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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 25  |  Issue : 3  |  Page : 127-134

Suction-assisted device: A substitute to postoperative packing of abscess cavity in patients with ear burns


1 Department of Plastic Surgery and Burns, Kasturba Hospital Affiliated to Topiwala National Medical College and B.Y.L. Nair Charitable Hospital, Mumbai, Maharashtra, India
2 Department of Plastic Surgery, Topiwala National Medical College and B.Y.L. Nair Charitable Hospital, Mumbai, Maharashtra, India
3 Department of ENT, Government Hospital, Marwad, Daman, India

Date of Submission23-Sep-2018
Date of Acceptance29-Jan-2019
Date of Web Publication18-Oct-2019

Correspondence Address:
Dr. Amit R Peswani
Department of Plastic Surgery, Second Floor, College Building, Topiwala National Medical College and B.Y.L. Nair Charitable Hospital, Mumbai - 400 008, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/indianjotol.INDIANJOTOL_81_18

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  Abstract 


Background: Ear burns abscesses managed by incision and drainage and daily packing cause significant pain. The management of ear burns abscess involves avoiding pressure on the ear and ensuring collapse of the dead space. To achieve this and a pain-free recovery, we used a technique – suction-assisted device (SAD). Methods: SAD technique was used in patients with an undamaged abscess cavity (cases). Patients who did not consent to use of SAD or with burst abscesses or exposed cartilages were managed by I and D (controls). The SAD was made from: (1) 10 ml syringe, (2) 5 ml plunger, and (3) 8 Fr infant feeding tube. In both groups, the VAS was documented daily. The mean VAS and the treatment-time were compared between cases and controls. Results: The mean VAS and treatment time were significantly lower with SAD (P < 0.001). Conclusion: SAD has some distinct advantages over the standard dressing and was accepted by patients.

Keywords: Ear abscess, ear burns, suction-assisted dressing


How to cite this article:
Chalwade C, Peswani AR, Patil D, Baliarsing A. Suction-assisted device: A substitute to postoperative packing of abscess cavity in patients with ear burns. Indian J Otol 2019;25:127-34

How to cite this URL:
Chalwade C, Peswani AR, Patil D, Baliarsing A. Suction-assisted device: A substitute to postoperative packing of abscess cavity in patients with ear burns. Indian J Otol [serial online] 2019 [cited 2019 Nov 12];25:127-34. Available from: http://www.indianjotol.org/text.asp?2019/25/3/127/269556




  Introduction Top


The management of ear burns is challenging as it involves not just skin and soft tissue but cartilage as well. The anatomical peculiarity of the external ear makes it vulnerable to thermal burns.[1] However, burns of the ear are very rarely isolated. They are usually associated with facial burns and may be associated with other body parts burns as well. Considering the nonisolated nature of ear burns and overall severity of patient's general condition, the management of ear burns often takes a backseat and gets less importance in the initial period. However, the body retaliates in the form of chondritis or an abscess [Figure 1], thus leading to significant morbidity as it acts a focus of excruciating pain and suffering for the patient.
Figure 1: Formed right ear abscess

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The standard way of managing a burns abscess in the ear is incision and drainage followed by daily packing. However, packing of the ear causes significant pain to the patient who is already going through a lot of physical and mental trauma. Hence, the management in the acute phase should not just focus on removing the nociceptive stimulus by draining the abscess but also attenuation of the pain that follows with dressing in the postoperative period. Any modification from current standards which keeps the “iatrogenic” pain to the minimum is desirable in the management of burns. Chondritis of the ear is better prevented than treated.[1] However, it is also important to halt the progress of chondritis. Pressure is the biggest cofactor in the production of chondritis.[2] And so, the management of ear burns abscess is a constant battle between avoiding pressure on the ear and ensuring collapse of the dead space. To tackle this unique problem and to achieve a pain-free recovery phase, we used a novel technique by assembling a suction-assisted device (SAD) to prevent refill of the dead space without applying external pressure.

Aims and objectives

The aim of the study is to assess the efficacy of the designed SAD in evacuating purulent discharge. Another aim was to quantify the patient response to pain by documenting the decrease in pain score as indicated by visual analog score (VAS). However, the ultimate goal was to lessen the suffering of the patients and to ensure a pain-free recovery period post ear abscess drainage. Hence, the prime emphasis was on curtailing the number of dressing changes and associated packing of cavities.


