should be considered. In these cases even with appropriate treatment, mortality approaches
100% as a reflection of the severity of the burn injury.
Sinusitis is a concern in burn patients because of the need for prolonged intubation of one
or both nostrils with feeding tubes or an endotracheal tube (55). Headache, facial pain, or a
purulent discharge suggests this diagnosis. Computed tomography of the head and face is
used to confirm the diagnosis. Treatment is generally focused on removal of the tubes if
possible, and topical decongestants. Sinus puncture for a specimen should be considered if the
infection is thought to be life-threatening, with systemic antibiotic treatment of the isolate.
Meningitis is an uncommon infection in the burned patient, but has been found in
patients with deep scalp burns involving the calvarial bone and in those with indwelling
intraventricular catheters for monitoring of intracranial pressures when there are concomitant
head injuries. Only in these cases should this diagnosis be considered, which can be confirmed
with computed tomography of the head with intravenous contrast, or lumbar puncture. The
diagnosis and treatment of meningitis is covered in depth in other chapters.
An infection that is unique to burned patients is the development of infected chondritis
of the ear cartilage. When the skin of the ear is damaged by a burn, this leaves a portal of entry
for microorganisms to invade the cartilage of the ear, which is relatively privileged because of
a lack of vascularization. This complication occurs two to three times per year in busy burn
centers and can be minimized by the use of mafenide acetate cream for treatment of ear burns.
This compound diffuses into the cartilage, making it a forbidding environment for bacteria.
When the complication occurs, it is characterized by a red, painful, swollen ear that has been
burned with open or recently healed wounds. Treatment is surgical with debridement of
necrotic and infected cartilage. Adequate drainage of the area must be established with
incisions along the outer edge of the pinna or posterior pinna to ‘bivalve’ the ear if necessary.
Following debridement, the wound should be treated with topical mafenide acetate cream.
Lastly, another infection that is common in burned patients is the development of scalp
folliculitis (Fig. 6). Burns to the scalp that heal secondarily are susceptible to chronic growth of
organisms in remaining hair follicles that result in ulceration and open wounds. Donor sites
taken from the scalp because of limited donor sites in other areas can also result in this
problem. Initial therapy is aimed at topical treatment to eradicate organisms and allow healing.
Because gram-positive organisms predominate, mupirocin is commonly used; alternatively,
acetic acid washes are employed. After a reasonable course of treatment (two to three weeks),
if the wound does not heal, split thickness grafting may be required.
Figure 6 Photograph of folliculitis of the scalp. Note the chronic nature and ulceration.
372 Wolf et al.