2017-18 HSC Section 3 Green Book

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Table 2 – Outcome measures utilised. Outcome measure

Description

Time point assessed

Orofacial contracture/scarring VROM [19]

Measurement in mm from the inner border of the medial top lip to the inner border of the medial lower lip whilst in the maximally stretched open position Measurement in mm from one lateral oral commissure to the other lateral oral commissure whilst in the maximally stretched lateral retraction position Pigmentation: 0, normal colour; 1, hypopigmentation; 2, hyperpigmentation. Vascularity: 0, normal, 1, pink; 2, red; 3, purple. Pliability: 0, normal; 1, supple; 2, yielding; 3, firm; 4, rope; 5, contracture. Height: 0, flat; 1, < 2 mm; 2, 2–5 mm; 3, > 5 mm Patient scale: 1–10 numerical scale for each factor of pain, itch, colour, stiffness, thickness, irregularity (total score 6– 60) Observer scale: 1–10 numerical scale for each factor of vascularisation, pigmentation, thickness, relief, pliability (total score 6–60) 7 point scale where 1, nothing by mouth; 3, tube dependent with consistent intake of food and fluid; 7, total oral diet with no restriction 6 point scale where 0, high and consistent levels of distress or concern; 5, able to cope with most situations. Accepts and understands own limitations 1, material does not enter airway; 2, material enters airway above vocal cords and is ejected; 3, material enters airway above vocal cords and is not ejected; 4, material enters airway, contacts vocal cords and is ejected; 5, material enters airway, contacts vocal cords and is not ejected; 6, material enters airway, passes below vocal cords and is ejected; 7, material enters airway, passes below vocal and is not ejected despite effort; 8, material enters airway, passes below vocal cords with no effort made to eject 1, none; 2, trace; 3, mild; 4, moderate; 5, severe 1, normal; 2, mild; 3, moderate; 4, severe; 5, profound

Weekly

HROM [19]

Weekly

Vancouver scar scale [33]

Discharge

Patient and observer scar assessment scale [34]

Discharge

Swallow related outcomes FOIS [35]

Weekly

AusTOMS [36]

Monthly

Fibreoptic endoscopic assessment of swallowing Penetration aspiration scale [37]

Monthly

Yale pharyngeal residue severity rating scale [38]

Monthly Monthly Monthly

Marianjoy secretion scale [39] Patterson oedema scale [40]

1, normal; 2, mild; 3, moderate; 4, severe

and profound dysphagia (FOIS 1; PAS 7; Marianjoy secretion scale 4; Yale Pharyngeal Residue Severity Rating Scale 5; Patterson oedema scale 3) and AusTOMS Distress score of 3. At this time, Case 1 was also noted to have a left vocal cord palsy, with the cord fixed in the midline position. Rehabilitation was commenced and adherence to the prescribed dysphagia therapy programme was high, facilitated by daily therapist support. Case 1’s duration to complete resolution of dysphagia and resumption of full oral diet with nil impairment on FEES was achieved by 222 days post injury (118 days post intervention). From this point on the swallowing exercise components of the therapy protocol were discontinued. Fig. 1 shows the progression from complete dependence on non-oral tube feeding (FOIS 1), to partial oral and non-oral feeding (FOIS 3) following 3 months of rehabilitation. Case 1 then progressed from consuming a modified texture diet to resuming full unrestricted normal oral intake in the final month of rehabilitation. Table 3 illustrates Case 1’s FEES data, indicating the presence of considerable issues with oedema, impaired secretion management and residue at baseline. Each monthly

re-assessment revealed improving status until all impair- ments had resolved 4 months post except for some trace residue. At each subsequent FEES procedure, including the final FEES at Day 222 post injury, the left vocal cord palsy remain unchanged indicating a left recurrent laryngeal nerve paralysis. Case 1 reported experiencing moderate concern regarding his swallowing impairment at the commencement of therapy which began to improve by 2 months of rehabilita- tion and had resolved when assessed 4 months rehabilitation, coinciding to return to full normal diet ( Fig. 2 ). Following commencement of the treatment protocol, consistent progress in mouth range of movement was observed in Case 1 ( Fig. 3 ). Surgical mouth angle release was conducted early at the request of the managing clinician (Day 118 post injury; Day 14 post admission to our facility) to allow appropriate orofacial contracture rehabilitation. VROM and HROM achieved normal range at Day 237 post injury (133 days of intervention) though scar stabilisation was ongoing. Treatment weaning from the contracture management ele- ments of the protocol was commenced at Day 356 post injury (252 days of intervention), with eventual cessation of all

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