Systematic Review/Meta-analysis
Otolaryngology–
Surgical Fires in Otolaryngology:
A Systematic and Narrative Review
Andrew T. Day, MD, MPH1, Erika Rivera2, Janice L. Farlow, MD, PhD3,
Christine G. Gourin, MD, MPH4, and Brian Nussenbaum, MD5
No sponsorships or competing interests have been disclosed for this article.
Abstract
Objective. To bring attention to the epidemiology, prevention,
management, and consequences of surgical fires in otolaryn-
gology by reviewing the literature.
Data Sources. PubMed, EMBASE, Web of Science, and Scopus.
Review Methods. Comprehensive search terms were devel-
oped, and searches were performed from data source
inception through August 2016. A total of 4506 articles
were identified; 2351 duplicates were removed; and 2155
titles and abstracts were independently reviewed. Reference
review was also performed. Eligible manuscripts described
surgical fires involving patients undergoing otolaryngologic
procedures.
Results. Seventy-two articles describing 87 otolaryngologic
surgical fire cases were identified. These occurred during
oral cavity or oropharyngeal procedures (11%), endoscopic
laryngotracheal procedures (25%), tracheostomies (36%),
‘‘other’’ general anesthesia procedures (3%), and monitored
anesthesia care or local procedures (24%). Oxidizing agents
consisted of oxygen alone (n = 63 of 81, 78%), oxygen and
nitric oxide (n = 17 of 81, 21%), and room air (n = 1 of 81,
1%). The fractional inspired oxygen delivered was .30% in
97% of surgical fires in non–nitrous oxide general anesthesia
cases (n = 35 of 36). Laser-safe tubes were used in only 12%
of endoscopic laryngotracheal cases with endotracheal tube
descriptions (n = 2 of 17). Eighty-six percent of patients
experienced acute complications (n = 76 of 87), including 1
intraoperative death, and 22% of patients (n = 17 of 77)
experienced long-term complications.
Conclusion. Surgical fires in otolaryngology persist despite
aggressive multi-institutional efforts to curb their incidence.
Guideline recommendations to minimize the concentration
of delivered oxygen and use laser-safe tubes when indicated
were not observed in many cases. Improved institutional fire
safety practices are needed nationally and internationally.
Keywords
surgical, operating room, fire, fires, otolaryngology, head and
neck surgery
Head and Neck Surgery
2018, Vol. 158(4) 598–616
Ó American Academy of
Otolaryngology—Head and Neck
Surgery Foundation 2018
Reprints and permission:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/0194599817746926
http://otojournal.org
Received September 18, 2017; revised November 1, 2017; accepted
November 17, 2017.
S
urgical fires are preventable and can cause catastrophic
complications. According to the Emergency Care
Research Institute (ECRI), approximately 200 to 240
operating room (OR) fires occur in the United States each
year; in 2009, the ECRI estimated that OR fires resulted in 20
to 30 severe injuries and 1 or 2 deaths per year.1 Surgical fires
have been reported by every surgical subspecialty, although
they most commonly involve the airway (34%) or head and
neck (28%).2 In a survey of 349 otolaryngologists, 88 (25.2%)
reported witnessing at least 1 OR fire in their career.3 The
response to this issue has been significant. Through its
Preventing Surgical Fires Initiative, the US Food and Drug
Administration (FDA) has built a coalition of almost 30
member organizations, including the American Academy of
Otolaryngology—Head and Neck Surgery. The American
Society of Anesthesiologists (ASA) Task Force on Operating
Room Fires issued an updated ASA practice advisory (ASA-
PA) for the prevention and management of OR fires in 2013.4
Several other organizations—including the ECRI, Association
of periOperative Registered Nurses (AORN), Anesthesia
Patient Safety Foundation (APSF), and Joint Commission on
Accreditation of Healthcare Organizations (JCAHO)—have
also formally addressed this problem.1,5 Still, otolaryngologic
surgical fires continue to occur, and a lack of surgical fire edu-
cation and a failure to comply with existing guidelines persist
among OR team members.6,7 The objective of this review is to
1
Department of Otolaryngology–Head and Neck Surgery, UT
Southwestern Medical Center, Dallas, Texas, USA
2
Department of Otolaryngology–Head and Neck Surgery, Keck School of
Medicine, University of Southern California, Los Angeles, California, USA
3
Department of Otolaryngology–Head and Neck Surgery, School of
Medicine, University of Michigan, Ann Arbor, Michigan, USA
4
Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins
