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revealed mild ongoing issues with oedema, secretion man- agement and residue ( Table 3 ). By the end of the secondmonth transition to full oral intake (without non-oral supplementa- tion) was achieved, followed by progression to an unrestricted diet 3 weeks later. No physiological impairments were noted on FEES re-assessment at 77 days post injury (42 days post intervention). At the time of the final FEES procedure, complete resolution of the left vocal cord movement was also noted. Mirroring the recovery pattern of oral intake, Case 2 reported an AusTOMS Distress score of 1 at initial assessment when fully dependent on non-oral feeding. This resolved to nil concerns by the final assessment. As per case 1, Case 2 underwent surgical mouth angle release (Day 49 post injury) to facilitate orofacial contracture rehabilitation. Following recovery to full unrestricted diet, only the contracture management elements of the protocol were continued. By day 204 post admission (182 days of intervention) VROM and HROM had returned to within the normal range ( Fig. 3 ) though scar stabilisation was ongoing. Weaning from the contracture management elements of the protocol was commenced at Day 295 post injury (273 days of intervention), with eventual cessation of all treatment at Day 344 post injury (322 days of intervention). Full mouth opening with no functional limitations were demonstrated at treat- ment cessation with linear measurements recorded at 49 mm for VROM and 68 mm for HROM. At the time of orofacial treatment completion, the assessing clinician attributed an overall score of 7 on the VSS, with persistent issues featuring on the pliability aspect of the scar (4), and to a lesser extent on the vascularity component (1) and height of the scar (2). Case 2 obtained a cumulative score of 46/120 on the POSAS (Patient Scale 27; Observer Scale 19) representing a scar severity approaching mid-way on the scar scale, where normal tissue achieves a score of 12 and the worst scar imaginable achieves a score of 120. This study describes the positive outcomes achieved by two patients with severe head and neck burns who underwent a dysphagia and orofacial contracture rehabilitation pro- gramme. Despite profound dysphagia at presentation to rehabilitation, by the time of treatment cessation, both individuals safely returned to unrestricted diet and fluids without the need for compensatory strategies or supplemental non-oral nutrition. Patient reported dysphagia related distress had also resolved. Furthermore, both re-established full oral range of movement with no functional restrictions, despite the presence of residual scar tissue. However, despite the positive patient outcomes observed in response to treatment, the duration to resuming a normal diet in Case 1, and the duration to achieve VROM and HROM levels to within normal limits in both cases was protracted. At baseline, both cases presented with profound dysphagia characterised by reduced oropharyngeal muscle strength, marked issues with secretion management, pharyngeal residue and high risk of aspiration. This was evidenced by poor scores on the FOIS, PAS, Yale Pharyngeal Residue Severity Rating scale and Marion Joy secretion rating scale. Whilst 4. Discussion

extensive oropharyngeal impairment was observed, the main areas of reduced muscle tone specifically noted on FEES were at the base of tongue and hypopharynx. This was substanti- ated by the marked accumulation of residue in the valleculae and piriform fossae resulting in mid and post swallow aspiration. The dysphagia profile of these two cases is consistent with previously published literature describing the nature of dysphagia following severe head and neck burn [1–8,22,23] . These studies also indicate that key features of pharyngeal dysphagia after severe head and neck burns include reduced base of tongue to posterior pharyngeal wall contact, impaired pharyngeal clearance, and increased risk of aspiration [1,2,6–8,18,22,23] . Both patients in the current study also demonstrated a positive response to intervention. Previous single case reports in the literature have described the use of oromotor exercises [6,18,19,23] , manoeuvres for bolus control and transit [6] , airway protection and laryngeal range of movement exercises [18,22,23] , as well as strategies to reduce odynophagia [3,19] . Although those studies differ in the specific nature of the protocols used, with lack of detail regarding timing of commencement, intensity and duration of treatment, positive responses to such behavioural treatment protocols have been reported. As further research continues in this area, determining the most beneficial therapy tasks to complete with this population will become increasingly transparent. However from the studies to date and the current clinical case data, it would appear that exercises targeting lingual and pharyngeal strengthening are useful therapeutic targets. Whilst the treatment programme implemented did appear to be effective, return to normal oral intake was particularly lengthy at 118 days of treatment for Case 1. This protracted duration of rehabilitation may be due to Case 1’s need for lengthy and repeated endotracheal intubation, extended period of mechanical ventilation and general medical insta- bility. This concept is supported by Dubose et al. [5] and Clayton et al. [2] who have described a positive linear relationship between days of mechanical ventilation and tracheostomy and days to initiation of oral feeding. Further- more, other studies in critical care populations have also identified that prolonged mechanical ventilation exacerbates dysphagia as a consequence of swallowing muscle inactivity [41,42] . In contrast, the relatively modest recovery period (42 days of rehabilitation) observed in Case 2 is more consistent with other studies where duration of dysphagia rehabilitation has been reported to range between 29 and 43 days [7,13,22] . Orofacial function was also severely compromised at baseline for both patients, defined by profoundly limited vertical (15 mm; 18 mm) and horizontal (47 mm; 52 mm) linear mouth opening. This extent of initial deficit following severe burn is consistent with prior research [3,6,17,21,43–47] . Despite the severity of initial deficit, both cases did respond positively to the orofacial contracture elements of the rehabilitation programme exhibiting mouth opening mea- surement gains in both the vertical (24 mm; 31 mm) and horizontal planes (17 mm; 16 mm). By the time of treatment cessation, mouth opening measurements were achieved within the normal range [20] and without evidence of functional limitation. Previous studies also describe similar degrees of mouth opening impairment at baseline after full

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