case Report

A 10-year-old male patient presented with a complaint of

deep injury on his lip. The patient’s physical examination

demonstrated that he had a third-degree burn of about 2

cm in size covering the skin, mucosa, and the orbicular

muscle on his lower lip’s right comissure and he was

hospitalized for treatment (Figure 1). The patient’s me-

dical history revealed that he had had an adenotonsillec-

tomy procedure performed under general anesthesia be-

cause of chronic adenotonsillitis at another medical cen-

ter 3 weeks before his presentation at our clinic. His rou-

tine pre-op lab results were normal. The necrotic tissue

on the lower lip was debrided under general anesthesia

and the oral mucosa was repaired with 5-0 absorbable

suture. Following the repair of the orbicularis oris muscle,

which was dissected on both sides of the defect, with 4-0

absorbable suture, the skin was primarily closed with 6-0

polypropylene suture. The patient’s post-op course was

without any problems and the result was satisfactory

(Figure 2).

3. Discussion

Perioral burn is a rarely reported complication (0.01% -

0.04%) when its incidence rate is compared to complica-

tions like bleeding, pain, dehydration, fever, airway ob-

struction related to edema, nasopharyngeal stenosis, voice

A Rare Complication: Perioral Burn Related to Electrocautery Use during Adenotonsillectomy 69

Figure 1. Preoperative view.

Figure 2. Postoperative view.

change, and velopharyngeal insufficiency which are fre-

quently reported related to the adenotonsillectomy pro-

cedure [5-7]. Although cases of perioral burn related to

electrocautery use are rarely reported complications in

literature, they account for a significant portion of mal-

practice lawsuits [1,7].

While 81% of perioral burns that develop during ade-

notonsillectomy procedures are first-degree, 12% of them

are third-degree burns [7]. First-degree and second-de-

gree burns can frequently be healed by antibiotic oint-

ments without having to perform surgical procedures.

Third-degree perioral burns, however, might necessitate

advanced reconstructive surgical procedures depending

on the size of the defect. Though rarely seen, when burns

include the oral comissure they might cause aesthetic and

functional losses like microstomia. The period following

the separation of the eschar tissue from the surrounding

healthy tissues is the most viable period for the surgical

reconstruction of third-degree burn cases [9].

Electrocautery is frequently used for incisions and

hemostasis in oropharyngeal surgery. Perioral burns are

most commonly caused by monopolar cautery use which

is followed by the coblation technique. Bipolar and aspi-

ration cautery result in relatively less injury. The defects

of the tip of the electrocautery device are most com-

monly identified as the cause of perioral burns [7,8].

Other than these causes, oropharyngeal burns were de-

fined as resulting from the inflammation of the flamma-

ble anesthetic gases which infiltrate into the surgical site

related to the use of intubation tubes without balloons [6,

10].

The use of endotracheal tubes with balloons may de-

crease the risk of complications related to inflammation

by reducing the amount of oxygen-rich gas leaks into the

surgical site [10]. Aspiration that continues during the

whole procedure may prevent inflammation by blocking

the accumulation of flammable gas in the surgical site.

Surgical techniques have been defined in order to prevent

burns caused by leaks in the electrocautery device [8,11].

In addition to these techniques, a careful check of the

insulation errors of the surgical equipment during the

procedure will bring about adequate protection. Further,

the use of protective barriers and lip protecting equip-

ment that increases vision and decreases potential inju-

ries for oropharyngeal procedures prevents injuries in

this site. These devices increase the intraoral vision of

the tonsils and may prevent potential injuries in the lat-

eral oral comissure.

Tonsillectomy and adenotonsillectomy surgeries ac-

count for the most frequent malpractice complaints in

otorhinolaryngological procedures [12]. When the rates

of malpractice complaints following tonsillectomy or

adenoidectomy are evaluated (bleeding 17.5%, airway

burns 1.5%, burns 18.2%, related to consent 5.8%, re-

lated to medication 5.8%, residual tissue/recurrence 5.8%)

it is seen that burns are the most frequent malpractice

claims [1]. Another study states that while physicians

think that the perioral burn complication is 4%, parental

observation puts the figure to 14% [13]. The differences

between these data suggest that the reporting of perioral

burns at different stages is not being done adequately and

A Rare Complication: Perioral Burn Related to Electrocautery Use during Adenotonsillectomy

correctly. The evaluation of this complication as mal-

practice by physicians remains as a block against correct

reporting and data collection. We believe that informing

the patient and patient’s relatives about perioral burns as

complications in re-op information processes and consent

forms will overcome

4. Conclusion

There are a limited number of sound studies in literature

on perioral burn which is a possible complication of

adenotonsillectomy. Perioral burn can be a significant

complication that delays healing and that may leave

permanent marks. Protective barriers should be used;

careful surgical and observational measures should be

taken in order to prevent this anticipated complication.