Medical Institutions, Baltimore, Maryland, USA
5
Department of Otolaryngology–Head and Neck Surgery, School of
Medicine, Washington University in Saint Louis, Saint Louis, Missouri, USA
Corresponding Author:
Andrew T. Day, MD, MPH, Department of Otolaryngology–Head and Neck
Surgery, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas,
TX 75390-9035, USA.
Email: andrew.day@utsouthwestern.edu
Day et al
Idenficaon
Records idenfied through Embase, Pubmed,
Scopus, and Web of Science
(n = 4,506)
Records aer duplicates removed
(n = 2,351)
Screening
Titles and abstracts
screened
(n = 2,155)
Eligibility
Abstracts and full-text arcles
assessed for eligibility
(n = 95)
Included
Studies meeng all
inclusion criteria
(n = 72)
Figure 1. PRISMA diagram (Preferred Reporting Items for Systematic Reviews and Meta-analyses).8
bring greater attention to surgical fires in otolaryngology by
reviewing the literature and discussing the causes, prevention,
management, and consequences of these fires.
Materials and Methods
Based on search concepts—including otolaryngology, surgi-
cal, operating room, tracheostomy, oropharyn*, laryn*, tra-
chea, endotracheal, and fire—comprehensive search terms
were developed with the assistance of 2 medical librarians
(see supplement in the online version of the article). PubMed,
EMBASE, Web of Science, and Scopus searches were per-
formed from their inception through August 2016 (Figure 1)
according to PRISMA guidelines (Preferred Reporting Items
for Systematic Reviews and Meta-analyses).8 A total of 4506
articles were identified via the literature search and exported
to EndNote7; 2351 duplicates were removed. In sum, 2155
candidate titles and abstracts were independently reviewed by
2 authors (E.R., J.F.) using the inclusion criteria.
Disagreements were resolved by consensus or arbitration
with a third author (A.T.D.). Manuscripts meeting inclusion
criteria described surgical fires involving a patient of any age
during a procedure within the domain of otolaryngology–
head and neck surgery. Non–English language studies with-
out an available translation, OR fires not involving a patient,
and otolaryngologic surgical fires without a description of the
procedure or complications were excluded. Reference review
599
Arcles excluded
(n = 2,060)
Arcles excluded
Arcle without an available English
translaon, procedure not
described, or complicaons not
described
(n = 47)
Arcles included
Bibliographic review idenfies other
eligible arcles
(n = 24)
was then performed and additional eligible articles identified.
Data extracted from studies included procedure type, patient
age and sex, heat source type, fuel type, oxidizer type and
quantity or concentration (if described), acute complications,
and long-term complications.
Definitions, Fire Theory, and Specific Causes
of OR Fires
We provide the following definitions for this review, as
adapted from the ASA-PA.4 An operating room fire is a
blaze, or destructive burning, that occurs on or near a patient
in a surgical suite. A surgical fire is a type of OR fire that
occurs in or on the patient. An airway fire is a type of surgi-
cal fire involving the upper aerodigestive tract or tracheo-
bronchial tree. Equipment-related or environmental OR fires
not directly involving the patients have been reported but are
not in the scope of this review. A high fire-risk surgery
occurs when a fuel source, oxidizer-enriched atmosphere
(OEA), and ignition source are employed in close proximity.
Fire, or the initiation and continuance of combustion, is
a complex set of chemical reactions that results in the rapid
oxidation of a fuel producing heat, light, and a variety of
chemical by-products.9 The initiation and continuance of
combustion require 4 components: fuel, an oxidizer, heat,
and uninhibited chemical chain reactions. The former 3
600
Figure 2. Fire tetrahedron. Reproduced with permission from
Wikipedia. Fire triangle. https://en.wikipedia.org/wiki/Fire_triangle.
Accessed August 28, 2017.
components compose the fire triad or fire triangle and are
referenced throughout this review.10 The addition of the last
component, uninhibited chemical chain reactions, completes
the more recently described fire tetrahedron and is neces-
sary for the continuance of combustion (Figure 2).11
Fuel is any substance that can undergo combustion. An
oxider, oxidant, or oxidizing agent acquires electrons from
reducing agents (ie, fuel molecules), thus oxidizing them; in
most fire situations, this oxidizer is oxygen. The heat compo-
nent of the triangle refers to the minimum heat energy neces-
