SHORT REPORT

Management of firecracker induced oropharyngeal burns:A case report

NICOLA A. CLAYTON & PETER J. KENNEDY

Burns Unit, Concord Repatriation General Hospital, Concord, NSW, Australia

AbstractBurn injuries as a result of inhalation or ingestion have been reported to cause a number of long-term complicationsincluding oral contracture. Circumoral contracture may result in microstomia and subsequently manifest as difficulties withcommunication, swallowing, intubation, oral and dental hygiene. This case study describes a young woman that presentedwith severe burns of the oropharynx following insertion of a Roman Candle firecracker into her mouth, in an attemptedsuicide. A multidisciplinary team approach was utilised to facilitate the patient’s recovery with considerable involvement ofthe psychiatrist, dietician and speech pathologist. Meticulous oral hygiene was imperative in facilitating wound healingalthough minimal pain relief was required. In view of the depth and extent of burn injury, the patient was considered to be athigh risk of developing oral contractures. Long-term goals of contracture management were to: (1) prevent the developmentof oral contractures, including microstomia and velopharyngeal insufficiency (VPI), and (2) eliminate the need forreconstructive surgery. Intervention consisted of a rigorous splinting and exercise regime to preclude microstomiadevelopment. At 6 months post-injury, the patient’s outcomes continue to be positive, with no loss in range of movement tothe lips, buccal mucosa and soft palate. Other focuses of intervention discussed include the management of oral dysphagia,odynophagia, dysphonia and hypogeusia.

Keywords: Oropharyngeal burns, microstomia, contracture, intervention.

Introduction

Severe burns to the lips, oral cavity, pharynx and

larynx may occur as a result of three main causative

factors: thermal injury including inhalation of hot air

or gases, electrical injury, and ingestion of hot

substances or caustic agents. A severe burn injury is

regarded as the most serious form of all traumas and

has a significant mortality and morbidity. It is

accompanied by fluid loss and shock and is char-

acterised by a profound hypermetabolic response as

well as depressed immunity (Herndon, 2002). The

metabolic sequelae may result in considerable weight

loss which may not be reversed until well after healing

is complete. Evidence of depressed immunity be-

comes apparent as following a burn injury, the wound

is rapidly colonised by micro-organisms and septic

complications may ensue. Prolonged healing time

occurs in deep dermal or full thickness burns when the

epidermis and dermal structure are destroyed or

injured, and is accompanied by both cosmetic and

functional impairment as a result of contraction of the

healing wound. Scarring and pigmentary changes are

common if healing time exceeds 3 weeks (Herndon,

2002). Inhalational and ingestional injuries have

also been reported to cause a number of long-term

complications. Oral contractures, pharyngeal, laryn-

geal and tracheal stenoses, and cricoarytenoid hetero-

topic ossification are some of the sequelae that

may occur post-inhalational injury, as reported by

Shikowitz, Levy, Villano, Graver and Pochaczevsky

(1996) and Flexon, Cheney, Montgomery and Turner

(1989). A number of other authors confirm and

describe these findings in further detail (Heinle,

Kealey, Cram, & Hartford, 1988; Lippin et al.,

1994; Meredith, Kon, & Thompson, 1988; Scott,

Jones, Eisele, & Ravich, 1992; Silverglade & Ruberg,

1986; Taylor & Walker, 1997).

Complications as a result of inhalation or ingestion

injury may also manifest in secondary sequelae.

These include difficult intubation, communication

impairment, poor oral hygiene and disorders of

swallowing. Intubation may be challenging due to a

number of reasons: restricted mouth opening as a

result of microstomia (Daugherty & Carr-Collins,

1994), reduced upper airway patency due to

Correspondence: Nicola A. Clayton, Burns Unit, Concord Repatriation General Hospital, Hospital Rd Concord NSW 2139, Australia. Tel: þ61 2 9767 7449.

