Thermal Injuries

FROSTBITE With its position of prominence and large surface area, the auricle is extremely susceptible to extremes in temperature. The thin subcutaneous tissue makes the auricle particularly susceptible to cold-induced injury. In frostbite, the ear will initially appear pale. In superficial frostbite injuries, the underlying tissue remains soft and pliable. In deep injuries, the underlying tissue is very hard. With rewarming, the ear may become painful, with edema and blister formation. If blisters do form, they should be allowed to reabsorb spontaneously. The ear should be aseptically and quickly rewarmed with saline-soaked gauze that has been warmed to 38 to 40°C (100.4 to 104°F). The rewarming process may be very painful and conscious sedation may be necessary.

BURNS Burns of the upper body occur frequently, with burns of the face and neck representing about 30 percent of all burn injuries. In one study of patients sustaining significant facial burns, 42 percent suffered burns to the ears. 26 Direct thermal burns may be severe enough to cause necrosis and sloughing of the entire external ear. Even with lesser injury, disruption of the auricular skin can lead to damage of the underlying cartilage, which, once damaged, is particularly susceptible to infection. Factors that affect the healing of burn injuries include the depth of the burn, development of infection, and external pressure or friction on the burned auricle.23 Otochondritis is a potentially disfiguring complication of otic burns. Chondritis may occur in up to 20 percent of significant otic burns and may appear anywhere from 2 to 5 weeks after the injury. The hallmarks of chondritis consist of helical dull pain followed by erythema, edema, exquisite tenderness to palpation, and an increase in the auriculocephalic angle (lateral protrusion of the ear from the head). 26 Once chondritis is present, treatment must be aggressive to preserve ear architecture; it usually consists of surgical debridement. Systemic antibiotics alone are generally considered ineffective.

First-degree burns involve only the superficial layers. Vascular congestion and dilation occur in the intradermal vessels. First-degree burns can be gently cleaned, and the patient can be discharged with mild analgesics as needed. Second-degree burns exhibit destruction of varying depths of epidermis, with coagulation necrosis. Third-degree burns involve destruction of all skin elements with coagulation of the subdermal plexus.

Burns more severe than first-degree should be seen in consultation with a burn unit or an otolaryngologist. If the burn is an isolated injury and a mild second-degree type, treatment in the emergency department should consist of meticulous cleaning and irrigation with normal saline, application of a non-sulfa-containing antimicrobial ointment, and a nonpressure dressing. Silvasulfadiazine ointment can cause skin pigmentation changes and should not be used above the clavicles. Referral should be made within 24 h. Substantial second-degree burns with blistering or any third-degree burns should be referred to a burn center for further management.

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