sary to sufficiently increase oxidation-reduction reaction
rates, release fuel vapors, and cause ignition. Uninhibited
chemical chain reactions are required for self-sustained com-
bustion and broadly refer to the excess heat from the exother-
mic reaction radiating back to the fuel to produce vapors and
cause ignition in the absence of the original ignition source,
thus maintaining the heat of the reaction zone.9,11
Results
Eighty-seven cases meeting the search criteria were identi-
fied. These consisted of oral cavity or oropharyngeal proce-
dures (n = 10, 11%; Table 1), endoscopic laryngotracheal
procedures (n = 22, 25%; Table 2), tracheostomies (n = 31,
36%; Table 3), ‘‘other’’ general anesthesia procedures (n =
3, 3%; Table 1), and monitored anesthesia care (MAC) or
local procedures (n = 21, 24%; Table 4). Among the 76
cases reporting patient age, the range was 1 to 88 years, and
the median age was 47 years. Seventy-nine cases reported
sex: 28 (35%) were female and 51 (65%) were male.
Electrocautery settings, laser settings, and the presence or
absence of a cuff leak were often not described and hence
not recorded. Case fire management was variable,
Otolaryngology–Head and Neck Surgery 158(4)
occasionally strayed from ASA-PA guidelines, and was also
not recorded.
Eighty-six cases identified the heat source, and 4 types
were implicated: electrocautery (n = 67, 78%), CO2 laser (n
= 15, 17%), Nd:YAG laser (n = 3, 3%), and gallium alumi-
num arsenide diode laser (n = 1, 1%). A variety of fuel
sources were identified: alcohol preparation, cottonoids,
cotton-tipped applicators, endotracheal tubes, gauze, the
laser tip, muslin strips, nasal cannulas, oxygen masks,
oxygen tubing, patients, surgical drapes, surgical gloves,
surgical tapes, suture, and towels. Among the 85 cases
reporting a fuel source, the most common (other than the
patient) were the endotracheal tube (n = 42, 49%), gauze (n
= 12, 14%), surgical drapes (n = 8, 9%), and oxygen tubing
(n = 5, 6%). The patient was the only reported fuel source
in 12 cases. The oxidizer composition was reported in 81 of
87 cases and consisted of oxygen alone (n = 63, 78%),
oxygen and nitric oxide (n = 17, 21%), and room air (n = 1,
1%). The surgical fire case involving room air was a MAC
case in which the patient had been recently preoxygenated
via nasal cannula.12 Of 64 general anesthesia cases, 39 used
oxygen alone; fractional inspired oxygen (FiO2) was
reported in 36 of these and ranged from 30% to 100%.
Twenty-seven cases (75%) reported FiO2 of 100%. Only 1
case reported FiO2 of 30%, and 2 cases reported 40%.
Oxygen flow was reported in 13 of 21 MAC cases and
ranged from 0 to 10 liters per minute (LPM). The oxygen
flow was 2 LPM in 11 cases (85%), 4 LPM in 5 (38%),
and 6 LPM in 2 (15%).
Among the 22 endoscopic laryngotracheal procedure fire
cases, a PVC (polyvinyl chloride) tracheostomy tube was
used in 1 case, no endotracheal tube in 2 cases (1 jet venti-
lation, 1 not recorded), and endotracheal tubes in the
remaining 19 cases. Among the 17 cases in which the type
of endotracheal tube used was reported, 4 (24%) involved
plastic tubes (ie, ‘‘plastic,’’ PVC, portex, and ‘‘vinyl plas-
tic’’); 7 (41%), plastic tubes wrapped in aluminum or metal;
3 (18%), red rubber tubes (2 of which were at least partially
wrapped in aluminum); 1 (6%), a reinforced flexometallic
tube wrapped in aluminum; 1 (6%), a ‘‘metal-sheathed’’
laser resistant tube; and 1 (6%), a Xomed Laser Shield tube.
Hence, laser-safe tubes were used in only 2 (12%) cases: in
the former case, the cause of the fire was not described, and
in the latter case, the fire was attributed to cuff perforation
(Table 3).
A number of acute complications were identified in 76
cases (86%), including 1 intraoperative death; 12 patients
(14%) experienced no injury. At least 20 patients (23%)
experienced prolonged hospitalization, and at least 13
(15%) required unexpected mechanical ventilation following
their surgical fires. Among the 86 patients surviving the sur-
gical fire, the presence or absence of long-term complica-
tions was reported in 77 cases. Sixty patients (78%) had no
long-term complications; 4 (5%), 4 (5%), and 3 (3%) devel-
oped tracheal stenosis, scars, and anxiety disorders or post-
traumatic stress disorder, respectively; and 2 patients (2%)
experienced other complications. Of the 17 patients with
 Table 1. Surgical Fires during Oral Cavity, Oropharyngeal, and Other Nonlaryngotracheal General Anesthesia Procedures.
Long-term
Reference Procedure Age, y Sex Heat Source Fuel Oxidizer Acute Complications Complications