Fax: þ61-2-9767 8431. E-mail: nicola.clayton@email.cs.nsw.gov.au

Advances in Speech–Language Pathology, September 2007; 9(3): 265 – 270

ISSN 1441-7049 print/ISSN 1742-9528 online ª The Speech Pathology Association of Australia Limited

Published by Informa UK Ltd.

DOI: 10.1080/14417040701302576

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heterotopic ossification of the crico-arytenoid joints

(Lippin et al., 1988) and glottic or subglottic stenosis

(Flexon et al., 1989). Communication is affected, as

articulating labial speech sounds and use of facial

expression to convey supra-segmental aspects of

conversation may be impaired (Shikowitz et al.,

1996; Silverglade & Ruberg, 1986; Wust, 2006).

Oral hygiene is also compromised as access to the

oral cavity and dentition is impeded (Bahnof, 2000;

Macmillan, Oliver, Richardson, & Reade, 1991;

Taylor & Walker, 1997). Swallowing disorders

following inhalational burn injury manifest as poor

lip seal, poor mouth opening and restricted buccal

movement affecting the oral phase of swallow

function (Casper, Clark, Kelley, & Colton, 2002;

Heinle et al., 1988; McKinnon DuBose, Groher,

Carnaby Mann, & Mozingo, 2005; Shikowitz et al.,

1996). Many other studies have also verified these

findings (Clark & McDade, 1980; Dougherty &

Warden, 2003; Gaissert, Lofgren, & Grillo, 1993;

Hashem & Al Kayal, 2003; Ridgway & Warden,

1995; Scott et al., 1992; Ward, Uriate, & Conroy,

2001).

There are several approaches to treating oral

contractures discussed within the literature (Bahnof,

2000; Clark & McDade, 1980; Daugherty &

Carr-Collins, 1994; Dougherty & Warden, 2003;

Heinle et al., 1988; Macmillan et al., 1991; Ridgway

& Warden, 1995; Silverglade & Ruberg, 1986; Sykes,

1996). These include surgery, active and passive

stretches, and the use of traction appliances. More

recently, Barone, Hulnick, Grigsby de Linde, Bush

Sauer and Mitra (1994) and Fraulin, Illmayer and

Tredget (1996) have suggested that non-surgical

methods such as exercise and splinting may poten-

tially have more positive aesthetic as well as func-

tional outcomes for the patient.

This case study describes the physical rehabilita-

tion of a patient with self-inflicted deep partial and

full thickness thermal burns to the oropharynx with

specific focus on contracture management. The

depth of burn injury and duration of wound healing

placed the patient at high risk of developing

contractures of the lips and soft palate.

Case history

A 31-year-old female was referred from a rural

hospital with self-inflicted thermal burns to the

oropharynx. She had attempted suicide by lighting

a Roman Candle firecracker and inserting it into her

mouth but removed the firecracker prior to explosion

and subsequently presented to hospital. She had a

past medical history of Bipolar Affective Disorder

and had recently reduced her medications. The

patient had reportedly not shown any signs of airway

compromise: absence of wheeze and stridor, normal

respiratory rate and 97% oxygen saturation. For

these reasons, she was not prophylactically intubated

prior to transfer. Upon arrival at the burns unit,

burns team medical staff diagnosed deep partial and

full thickness burns to the lips, tongue, hard palate,

soft palate, uvula, buccal mucosa, gingiva and

posterior pharyngeal wall (see Figures 1 and 2).

Referrals were made to the multidisciplinary team

including the psychiatrist for mental health evalua-

tion and the speech pathologist for communication

and swallowing assessment.

The psychiatrist confirmed the patient’s mental

health diagnosis as Bipolar Affective Disorder, with a

current episode of severe depression and suicidal

behaviour. It was also identified that the patient’s

Olanzapine medication had recently been reduced

from 10 mg to 5 mg. The psychiatrist determined

that the current medication regime was inadequate to

manage the patient’s present psychiatric state, com-

mencing the patient on Lithium, Temazepam and

Cipramil in addition to continuing the Olanzapine.

