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thickness orofacial burn, with vertical ranges cited between 10 and 42 mm and horizontal ranges between 40 and 65 mm [6,18,19,21,43–47] . Additionally, these studies describe compa- rable gains in mouth opening dimensions quoting measure- ment improvements of 2–26 mm for vertical and 5–33 mm for horizontal mouth opening. Surgical mouth angle release at one time point for each case was [13_TD$DIFF] done to facilitate rehabilita- tion progress. Even though positive outcomes can be achieved by behavioural treatment alone [20] surgery is often recog- nised as necessary to achieve functional improvement in cases with this depth of burn [21,48,49] . Although the oral range of movement outcomes was positive in both cases, the duration of orofacial contracture rehabilitation was lengthy with treatment cessation at 433 days (Case 1) and 344 days (Case 2) from the time of injury. These durations are consistent to prior research, where patients with full thickness facial burns [14_TD$DIFF] received between 82 and 1235 days to achieve optimal outcomes [21] . Where studies report less extensive periods of rehabilitation, most do not specify continuing therapy until scar tissue had stabilised; rather they focus on the time taken to achieve maximal mouth opening gain [3,6,17,44–47] explaining the discrepancy be- tween reported therapy durations. The psychosocial effect of dysphagia as it relates to head and neck burn has also not been previously examined in the literature but is discussed in this current study. Both cases experienced considerable levels of dysphagia related distress on the AusTOMS at the commencement of their dysphagia rehabilitation; however this resolved in one case and improved considerably in the other throughout the course of intervention, with no convincing evidence of dysphagia related distress by the time of dysphagia resolution. In contrast, the patient perceptions of their orofacial scarring did not resolve with physical treatment. Many papers have illustrated that severe facial burns have a significant psycho- social impact on patients due to the permanent aesthetic changes in facial contour, colour, texture and pliability of the resultant scar tissue [49–51] . Both cases’ perceptions of their scarring in this study further substantiate these reports with the outcomes as described on the VSS and POSAS. Case 1 demonstrated a more favourable score on the VSS (1) and correspondingly on the POSAS (25), whereas Case 2 who clearly had a poorer scar outcome on the VSS (7) also reported a poorer score on the POSAS (46). Whilst this study demonstrated encouraging results in response to dysphagia and orofacial contracture treatment there are certain limitations. This multifaceted treatment programme was trialled on only 2 participants and therefore the results should be interpreted with caution. Despite the low number of participants, the treatment programme utilised in this study does indicate a potential for implemen- tation that is practical and feasible in the severe burn population. A further consideration is that both cases were suspected of having an inhalation component to their burn, however the severity of this inhalation injury was not quantified, nor was the presence and effect of laryngophar- yngeal contractures examined. One must consider that the presence of laryngopharyngeal contractures may impact upon swallowing function, and therefore impact the out- comes of dysphagia rehabilitation. Despite the current

protocol appearing to contribute to the recovery of functional mouth opening and safe swallowing, there is a considerable amount of research required to determine the most effect combination of rehabilitation strategies. Although the pres- ent study suggests one rehabilitation regime that can result in positive outcomes for orofacial function, the authors do accept that this programme may not be appropriate to all patients’ needs.

5.

Conclusion

The intensive multifaceted rehabilitation programme de- scribed in this study was successful in achieving return to full functional outcomes for swallowing and orofacial range of movement following severe head and neck burns. This research also indicates that a protracted duration of therapy and variable patient perception of scarring at treatment conclusion can be anticipated in this complex population.

Conflicts of interest and source of funding

The authors report no conflicts of interest or sources of funding associated with the conduct of this study or preparation of this manuscript. The authors alone are responsible for the content and writing of the paper. All authors contributed to the conception and design of this study, data analysis and interpretation, preparation and verification of this final manuscript prior to submission for publication.

Acknowledgements

The authors would like to acknowledge and thank Laura O’Carrigan (SP) and Michelle McSweeney (OT) for their contributions to patient intervention, as well as collection of patient outcome measure data. The authors would also like to thank the 2 patients who consented to participate within the study, whose assessment and intervention data will positively guide the dysphagia and orofacial contracture management of other burn patients with the aim to optimise efficacious outcomes.

r e f e r e n c e s

[1] Cheung W, Clayton N, Li F, Tan J, Milliss D, Thanakrishnan G, et al. The effect of endotracheal tube size on voice and swallowing function in patients with thermal burn injury: an evaluation using the Australian Therapy Outcome Measures (AusTOMS). Int J Speech-Lang Pathol 2013;15(2):216–20. [2] Clayton N, Kennedy P, Maitz P. The severe burns patient with tracheostomy: implications for management of dysphagia, dysphonia and laryngotracheal pathology. Burns 2010;36(6):850–5. [3] Clayton NA, Kennedy PJ. Management of dysphagia in toxic epidermal necrolysis (TEN) and Stevens-Johnson syndrome (SJS). Dysphagia 2007;22(3):187–92.

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