Akhtar (2016)62 Adenotonsillectomy 8 M EC ETT FiO2 50%, N2O None None

Boyd (1969)63 Tonsillar tumor resection NR NR EC ETT, Pt 3-LPM O2, 5-LPM N2O Second-degree burn of NR
pharynx, uvular
erythema
Gupte (1972)64 Oral leukoplakia resection 54 M EC Pt, gauze 3-LPM O2, 6-LPM N2O ‘‘Little damage to the oral NR
cavity’’
Kaddoum (2006)65 Adenotonsillectomy 7 M EC Pt FiO2 100% None None
Kaddoum (2006)65 Adenotonsillectomy 5 M EC Pt O2, N2O None None
Keller (1992)66 Adenotonsillectomy 7 F EC ETT FiO2 98% None None
Partanen (2014)67 Tonsillectomy 7 M EC ETT, Pt, gauze FiO2 50% Small supraglottic burn, None
second-degree burns in
oral cavity, 2-d
intubation
Reilly (2006)68 Adenotonsillectomy 5 F EC Pt NR Partial-thickness burns in Persistent scar
oral cavity and lip
Simpson (1986)69 Adenotonsillectomy 4 M EC ETT, Pt 3-LPM O2, 3-LPM N2O Charring of oropharynx None
and trachea, edema of
vocal cords and
mainstem bronchus,
short ICU stay, 5-d
hospitalization
Tsuchida (1997)70 Adenotonsillectomy 5 M EC Pt, gauze 60% N2O, 40% O2 Grade 1 burn oral None
mucosa, hospitalized
23 d
Axelrod (1993)71 Otoplasty 6 M EC Pt, gauze, drape O2, N2O Second-degree burn None
Chestler (1989)72 Orbital dermoid excision 3 NR EC Pt, cotton-tipped applicator O2 Upper and lower eyelash None
burns
Meltzer (2005)73 Retroauricular scalp 1.5 F EC Pt, prep, gauze NR Small partial-thickness None
mass resection burns, singed hair

Abbreviations: EC, electrocautery; ETT, endotracheal tube; F, female; FiO2, fraction of inspired oxygen; ICU, intensive care unit; LPM, liters per minute; M, male; N2O, nitrous oxide; NR, not reported; O2,
oxygen; prep, skin preparation; Pt, patient.
601
602

Table 2. Surgical Fires during Endoscopic Laryngotracheal Procedures.

Long-term
Reference Procedure Age, y Sex Heat Source Fuel Oxidizer Acute Complications Complications

Bingham (1990)74 Endoscopic laryngeal 45 F CO2 laser ETT, Pt FiO2 40% Severe burns, subclinical None
papilloma resection lung infiltrates, 25-d
hospitalization
Burgess (1979)75 Endoscopic laryngeal 6 F CO2 laser ETT, Pt FiO2 100% Mild transient voice None
papilloma resection changes
Chiu (1997)76 Microlaryngeal tumor 75 M CO2 laser ETT, Pt FiO2 33%, N2O Charred epiglottis and Restricted left
resection vocal cords arytenoid
movement, distorted
epiglottis
Cozine (1981)77 Endoscopic laryngeal 41 M CO2 laser ETT, Pt O2, N2O Supraglottic edema NR
tumor resection necessitating temporary
tracheostomy,
mechanical ventilation
3 8 d, PNA, 1-mo
hospital stay
De Vane (1990)78 Laser bronchoscopy for 62 M NR ETT, Pt O2 First- and second-degree None
subglottic/tracheal burns to the
stenosis, Montgomery supraglottis, base of
T-tube placement tongue
Denton (1988)79 Endoscopic laryngeal 65 F Nd:YAG laser ETT, Pt FiO2 100% Burns and airway None
tumor ablation narrowing, 19-d
intubation, 23-d
hospitalization
Handa (2001)80 Endoscopic subglottic 2 M Nd:YAG laser Pt, laser tip FiO2 30%, N2O Mucosal damage None
stenosis management
Hirshman (1980)81 Endoscopic 14 M CO2 laser ETT, Pt 50:50 O2, N2O Superficial tracheal burn None
laryngotracheal
papilloma resection
Ilgner (2002)29 Endoscopic vocal fold 56 F CO2 laser ETT, Pt FiO2 30% Inflamed oropharynx, Tracheal stenosis
granuloma ablation 10-d ICU stay, 16-d presenting 14 wk
hospitalization after event requiring
tracheal resection
Krawtz (1989)82 Endoscopic tumor 65 M Nd:YAG laser ETT, Pt FiO2 40% Mucosal charring, delayed None
ablation of the trachea obstructive hypoxia
requiring therapeutic
bronchoscopy 32 , 10-d
hospitalization

(continued)
 Table 2. (continued)
Long-term
Reference Procedure Age, y Sex Heat Source Fuel Oxidizer Acute Complications Complications