Speech pathology initial assessment involved

visual examination of the oromusculature, cranial

nerve assessment, perceptual evaluation of voice

quality and swallowing assessment. Oromusculature

examination revealed a charred appearance of the

Figure 2. Hard palate burns on admission.

Figure 1. Lip and tongue burns on admission.

266 N. A. Clayton & P. J. Kennedy

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hard palate, soft palate, buccal mucosa, gingiva,

superior and anterior surfaces of the tongue and inner

aspect of the lips. The posterior pharyngeal wall could

not be visualized due to tongue base oedema. There

was reasonable range of movement (ROM) of the jaw

and lips, reduced soft palate elevation, mild facial

swelling, reported sensation of mild ‘‘tightness’’

around the mouth and surprisingly complete absence

of pain. ROM on mouth opening was measured as

42 mm vertically (from inner aspects of upper and

lower lips), and 55 m horizontally.

The patient’s voice was mildly dysphonic and

characterized by a slightly hoarse vocal quality on

initial assessment which resolved by day 2 post-

injury. The patient’s oral and pharyngeal phases of

swallow function were evaluated to be essentially

within normal limits on bedside clinical examination,

and the patient denied any presence of odynophagia.

In view of the reported lack of pain on swallowing,

the patient was considered to potentially have

disorders of sensation and taste and these were

assessed later in the patient’s admission. Thin fluids

and a puree diet were initially recommended. More

solid food was not suggested in view of the likely

abrasive nature upon the oral wounds. Saline

mouthwashes were also prescribed prior to and after

oral intake in the effort to minimize wound

contamination and infection.

A nasendoscopy by an ear, nose and throat

surgeon was performed which revealed full thickness

burns to the posterior as well as anterior surface of

the soft palate, deep partial thickness burns to the

upper portion of the posterior pharyngeal wall and

tip of the epiglottis. The larynx was spared from burn

injury; the vocal cords being assessed as fully

functional with a patent airway.

Dietetics assessment indicated that the patient was

at low risk of re-feeding syndrome given the short

period of fasting, but at risk of malnutrition should

reduced oral intake secondary to pain become an

issue. The patient was educated regarding the

importance of nutrition in the process of wound

healing, and the dietician agreed with recommenda-

tions for diet and fluids as specified by the speech

pathologist. Food charts were implemented to

monitor the amount of oral intake consumed.

The patient tolerated the prescribed diet and fluids

without complications. She complained of slight

odynophagia on day 1 post-injury but stated that it

was not significant to reduce oral intake. The patient

reported that there was also very little irritation to the

oral wounds caused by mastication of food sub-

stances. The patient was subsequently upgraded to a

soft diet, followed by progression to a full diet by day

4. Amount of oral intake consumed was monitored

by food charts and remained adequate at all times.

A perceptual assessment of taste was conducted on

day 6 post-burn. This was performed by administra-

tion of small amounts (2 – 3 ml) of equally concen-

trated flavoured liquid (sweet, sour, bitter and salty)

onto the patient’s tongue, and the patient being

asked to identify the flavour that had been adminis-

tered. Flavours were presented in a random order,

with oral rinses of water between presentations to

remove any residue from the previous flavour. The

patient was found to have intact taste discrimination,

but described mild hypogeusia (reduced taste) for all

four flavours. She reported that this had been

affecting her appetite, but not her ability to consume

adequate amounts of oral intake. The patient

reported that her symptoms of hypogeusia had

resolved by the time of discharge.

At day 7 post-injury, it was noted that burns to the

hard palate had progressed through to bone once the

necrotic tissue had separated from the hard palate.

Wound management consisted of a rigorous mouth

care regime, involving the use of Toothette1 swabs

to clean and debride the oral wounds, saline

mouthwash and application of paraffin to the lips.

This regime was performed independently by the

patient and continued through to day 49 post-burn

injury. Complete wound healing occurred at ap-

proximately 5 weeks from time of injury.