  Materials and Methods Top


The study was conducted in the burns department affiliated to a tertiary care center over a period of 1 year. Informed consent was obtained from all patients. The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional guidelines on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. Patients with ear abscesses following burns were included in the study and divided into two groups of 15 each. Those with a well-formed abscess were grouped as “cases,” and the SAD technique was used in them. The prerequisite for the use of this method was the presence of an undamaged abscess cavity. Those patients who did not consent to use of SAD or with burst abscesses or exposed cartilages were included in the second group [Figure 2]. These were managed in the standard way by daily packing of cavity.
Figure 2: Patient with exposed ear cartilage. Hence, included in the “controls” group

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To assess the pain severity, we used the VAS. In both groups, the VAS was documented daily. The mean VAS was compared between cases and controls.

Children under the age of 12 years and mentally unstable patients were excluded as it would be difficult for them to take care of the apparatus. Patient with severe systemic compromise and altered mentation were not included in the study as it would be not possible to take a feedback on pain.

The apparatus consisted of readily available daily use material from the ward.

  1. 10 ml syringe
  2. 5 ml syringe plunger
  3. 8 Fr infant feeding tube [Figure 3].
Figure 3: “Raw material” required for assembling the suction apparatus

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Technique used in cases group (suction-assisted device)

The diagnosis of an evolved abscess was confirmed by clinical signs of tenderness, warmth, and fluctuation. The procedure was explained to the patient in detail. The suction apparatus was the assembled using the above-mentioned raw materials. The terminal part of the feeding tube having the “female luer mount” was used. An appropriate length (approximately 15 cm) from the end was cut and the rest of the tube discarded [Figure 4]. New fenestrations (1 or 2) were created subterminally in the usable length of the tube. The tube length was customized for each patient depending on the depth of the cavity and the patient's comfort with the length outside the ear which determined the position of the syringe. A 10 ml syringe was then connected, and negative pressure was created by pulling the plunger. To maintain the suction effect, a plunger of another 5 ml syringe was aligned and placed parallel to the 10 ml syringe plunger. Care was taken to ensure the 5 ml plunger fits snugly between the 10 ml barrel flange and the plunger flange. The two plungers were held in position using adhesive paper tape [Figure 5]. The final ready to use assembly is shown in [Figure 6]. Under all aseptic precautions, the ear was anesthetized using a field block. A small stab incision was taken at the summit of the distorted helix. Pus swab was taken for culture and sensitivity. The pus was drained. The cavity was irrigated with normal saline. A small scoop was used to curette out the affected cartilage [Figure 7].
Figure 4: Approximately terminal 15 cm of the infant feeding tube at the syringe luer end is used. The length can vary as per patients' preference

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Figure 5: The suction effect is maintained by snugly placing a plunger of a 5 ml syringe parallel to the native plunger of 10 ml syringe. Paper adhesive tape is used to wrap around the two plungers to keep them secure between the barrel flange and plunger flange of 10 ml syringe

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Figure 6: The final assembly of suction apparatus

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Figure 7: Scooping of infected cartilage from abscess cavity

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The feeding tube segment of the SAD was then introduced into the cavity, ensuring all the fenestrations are inside. Approximate depth of the cavity was 1.5–2 cm in our series. The tube was then sutured and fixed to the skin at the site of incision. The external part of tube is sutured above the ear [Figure 8]. The syringe connected to the luer port was then sutured behind the ear or in front of it as per patient's choice [Figure 9]. The tubing was covered with a mastoid dressing while the syringe was kept exposed or covered with a transparent film dressing [Figure 10]. The drain output was measured daily and documented [Figure 11]. The cavity was flushed with normal saline every day and the suction effect recreated. The apparatus was removed after the drain output was minimal. VAS score was documented daily. After the use of SAD was discontinued, the patient was advised to use a conforming external dressing with gauze and paper tape or silicon sheet for 1 week. This helped to prevent refill of cavity.
Figure 8: The external part of tube fixed above the ear with sutures

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Figure 9: The syringe has been secured anterior to the ear as per patient's choice. Alternatively, it may be sutured posterior to the ear

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Figure 10: A mastoid dressing is given taking care to keep the syringe under vision. Alternatively, a transparent film dressing may be given for the syringe

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Figure 11: The discharge output is measured

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Technique used in control group

The abscesses were drained using adequately long incisions under field block. Debridement of infected cartilage was done. The cavity was irrigated with normal saline. The cavity was packed with gauze roller pack with povidone-iodine solution. In patients with a burst abscess, the cavity was scooped and packing was done.


