Understanding Neural Factors in Burn-related Pruritus and Neuropathic Pain.

Post-burn pruritus and neuropathic pain significantly affect the quality of life of affected individuals in several domains including psychosocial well-being, sleep and general impairment in activities of daily living. Whilst neural mediators involved in itch in the non-burns setting have been well investigated, there remains a lacuna of literature examining the pathophysiological and histological changes unique to burn-related pruritus and neuropathic pain. The aim of our study was to conduct a scoping review into the neural factors that contribute to burn-related pruritus and neuropathic pain. A scoping review was conducted to provide an overview of the available evidence. The PubMed, EMBASE and Medline databases were searched for publications. Data regarding neural mediators implicated, population demographics, total body surface area (TBSA) affected and sex was extracted. In total, 11 studies were included in this review with a total of 881 patients. The most frequently investigated neurotransmitter was the Substance P (SP) neuropeptide which appeared in 36% of studies (n = 4), followed by calcitonin gene-related peptide (CGRP) in 27% of studies (n = 3). Post-burn pruritus and neuropathic pain are symptomatic experiences that are predicated upon a heterogeneous group of underlying mechanisms. What is clear from the literature, however, is that itch and pain may occur secondary to the influence of both neuropeptides, such as SP, and other neural mediators including Transient receptor protein channels. Of the articles included for review, they were characterized by small sample sizes and large differences in statistical methodology and reporting.

Tracheostomy in free-flap reconstruction of the oral cavity: can it be avoided? A cohort study of 187 patients.

BACKGROUND: Head and neck surgeons are moving away from routine tracheostomy in free-flap reconstruction. We reviewed prophylactic tracheostomy use in patients undergoing oral cavity or oropharynx free-flap reconstruction to identify patient groups who avoided tracheostomy. Secondary aims were to describe complications associated with and without tracheostomy. METHODS: A retrospective cohort study was undertaken, using a prospectively maintained database. Inclusion criteria was free-flap reconstruction for an oral cavity or oropharyngeal defect, excluding partial or total laryngectomy. Variables collected included demographics, comorbidity, American Society of Anesthesiologists grade, Charlson Comorbidity Index, tumour site and subsite, extent of resection, surgery duration, tracheostomy, complications, return to theatre and re-intubation. RESULTS: A total of 344 head and neck free-flap reconstructions were performed between January 2017 and July 2019. A total of 164 (87.7%) oral cavity and 23 (12.3%) oropharyngeal reconstructions were included totalling 187 free flaps. A total of 107 (57.2%) were males and 80 (42.8%) females, mean age 62.4 years (range 21-89). Of 187 patients, 100 (53.5%) underwent prophylactic tracheostomy at time of reconstruction. Longer operative time (P < 0.001), resection site (P < 0.001), number of subsites resected (P = 0.007), segmental mandibulectomy (P = 0.04), lip-split (P = 0.05), floor of mouth resection (P < 0.001), lingual release (P = 0.007), glossectomy (P < 0.001), extent of tongue resection (P < 0.001), extent of hard palate resection (P = 0.04), soft palate resection (P < 0.001) and double free-flap reconstruction (P = 0.04) were associated with tracheostomy use. CONCLUSION: A personalized approach to postoperative airway management allowed almost half of our cohort to avoid tracheostomy. In high-volume institutions with the necessary expertise and support, appropriately selected patients may be safely managed without routine tracheostomy.