Odynophagia became an increasing concern as the

oral wounds were observed to slough and demarcate.

At day 7 post-injury, the speech pathologist recom-

mended an oral rinse of Xylocaine Viscous prior to

meals to alleviate odynophagia. This was recom-

mended only in view of intact pharyngeal swallow

function so as not to increase the risk of aspiration.

On subsequent reviews, the patient reported to be

using the Xylocaine Viscous with very good effect,

continuing use until day 13, when odynophagia had

resolved and she was discharged from the burns unit

to a psychiatric hospital.

The patient was considered to be at risk of

developing contractures due to the severity of burn

injury. The burn surgeon prognosed that based on

clinical assessment, healing time for this patient’s

burn wounds would exceed 3 weeks, subsequently

placing the patient at high risk of developing scar

tissue and contractures. An active ROM exercise

programme (Edgar & Brereton, 2004) was com-

menced on day 1 post-injury; stretching exercises

targeted the lips, cheeks and soft palate, performed 5

times daily. The primary objectives of treatment were

to prevent: (1) contracture of the soft palate resulting

in velopharyngeal insufficiency (VPI) and (2) con-

tracture of the lips resulting in microstomia.

Further education regarding the risk of developing

oral contractures was conducted with the aid of

photos on day 6. This was followed by introduction

of the Free Access II Cheek Retractor1 mouth splint

(see Figure 3). The mouth splint was used prophy-

lactically to minimize the development of micro-

stomia and applied for a 1-hour period twice daily,

with paraffin applied to the device and patient’s lips

prior to insertion to facilitate tissue stretching and

comfort. The patient was able to independently

assemble, insert and remove the splint, and adhered

Firecracker induced oropharyngeal burns 267

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diligently to the prescribed splinting regime. The

Free Access II Cheek Retractor1 mouth splint was

selected in view of its ability to provide a circumoral

stretch, as opposed to a vertical or horizontal stretch

alone as several other mouth splints provide,

although it has not yet been evaluated with respect

to its efficacy in preventing microstomia.

Application of the mouth splint twice daily as well

as the Active ROM exercise regime was continued

throughout the patient’s admission and post-dis-

charge to the psychiatric hospital. At day 28, the

patient was reviewed and recommended to continue

application of the mouth splint twice daily. At this

time she reported some persistent oral tightness in

the morning that was relieved by use of the splint as

well as the Active ROM exercises. Mouth opening

measures were taken indicating that vertical ROM

had improved to 50 mm and horizontal ROM to

66 mm. Minor wounds were still evident at the

lateral commissures of the oral cavity and on the hard

palate. At day 49, all wounds were completely healed

and the patient no longer reported sensation of oral

tightness upon waking in the morning. Further

progress had been made in increasing mouth open-

ing ability. The patient’s vertical ROM was measured

at 58 mm and horizontal ROM at 74 mm. The

mouth splint regime was subsequently reduced to a

one-hour period once daily and active ROM

exercises were continued.

As the patient continued to report no deterioration

in oral ROM, the mouth splint regime was system-

atically reduced and Active ROM exercises were

ceased at days 56 and 63 respectively. The mouth

splint regime was terminated at day 71, and at day

178 (exactly 6 months from the day of injury) the

patient continued to maintain adequate oral ROM

(vertical ROM¼ 58 mm, horizontal ROM¼ 75 mm)

and deny symptoms of VPI. Throughout the patient’s

burns unit admission as well as up to 6 months post-

discharge, there was no evidence of velopharyngeal

insufficiency and the patient maintained full ROM of

the cheeks and lips (see Figures 4 and 5).

Discussion

Oral contractures that occur as a result of severe burn

injury resulting in microstomia may have serious

adverse effects upon a patient’s ability to perform

activities of daily living. These include difficulties

with feeding, brushing teeth, and communication via

speech and facial expression. Several authors have

described how microstomia may affect intubation,

oral hygiene, swallowing and communication

(Bahnof, 2000; Clark et al., 1980; Dougherty et al.,

2003; Heinle et al., 1988; Johnson et al., 1992;

Macmillan et al., 1991; Shikowitz et al., 1996).