  Results and Analysis Top


Details of the patients in the cases group study are tabulated in [Table 1]. Six males and 9 females were included in the cases group. The mean age of patients in the study was 35.06 years. The maximum VAS score preoperatively was 10 while the minimum score was 6. Postoperatively on day 1, the minimum VAS score was 0 and maximum was 3. The number of the days, the apparatus was kept in situ varied from 3 to 7. The mean period was 5.26 days. The maximum mean VAS score 3.25 was and the minimum VAS score was 0.
Table 1: Details of patients managed by suction-assisted device

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[Figure 12]a shows a 33-year-old female with right ear abscess with a VAS pain score of 8. The abscess was drained and the suction apparatus connected as described above. Pus swab was sent for culture and sensitivity and the organism found was Pseudomonas aeruginosa. She was treated concomitantly with intravenous antibiotics. [Figure 12]b shows postoperative picture on day 5 with considerably better appearance of the ear. The parameters of pain assessment showed a significant improvement from 8 to 3. As the patient was not subjected to the trauma of daily dressings and packing of cavity, the overall compliance of the patient was good.
Figure 12: (a) Preoperative view of post burns abscess of the right ear. (b) Postoperative view of post burns abscess of the right ear

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As shown in [Figure 13]a, a 48-year-old man who had sustained deep partial-thickness flash burns of the right side of his face and both arms caused by flames. The patient had been previously hospitalized for 20 days for systemic care and general wound management. The burn wounds on the body had healed, but he developed an abscess in the right ear after 1 month. The abscess was drained under ear block, the infected cavity was scooped, and the SAD was applied. He was managed as domiciliary care. The drain had to be kept in situ for 7 days [Figure 13]b. At 1-month postprocedure, there was no acute signs of inflammation. However, some residual deformity due to loss of cartilage was seen in [Figure 13]c. [Figure 14] shows pictures of the same patient at different stages in lateral view. The pain score had reduced from 7 to 1.
Figure 13: (a) Preoperative oblique view of burns abscess of the right ear. (b) With suction-assisted device in situ on day 3. (c) Postoperative view at 1 month of postburns abscess of the right ear

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Figure 14: (a) Preoperative lateral view of post burns abscess of the right ear. (b) Postsuction-assisted device removal lateral view on day 7. (c) Postoperative view at 1 month of post burns abscess of the right ear

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A 24 year old man with right ear abscess [Figure 15]a was managed with the use of SAD for 5 days [Figure 15]b. The mean VAS score was 1.5 and subjectively patient was satisfied with the treatment. [Figure 15]c and [Figure 15]d shows delayed postprocedure photographs taken at 1 month and 3 months, respectively.
Figure 15: (a) Right ear abscess, (b) Covered in a mastoid dressing and the syringe kept exposed such that the exudate is under vision. (c) Postoperative photograph at 4 weeks after removal of suction-assisted device. (d) Appearance of the ear at 6-month postsuction-assisted device removal

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Another patient with left ear abscess was managed similarly using the above technique was extremely satisfied with the decrease in pain score from 9 to mean VAS 1.4 in the postoperative period [Figure 16].
Figure 16: (a) Preoperative view of post burns abscess of left ear. (b) Postoperative view of post burns abscess of the left ear

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However, the technique is not free of complications. In one of the patients, there was migration of the tube out of the cavity requiring a secondary procedure [Figure 17].
Figure 17: Migration of tube out of the cavity seen in one patient

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The details of patients enrolled in the control group are tabulated in [Table 2]. Seven males and eight females were included in the control group. The mean age of patients in this group was 34.73 years. The maximum VAS score preoperatively was 10 while the minimum score was 6. Postoperatively on day 1, the minimum VAS score was 6 and maximum was 10. In some patients, pain experienced after packing was more than preoperative pain. The number of the days packing of cavity had to be done varied from 8 to 15. The mean period was 11.26 days. The maximum mean VAS score was 7.1 and the minimum VAS score was 5.25.
Table 2: Details of patients managed by conventional method

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The comparison between the two groups is summarized in [Table 3]. On comparing the two groups, we found that the mean treatment period in the control group (11.26 days) was significantly longer than the cases group (5.26 days). This difference was tested statistically using the unpaired t-test and P < 0.0001. The mean VAS scores in the cases group were also statistically compared with the controls. This difference was statistically significant as well with P < 0.0001, implying the SAD was effective in reducing the pain of the patients substantially.
Table 3: Comparison of the two groups

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  Discussion Top


Chondritis is often a late sequel of deep partial-thickness ear burns. It is a severe complication that can destroy the unburned cartilage if not recognized early. Bhandari stated that 90% of patients with cervicofacial burns will have ear burns and 30% of ear burns develop chondritis.[3] Once infection of the cartilage has begun, it can rapidly involve adjacent cartilage and lead to destruction of the external ear cartilage.[4] Therefore, breaking this cascade by timely intervention is of paramount importance. The conventional treatment involves surgical drainage and debridement of infected tissue.[4]

With the advent and popularity of negative pressure wound therapy (NPWT) dressings circumventing the need for daily dressings, there has been a paradigm shift in the open wound management during the last decade.[5],[6] We have tried to extrapolate this concept in the management of ear burns. Primarily devised to substitute the conventional daily packing of cavity, we found this alternative to be not just patient-friendly but doctor-friendly and environment-friendly as well.