Pre-op information talks and consent forms should in-

clude this possible complication.

REFERENCES

[1] A. R. Simonsen, J. A. Duncavage and S. S. Becker, “A

Review of Malpractice Cases after Tonsillectomy and

Adenoidectomy,” International Journal of Pediatric Oto-

rhinolaryngology, Vol. 74, No. 9, 2010, pp. 977-979.

doi:10.1016/j.ijporl.2010.05.029

[2] D. J. Spencer and J. E. Jones, “Complications of Ade-

notonsillectomy in Patients Younger than 3 Years,” Ar-

chives of Otolaryngology—Head & Neck Surgery, Vol.

138, No. 4, 2012, pp. 335-339.

doi:10.1001/archoto.2012.1

[3] L. B. Johnson, R. G. Elluru and C. M. Myer III, “Com-

plications of Adenotonsillectomy,” Laryngoscope, Vol.

112, No. 8, 2002, pp. 35-36.

[4] T. Q. Gallagher, L. Wilcox, E. McGuire and C. S. Derkay,

“Analyzing Factors Associated with Major Complications

after Adenotonsillectomy in 4776 Patients: Comparing

Three Tonsillectomy Techniques,” Otolaryngology—Head

and Neck Surgery, Vol. 142, No. 6, 2010, pp. 886-892.

doi:10.1016/j.otohns.2010.02.019

[5] M. J. Reilly, G. Milmoe and M. Pena, “Three Extraordi-

nary Complications of Adenotonsillectomy,” Interna-

tional Journal of Pediatric Otorhinolaryngology, Vol. 70,

No. 5, 2006, pp. 941-946.

doi:10.1016/j.ijporl.2005.09.023

[6] M. Tsuchida, K. Sakuma, M. Maruyama, H. Hanazawa,

M. Urano and K. Shimoji, “Oro-Pharyngeal Burn during

Electrodissection of the Adenoid and Tonsil,” Masui, Vol.

46, No. 7, 1997, pp. 959-961.

[7] M. J. Nuara, et al., “Perioral Burns after Adenotonsillec-

tomy: A Potentially Serious Complication,” Archives of

Otolaryngology—Head & Neck Surgery, Vol. 134, No. 1,

2008, pp. 10-15. doi:10.1001/archoto.2007.5

[8] T. R. Lowry and J. R. Workman, “Avoiding Oral Burns

during Electrocautery Tonsillectomy,” Ear, Nose &

Throat Journal, Vol. 88, No. 2, 2009, pp. 790-792.

[9] M. Keskin, Z. Tosun, A. Duymaz and N. Savaci, “Pe-

rioral Electrical Burn in Children: Case Report,” Ulusal

Travma ve Acil Cerrahi Dergisi, Vol. 14, No. 4, 2008, pp.

326-329.

[10] R. N. Kaddoum, E. J. Chidiac, M. M. Zestos and Z. Ah-

med, “Electrocautery-Induced Fire during Adenotonsil-

lectomy: Report of Two Cases,” Journal of Clinical An-

esthesia, Vol. 18, No. 2, 2006, pp. 129-131.

doi:10.1016/j.jclinane.2005.09.032

[11] U. K. Shah, “A Simple Suggestion to Reduce Perioral

Burns during Adenotonsillectomy,” Archives of Otolar-

yngology—Head & Neck Surgery, Vol. 134, No. 6, 2008,

pp. 673-673. doi:10.1001/archotol.134.6.673-b

[12] G. Nikoghosyan-Bossen, A. Hauberg and P. Homøe,

“Systematic Analysis of Ear-Nose-Throat Malpractice

Complaints May Be Beneficial for Patient Safety,” Dan-

ish Medical Journal, Vol. 59, No. 2, 2012, p. A4422.

[13] D. Mistry and G. Kelly, “Consent for Tonsillectomy,”

Clinical Otolaryngology & Allied Sciences, Vol. 29, No.

4, 2004, pp. 362-368.

doi:10.1111/j.1365-2273.2004.00818.x