Oral intubation may prove challenging in the

patient with microstomia, often necessitating intuba-

tion via the nasal route so that ventilation can be

achieved (Clark & McDade, 1980; Ridgway &

Warden, 1995). The effect of microstomia on oral

hygiene is such that accessibility to the oral cavity is

reduced. This has implications for oral and dental

care, dental extraction and fabrication of dental

prostheses (Bahnof, 2000; Clark & McDade, 1980;

Dougherty & Warden, 2003; Heinle et al., 1988;

Macmillan et al., 1991; Ridgway & Warden, 1995;

Taylor & Walker, 1997). Implications for swallow

function in the patient with oral contractures include

the inability to take larger boluses of food or fluid and

impaired utensil access to the mouth, as the mouth

Figure 5. Horizontal ROM at conclusion of therapy.

Figure 4. Vertical ROM at conclusion of therapy.

Figure 3. Free Access II Cheek Retractor1 Mouth Splint in situ.

268 N. A. Clayton & P. J. Kennedy

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cannot be opened sufficiently (Heinle et al., 1988;

McKinnon DuBose et al., 2005; Shikowitz et al.,

1996). It may be postulated that severe microstomia

could potentially place a patient at risk of malnutri-

tion, as achieving adequate oral intake may become a

challenge. Communication disorders can also result

from microstomia. Facial expression is a key

component in facilitating the exchange of supraseg-

mental aspects of communication, which includes

the illustration of a wide range of emotions. Oral

contractures may inhibit or reduce facial expression,

as the face with scar tissue is insufficiently mobile

(Dougherty & Warden, 2003; Hashem & Al Kayal,

2003; Heinle et al., 1988; Macmillan et al., 1991;

Shikowitz et al., 1996; Silverglade & Ruberg, 1986;

Wust, 2006).

In the present case, the patient’s protracted healing

time predicted that she would be at high risk of

developing oral contractures. With implementation

of the Free Access II Cheek Retractor1 mouth splint

and rigorous active range of movement exercise

regime, the patient demonstrated progressive im-

provement throughout her rehabilitation, gaining

16 mm in vertical mouth opening and 20 mm in

horizontal mouth opening. As a result of her gains,

the patient did not exhibit any of the sequelae

described above that may manifest from oral con-

tractures. The patient’s improvement and mainte-

nance of range of movement supports the efficacy in

utilizing the described treatment regime. While there

is no documented case of severe burns to the soft

palate resulting in contracture, it may be hypothe-

sized that contracture could potentially occur result-

ing in velopharyngeal insufficiency (VPI) if burn

wound healing is considerably protracted. VPI

manifests as nasopharyngeal penetration or regurgi-

tation during oral intake, and may also cause

hypernasal speech and limit a patient’s ability to

achieve ranges of high vocal intensity. Again in the

present case study, prolonged healing time placed the

patient at high risk of developing contractures of the

soft palate. Exercise of the soft palate was employed

to maintain the flexibility of this tissue and the fact

that this patient did not develop symptoms of

velopharyngeal insufficiency as a result of soft palate

contracture substantiates the treatment regime used.

It is critical that contracture management is

commenced prior to the development of scar tissue.

As scar tissue lacks elastin, the flexible characteristic

of normal tissue, it is much more difficult to regain

adequate range of movement once scar tissue has

formed. Exercise and splinting assists in maintaining

a patient’s range of movement to a particular joint or

region of high movement as the burn wound heals.

For these reasons, contracture management should

commence as soon as possible in the event of deep

dermal or full thickness burn injury (Daugherty &

Carr-Collins, 1994).

There is currently no literature available regarding

the management of odynophagia in patients with

oropharyngeal burns. Burn injury frequently results

in hypermetabolism and weight loss, and sufficient

oral intake is essential in facilitating wound healing.