This technique, termed as SAD like NPWT, has notable advantages such as negating the need for daily dressing and packing of cavity, wound isolation, reduces chance of wound colonization, and safe disposal of infected materials.[7] Besides, it also avoids some other disadvantages of conventional dressing. To begin with, there is no soakage or opacification of dressings and thus a non-foul-smelling wound environment. The discharge output can be quantified, and hence, the improvement can be objectively assessed which is not feasible with the conventional dressing method. It requires use of easily available “raw material” and is also a very cost-effective option. It might be argued that the time required for the procedure is longer than a conventional I and D. However, if the cumulative treatment time is considered, it is less than the conventional method. SAD also offers an option to manage the patient out of the hospital as domiciliary care, thereby bypassing the hospital-associated problems and infections. Of the patients managed in the ward, in selected cases, the tube can be tunneled through and through the cavity such that the terminal end of the tube is outside [Figure 18].
Figure 18: (a) Alternative technique of using the tube by tunneling through and through the cavity thus facilitating lavage of the cavity. (b) Alternative technique of using the tube by tunneling through and through the cavity thus facilitating lavage of the cavity

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Both ends can then be connected to an infusion tubing to facilitate lavage of the cavity. This modification provides an “ex gratia” option of continuous irrigation of the abscess cavity. Antibiotic irrigation with polymyxin B 0.2% solution or culture-specific antibiotics every 2–3 h for 4–5 days has been reported as a modality.[8],[9]

The downside of SAD is that the technique needs special care and monitoring to ensure the apparatus does not slip off from its position. Only a vigilant patient or a relative can pick up malfunctioning of the suction device in the domiciliary setup. Besides this, if not flushed regularly, the tube might get blocked leading to failure of the system. We had a case of tube migration where the distal end had penetrated out of the cavity as mentioned above.

The biggest advantage of the technique was the patient compliance and this was reflected by the positive change in the VAS score. All the patients were satisfied with the pain control offered by this technique. One limitation of the study was the small sample size.


  Conclusion Top


The SAD technique for the management of post burns auricular abscesses has been readily accepted by our patients and has some distinct advantages over the conventional dressing. Although not foolproof, this method clearly scores over the standard method in terms of pain perceived during the course of postdrainage period. The cost-effectiveness and the ease of availability make it a desirable modality. In conclusion, the “SAD” is actually a “happy” alternative.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sarabahi S. Management of ear burns. Indian J Burns 2012;20:11.  Back to cited text no. 1
  [Full text]  
2.
Bilwani PK. Unfavourable results in acute burn management. Indian J Plast Surg 2013;46:428-33.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Bhandari PS. Total ear reconstruction in post burn deformity. Burns 1998;24:661-70.  Back to cited text no. 3
    
4.
Bentrem DJ, Bill TJ, Himel HN, Edlich RF. Chondritis of the ear: A late sequela of deep partial thickness burns of the face. J Emerg Med 1996;14:469-71.  Back to cited text no. 4
    
5.
Liu X, Zhang H, Cen S, Huang F. Negative pressure wound therapy versus conventional wound dressings in treatment of open fractures: A systematic review and meta-analysis. Int J Surg 2018;53:72-9.  Back to cited text no. 5
    
6.
Blum ML, Esser M, Richardson M, Paul E, Rosenfeldt FL. Negative pressure wound therapy reduces deep infection rate in open tibial fractures. J Orthop Trauma 2012;26:499-505.  Back to cited text no. 6
    
7.
Kumar P. Exploiting potency of negative pressure in wound dressing using limited access dressing and suction-assisted dressing. Indian J Plast Surg 2012;45:302-15.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Wanamaker HH. Suppurative perichondritis of the auricle. Trans Am Acad Ophthalmol Otolaryngol 1972;76:1289-91.  Back to cited text no. 8
    
9.
Apfelberg DB, Waisbren BA, Masters FW, Robinson DW. Treatment of chondritis in the burned ear by the local instillation of antibiotics. Plast Reconstr Surg 1974;53:179-83.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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