Meyers (1981)83 Microlaryngoscopy, 28 M CO2 laser ETT, Pt, cottonoid NR Mild infraglottic erythema None
laryngeal papilloma and edema
removal
Munksgaard Endoscopic NR M CO2 laser Muslin strips NR None NR
(1991)84 laryngotracheal
papilloma ablation
Pashayan (1988)85 Endoscopic NR NR CO2 laser ETT, Pt FiO2 70% Superficial tracheal burn None
laryngotracheal
procedure
Perry (1975)86 Endoscopic laryngeal 50 M EC Tape, Pt O2 Second-degree burns of None
polyp resection surrounding tissue
Prgomet (2013)87 Endoscopic laryngeal NR NR CO2 laser ETT, Pt NR Superficial burn of None
cancer resection surrounding tissue
Rita (1982)88 Bronchoscopy, subglottic 2 M Resectoscope ETT, Pt FiO2 50%, 50% N2O Lower tracheal, right and None
or tracheal dilation, (endoscope 1 EC) left bronchus burns
removal of
tracheostomy
granulation tissue
Santos (2000)89 Microscopic laryngeal 49 M CO2 laser Teflon jet ventilation FiO2 \50% Second tracheal ring None
tumor resection, jet catheter, Pt wound
ventilation
Snow (1976)90 Microscopic laryngeal 1 F CO2 laser ETT, Pt NR Small superficial burn of None
papilloma resection tracheal mucosa
Snow (1976)90 Endoscopic laryngeal 12 M CO2 laser ETT, Pt NR Small superficial burn of None
papilloma resection tracheal mucosa
Sosis (1990)30 Endoscopic vocal polyp 56 M CO2 laser ETT, Pt 2-LPM O2, 4-LPM N2O Extensive burns to Permanent
laser excision trachea and bronchi, tracheostomy with
prolonged ICU stay several dilatation
with mechanical procedures
ventilation, necessary
tracheostomy
Vourc’h (1979)91 Microlaryngeal papilloma NR M CO2 laser ETT, Pt FiO2 50%, N2O 50% Superficial upper airway None
resection burns
Wang (2006)92 Microlaryngeal lysis of 53 M Gallium aluminum TT, Pt FiO2 60% (TT) Tracheal mucosa edema None
glottis stenosis arsenide diode laser

Abbreviations: CO2, carbon dioxide; EC, electrocautery; ETT, endotracheal tube; F, female; FiO2, fraction of inspired oxygen; ICU, intensive care unit; LPM, liters per minute; M, male; N2O, nitrous oxide; NR,
not reported; O2, oxygen; PNA, pneumonia; Pt, patient; TT, tracheostomy tube.
603
604

Table 3. Surgical Fires during Tracheotomy Procedures.

Age, Heat
Reference Procedure y Sex Source Fuel Oxidizer Acute Complications Long-term Complications

Aly (1991)93 Tracheostomy 57 F EC ETT, Pt FiO2 100% Anterior tracheal wall charring Death unrelated to fire
Awan (2002)94 Tracheostomy 35 F EC ETT, Pt FiO2 100% Minimal damage to local tissue None
Bailey (1990)95 Tracheostomy 33 F EC ETT, Pt FiO2 100% Thermal injury to posterior Death attributed to underlying
midtrachea, enlarged PTX condition
Baur (1999)96 Tracheostomy 72 M EC ETT, Pt FiO2 100% Intraoperative death N/A
Bowdle (1987)97 Tracheostomy 60 M EC Pt, glove, drape FiO2 100%a Second-degree burn of neck None
Chee (1998)98 Tracheostomy 28 M EC ETT, Pt FiO2 100% Minimal burn of surrounding None
tissue
Gorphe (2014)99 Tracheostomy 66 F EC ETT, Pt FiO2 100% Severe acute respiratory failure Multiple laryngotracheal
stenoses
Kim (2014)100 Tracheostomy 76 M EC Pt FiO2 100% Deep peristomal burns, Death, no etiology reported,
progressive peristomal fire potentially contributory
infiltrates (Pt with
preoperative ARDS), death
(no etiology reported)
Le Clair (1990)101 Tracheostomy 64 F EC ETT, Pt FiO2 100% Thermal injury to third tracheal None
ring
Lee (2012)102 Tracheostomy NR M EC ETT, Pt FiO2 50%, N2O Diffuse tracheobronchial burns, Death due to underlying
unexpected 7-wk ICU stay condition
Lew (1991)103 Tracheostomy 72 M EC ETT, Pt FiO2 100% Laryngotracheal burns, ICU stay Death 13 d after tracheostomy
attributed to
bronchopneumonia, surgical
fire a contributing condition
Lim (1997)104 Tracheostomy 36 M EC ETT, Pt FiO2 100% Laryngeal edema None
Lin (2005)105 Tracheostomy 48 F EC ETT, Pt FiO2 50% Anterior tracheal wall burn None
Mandych (1990)106 Awake NR F EC Pt, oxygen tubing, 5-LPM O2 Partial-thickness burns on face None
tracheostomy drape, towel (blow-by) and neck, hair singed
Marsh (1992)107 Tracheostomy 41 F EC ETT, Pt FiO2 100% Charring of surrounding tissue None
Michels (1994)108 Tracheostomy 61 M EC ETT FiO2 100% (ETT) None None
Ng (2003)109 Tracheostomy 54 F EC ETT FiO2 100% (ETT) Superficial burns of the neck None
Niskanen (2007)110 Tracheostomy 45 M EC ETT FiO2 100% (ETT) Charring of surrounding tissue, Death after discharge
13-d ICU stay, 8-wk
hospitalization
Paugh (2005)111 Awake 64 M EC Pt, face 10-LPM O2 (OM) Facial first- and second-degree NR
tracheostomy mask, gauze burns
Rogers (2001)112 Tracheostomy 31 M EC ETT FiO2 100% (ETT) None None