Odynophagia is often correlated with reduced oral

intake, which can cause problems for the patient with

oropharyngeal burns. While the use of Xylocaine

Viscous appeared to be effective in this case, it is

acknowledged that the use of topical anaesthesia may

have adverse effects upon swallow function and

therefore warrants careful consideration before re-

commendation and use. The use of topical anaes-

thesia in the treatment of odynophagia and

facilitating nutritional intake warrants further inves-

tigation. There is also no literature presently

accessible on the effect of oropharyngeal thermal

burns on taste sensation. While taste buds have been

suggested to regenerate within 10 days post-insult

(Hutchins, 2001), it would be interesting to evaluate

if this varies in the oropharyngeal thermal burn

patient. It is recognized that the method of taste

assessment within this case study was perceptual;

however, it did appear to yield the results required.

A more rigorous and objective assessment of taste

sensation is suggested for future studies.

This paper highlights the importance of timely

intervention in the management of dysphagia, ody-

nophagia and oral contracture post-oropharyngeal

burn injury in facilitating optimal patient outcomes.

While dysphagia and odynophagia may be rehabili-

tated relatively promptly, contracture management is

a much lengthier process as scar issue takes months to

stabilize. It is well documented that early intervention

is paramount to prevent the development of scar

tissue and contractures (Daugherty & Carr-Collins,

1994, Edgar & Brereton, 2004). A regime combining

the use of splints and exercise has been suggested to

result in optimal outcomes when compared to

surgical techniques or no intervention at all (Barone,

Hulnick, Grigsby de Linde, Bush Sauer, & Mitra,

1994; Fraulin et al., 1996). The contracture manage-

ment regime implemented in this case study also

utilized a combination of exercise and splinting. The

favourable results were attributed to holistic approach

by the multidisciplinary team, early rigorous inter-

vention as well as the patient’s commitment to the

prescribed orofacial therapy regime.

References

Bahnof, R. (2000). Intra-oral burns: Rehabilitation of severe

restriction of mouth opening. Physiotherapy, 86, 263 – 266.

Barone, C. M., Hulnick, S. J., Grigsby de Linde, L., Bush Sauer,

J., & Mitra, A. (1994). Evaluation of treatment modalities in

perioral electrical burns. Journal of Burn Care and Rehabilita-

tion, 15, 335 – 340.

Casper, J., Clark, W. R., Kelley, R. T., & Colton, R. H. (2002).

Laryngeal and phonatory status after burn/inhalation injury: A

long term follow-up study. Journal of Burn Care and Rehabilita-

tion, 23, 4, 235 – 243.

Clark, W. R., & McDade, G. O. (1980). Microstomia in burn vic-

tims: A new appliance for prevention and treatment and litera-

ture review. Journal of Burn Care and Rehabilitation, 1, 33 – 36.

Firecracker induced oropharyngeal burns 269

Int J

Spe

ech

Lan

g Pa

thol

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Uni

vers

ity o

f C

onne

ctic

ut o

n 10

/29/

14Fo

r pe

rson

al u

se o

nly.

Daugherty, M. B., & Carr-Collins, J. A. (1994). Splinting

techniques for the burn patient. In R. L. Richard &

M. J. Staley (Eds.), Burn care and rehabilitation: Principles and

practice. Philadelphia, PA: F. A. Davis Company.

Dougherty, M. E., & Warden, G. D. (2003). A 30-year review of

oral appliances used to manage microstomia, 1972 – 2002.

Journal of Burn Care and Rehabilitation, 24, 418 – 431.

Edgar, D., & Brereton, M. (2004). Rehabilitation after burn

injury. British Medical Journal, 329, 343 – 345.

Flexon, P. B., Cheney, M. L., Montgomery, W. W., & Turner

P. A. (1989). Management of patients with glottic and

subglottic stenosis resulting from thermal burns. Annals of

Otology Rhinology Laryngology, 98, 27 – 30.