(continued)
 Table 3. (continued)
Age, Heat
Reference Procedure y Sex Source Fuel Oxidizer Acute Complications Long-term Complications

Rogers (2001)113 Tracheostomy 83 M EC ETT, Pt FiO2 100% (ETT) Stoma and tracheal burns None
Shin (2012)114 Tracheostomy 54 M EC ETT FiO2 100% (ETT) None None
Thompson (1998)115 Tracheostomy 4 M EC Pt, glove, drape, FiO2 50%, N2O Low neck second-degree burns None
suture
Thompson (1998)115 Tracheostomy 14 M EC Glove O2, N2O (ETT) None None
Thompson (1998)115 Tracheostomy NR NR EC NR FiO2 100% (ETT) None None
Tykocinski (2006)116 Tracheostomy 69 M EC Pt FiO2 100% (ETT) Stomal and laryngotracheal Tracheal stenosis, death not
burns attributed to the fire
Varcoe (2004)117 Tracheostomy 69 M EC ETT, Pt FiO2 100% (ETT) Partial- and full-thickness burns NR
of neck, circumferential
tracheal burns extending into
upper main bronchi
Weber (2006)50 Awake 62 M EC Pt, prep O2 via OM Second- and third-degree neck/ Second- and third-degree neck/
tracheostomy shoulder burns shoulder burns
Wheatley (2002)118 Tracheostomy 66 M EC ETT, Pt FiO2 100% (ETT) Full-thickness burn around None
stoma
Wilson (1994)119 Tracheostomy 61 M EC ETT FiO2 100% (ETT) None None
Wu (2002)120 Tracheostomy 88 M EC Pt O2 Tracheal injury (no further None
description)
Abbreviations: ARDS, acute respiratory distress syndrome; EC, electrocautery; ETT, endotracheal tube; F, female; FiO2, fraction of inspired oxygen; ICU, intensive care unit; M, male; N2O, nitrous oxide; NR,
not reported; O2, oxygen; OM, oxygen mask; prep, skin preparation; Pt, patient; PTX, pneumothorax.
a
Delivered via transcricothyroid membrane, 14-g intravenous catheter, with ventilation at 50 psi.
605
606

Table 4. Surgical Fires during Monitored Anesthesia Care or Local Procedures.

Reference Procedure Age, y Sex Heat Source Fuel Oxidizer Acute Complications Long-term Complications

Axelrod (1993)71 Supraorbital lesion 11 M EC Pt, gauze, nasal cannula 3-LPM O2 (NC) First- and second-degree None
excision burns, 4-d
hospitalization
Axelrod (1993)71 Blepharoplasty 43 M EC Pt 3-LPM O2 (NC) Eyelashes singed None
Brechtelsbauer (1996)121 Mohs reconstruction 46 F EC Pt, gauze, O2 tubing 4-LPM O2 (NC) Partial-thickness burns of None
face
Brechtelsbauer (1996)121 Biopsy of neck mass 78 M EC Pt, O2 tubing 10-LPM O2 (OM) Tracheal edema, partial- Late mild stenosis of
thickness burns of neck, tracheal stoma
2-d ICU stay
Chang (1994)12 Facial skin cancer excision 35 M EC Pt, nasal cannula Room air, Second-degree burns of None
preoxygenated face
prior to start
of surgery (NC)
Chang (1994)12 Facial skin cancer excision 65 M EC Pt O2 (NC) First-, second-, and third- None
degree burns of face
Chestler (1989)72 Levator repair 66 F EC Pt 3-LPM O2 (NC) Upper and lower eyelash None
burns
Chestler (1989)72 Wedge resection of NR NR EC NR 1-LPM O2 (OM) None None
upper eyelid lesion
Dini (2006)122 Blepharoplasty NR NR EC Pt, gauze, oxygen mask, O2 (OM) Second-degree burns of None
cotton-tipped applicator face
Haith (2012)123 Facial skin cancer 65 F EC Pt, drape 5-LPM O2 Partial-thickness facial and Persistent scar, PTSD
resection anterior trunk burns
Haith (2012)123 Benign facial lesion 39 F EC Pt, OM O2 (OM) Partial-thickness facial Persistent scar, anxiety
resection burns, hoarseness, disorder
cough
Haith (2012)123 Nasal polyp resection 14 F EC Pt, gauze, O2 tubing 2-LPM O2 (NC) Partial-thickness facial and Anxiety disorder
nasal burns
Haith (2012)123 Supraclavicular lymph 53 F EC Drape 6-LPM O2 Lid, facial, ear, neck burns NR
node excisional biopsy
Howard (1997)124 Excision of cheek basal 77 F EC Pt, nasal cannula, drape 2-LPM O2 (NC) Partial thickness facial and None
cell carcinoma lip burns
Lucarelli (1998)125 Ectropion repair 78 M EC Pt O2 (NC) Eyelashes singed None
Milliken (1985)126 Facial cyst excision 4 F EC Pt, gauze O2 (OM) First-degree burns to face NR
Prado (2007)127 Lower blepharoplasties 52 F EC Pt O2 (‘‘distant cannula’’) First-degree burns of None
upper eyelids, lash loss

(continued)
Day et al 607

Abbreviations: EC, electrocautery; F, female; ICU, intensive care unit; LPM, liters per minute; M, male; NC, nasal cannula; NR, not reported; O2, oxygen; OM, oxygen mask; Pt, patient; PTSD, posttraumatic
Long-term Complications
long-term complications, 7 died; in 2 of these cases, the fire
was a potential contributing etiology.

Discussion
This systematic and narrative review addresses the results of
the literature review and in the following sections discusses
None

None

None
the epidemiology, preparation and prevention, management,
NR and legal implications of surgical fires in otolaryngology
patients. The section on surgical fire prevention highlights 4
Second-degree facial/nasal

partial-thickness burns
O2 (‘‘distant cannula’’) Second-degree burn left
Acute Complications

common or controversial surgical fire scenarios.

5-LPM O2 (blow-by) Superficial and deep

Epidemiology
Eyelashes singed

Surgical fires in otolaryngology are well described in the lit-

erature (Tables 1-4). Schroeck et al surveyed 322 pediatric
to face
burns

brow

anesthesiologists regarding airway laser procedures in chil-

dren, and 6 (2%) reported the occurrence of an airway fire
in a child under their care.7 Additionally, according to a
survey of otolaryngologists conducted by Smith and Roy,3
27% of fires occurred during endoscopic airway surgery,
2-LPM O2 (NC)
Oxidizer

24% during oropharyngeal surgery, 23% during cutaneous

surgery of the head and neck, and 18% during tracheost-
omy. In this review, more surgical fires occurred during tra-
cheotomy (36%), followed by cervicofacial procedures
O2

(28%), endoscopic laryngotracheal procedures (25%), and

oral cavity/oropharyngeal procedures (11%). The studies in
this review implicate the 3 components of the fire triad: oxi-
dizers (oxygen in 99% of cases), heat sources (electrocau-
Pt, gauze, drape

Pt, paper towel

tery or CO2 laser in 94% of cases), and fuel (endotracheal

Fuel

Pt, O2 tubing

tube in 49% of cases). The importance of keeping FiO2

\30% is highlighted by the findings that 97% of surgical
fires in non–nitric oxide general anesthesia cases involved
FiO2 levels .30% and 92% of surgical fires in non–nitric
Pt

oxide general anesthesia cases involved FiO2 levels .40%.

Age, y Sex Heat Source

Finally, the complications of surgical fires in otolaryngology

EC

EC

EC

EC

patients can be severe: 15% of patients required unexpected

mechanical ventilation, and at least 1 patient died.
M

NR

Preparation
As previously noted, the FDA, ASA, ECRI, AORN, APSF,
28

27

55

NR

and JCAHO have all made recommendations regarding the

prevention and management of surgical fires. An analysis of
the basis of all such recommendations is not within the
Lower blepharoplasties

scope of this review. Instead, prescient themes (in italics)

Closed rhinoplasty
Procedure

are identified and discussed.

Mohs resection

Blepharoplasty

Several articles highlighted lack of education and need

for increased fire awareness among operating team mem-
bers.6,13,14 Specific deficits included failure to minimize
OEAs in the presence of an ignition source, knowledge gaps
regarding the safe use of electrosurgery instruments, and
general knowledge deficits in surgical fire prevention and
management.6,13,14 Indeed, according to Watanabe et al,
Table 4. (continued)

among 145 Japanese general surgeons, including residents

Prado (2007)127

Prado (2007)127

Reyes (1995)128

(n = 57, 39%), 19% did not know how to manage an OR

Saha (2010)129

stress disorder.

fire.13 This is not surprising: a surgical fire is an unexpected

Reference

acute event for which most surgeons lack practical experi-

ence or formal simulation training. Fortunately, many
resources are available to the individual seeking to augment
608 Otolaryngology–Head and Neck Surgery 158(4)

Table 5. Preassigned Tasks in the Event of an OR Fire.