Fraulin, F. O. G., Illmayer, S. J., & Tredget, E. E. (1996).

Assessment of cosmetic and functional results of conservative

versus surgical management of facial burns. Journal of Burn

Care and Rehabilitation, 17, 19 – 29.

Gaissert, H. A., Lofgren, R. H., & Grillo, H. C. (1993). Upper

airway compromise after inhalation injury; complex strictures

of the larynx and trachea and their management. Annals of

Surgery, 218, 672 – 678.

Hashem, F. K., & Al Kayal, Z. (2003). Oral burn contractures in

children. Annals of Plastic Surgery, 51, 468 – 471.

Heinle, J. A., Kealey, G. P., Cram, A. E., & Hartford, C. E. (1988).

The microstomia prevention appliance: 14 years of clinical

experience. Journal of Burn Care and Rehabilitation, 9, 90 – 91.

Herndon, D. (Ed.) (2002). Total burn care (2nd ed.). Oxford: WB

Saunders, Harcourt Publishers Ltd.

Hutchins, M. (2001). Integrative oral sciences 1507: chemical sensory

system functions. Health Science Center at Houston, The

University of Texas. Accessed 15 February, 2007, available

at: http://www.uth.tmc.edu/courses/dental/smell-taste/

taste.html

Lippin, Y., Shvoron, A., Faibel, M., & Tsur, H. (1994). Vocal

cords dysfunction resulting from heterotopic ossification in a

patient with burns. Journal of Burn Care and Rehabilitation, 15,

169 – 173.

Johnson, J., Candia, J., La Trenta, G., Madden, M. R.,

Goodwin, C. W., & Finkelstein, J. (1992). A nasal trumpet

orthosis to maintain nares openings and respiratory function

for patients with facial burns: a case report. Journal of Burn Care

and Rehabilitation, 13, 677 – 679.

Macmillan, A. R. G., Oliver, A. J., Richardson, L., & Reade, P. C.

(1991). An intraoral splint for the prevention of microstomia

from facial burns. Burns, 17, 72 – 74.

McKinnon DuBose, C., Groher, M. G., Carnaby Mann, G., &

Mozingo, D. (2005). Pattern of dysphagia recovery after

thermal burn injury. Journal of Burn Care and Rehabilitation,

26, 233 – 237.

Meredith, J. W., Kon, N. D., & Thompson, J. N. (1988).

Management of injuries from liquid lye ingestion. The Journal

of Trauma, 28, 1173 – 1180.

Ridgway, C. L., & Warden, G. D. (1995). Evaluation of a vertical

mouth stretching orthosis: two case reports. Journal of Burn

Care and Rehabilitation, 16, 74 – 78.

Scott, J. C., Jones, B., Eisele, D. W., & Ravich, W. J. (1992).

Caustic ingestion of the upper aerodigestive tract. Laryngoscope,

102, 1 – 8.

Shikowitz, M. J., Levy, J., Villano, D., Graver, M., &

Pochaczevsky, R. (1996). Speech and swallowing rehabilitation

following devastating caustic ingestion: Techniques and

indicators for success. Laryngoscope, 106, 1 – 5.

Silverglade, D., & Ruberg, R. L. (1986). Non-surgical manage-

ment of burns to the lips and commissures. Advances in Burn

Care, 13, 87 – 94.

Sykes, L. (1996). Scar traction appliance for a patient with

microstomia: A clinical report. The Journal of Prosthetic

Dentistry, 76, 464 – 465.

Taylor, L. B., & Walker, J. (1997). A review of selected

microstomia prevention appliances. Pediatric Dentistry, 19,

413 – 418.

Ward, E. C., Uriarte, M., & Conroy, A. L. (2001). Duration of

dysphagic symptoms and swallowing outcomes after thermal

burn injury. Journal of Burn Care and Rehabilitation, 222, 441 –

453.

Wust, K. J. (2006). A modified dynamic mouth splint for burn

patients. Journal of Burn Care and Research, 1, 86 – 92.

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