Team Member Task

Anesthesiologist Turn off oxygen/nitrous oxide and maintain ventilation with mask respirator (ie, Ambu bag).
Communicate with the circulator to turn off the medical gas shutoff valves.
Disconnect all electrical equipment on the anesthesia machine.
Disconnect any leads, lines, or other equipment that may anchor the patient.
Maintain the patient’s anesthesia during transport.
Surgeon Remove from the patient materials that may be on fire.
Control bleeding and prepare the patient for evacuation.
Conclude the procedure as soon as possible.
Place sterile towels or covers over the surgical site.
Scrub nurse Remove from the patient materials that may be on fire, and help put out the fire.
Obtain sterile towels or covers for the surgical site and instruments.
Gather a minimal number of instruments onto a tray or basin, and place them with the patient for transport.
Assist with patient transfer from the OR table to a stretcher/bed for transport out of the OR.
Circulating nurse Ensure the patient’s safety by remaining with and comforting the patient.
Activate the fire alarm system, and call the fire code to alert all necessary personnel.
Extinguish small fires or douse them with liquid if appropriate.
Remove any burning material from the patient or sterile field, and extinguish it on the floor.
Collaborate with the anesthesia staff on the need to turn off the medical gas shutoff valves.
Carefully unplug all equipment if the fire is electrical.
Be aware of the safest route for escape.
Obtain a transport stretcher if necessary.
Remove intravenous solutions from poles, and place them with the patient for transport out of the OR.
Abbreviation: OR, operating room.

his or her fire safety knowledge base. The FDA, ASA,
ECRI, AORN, APSF, and JCAHO all either maintain online
resources or have published formal reviews or guidelines.
Two articles by DeMaria et al and Corvetto et al highlight
case simulations of airway fire during tracheostomy and
burr hole placement under MAC, respectively.15,16 Both the
ASPF and the FDA have made fire safety videos available
online.17,18
In addition to individual education, team-based training
in surgical fire prevention and management is recom-
mended.4 According to the ASA, OR fire drills—or the
formal and periodic rehearsal of the OR teams’ planned
response to a fire—should be prioritized and performed
during dedicated education time, not during patient care.
Preassigned fire response tasks recommended by the AORN
specific to each OR team member should be learned at this
time (Table 5).19 Continued efforts to optimize team com-
munication are critical to preparing for a cohesive response
to a surgical fire.20 The availability and use of a surgical
fire checklist are also indicated. Arriaga et al performed a
simulation-based study assessing the management of 12 sur-
gical crises (1 of which was an OR fire) by 17 OR teams.
They noted that failure to adhere to lifesaving processes of
care was significantly less likely when teams had access to
checklists (6%) versus when they did not (23%; P \
.001).21
Consideration of health care facility systems and prac-
tices are also necessary for delivery of an effective fire
response.22,23 Fire safety preparation requires OR team
knowledge of equipment and supplies that should be immedi-
ately available in the event of a fire. According to the ASA,
the following items are needed: several containers of sterile
saline, a carbon dioxide fire extinguisher, replacement tra-
cheal tubes and face masks, laryngoscope blades, possible
rigid videolaryngoscope, replacement airway breathing cir-
cuits and lines, replacement drapes, and sponges. Algorithms
documenting surgical fire prevention and management should
be easily visible in each OR in which high-fire risk surgery is
carried out (Figure 3).4 Facility compliance with fire safety
codes is also important but beyond the scope of this review.
Other available resources address issues such as maintenance
of fire alarms, fire extinguisher proximity, and adequate OR
walkway maintenance for access to fire safety equipment or
as a route of evacuation.22,24,25 The medical community
should also consider standardizing the reporting of surgical
fires to further refine existing guidelines in an evidence-
based manner.
Prevention
Preoperatively, the entire surgical team (including surgeon,
anesthesiologist, OR nurses) should evaluate the patient’s
fire risk using a formal risk assessment protocol. The popular
Surgical Fire Risk Assessment Score helps in the stratifica-
tion of fire risk and in the implementation of the appropriate
fire risk protocol, as described by Mathias (Figure 4).26
Staff should specifically attend to high-fire-risk surgery
Day et al 609

Figure 3. American Society of Anesthesiologists’ operating room fires algorithm. Reproduced with permission from Wolters Kluwers
Health, Inc and RightsLink. Copyright license 4185650746946 obtained September 10, 2017. Apfelbaum, JL, Caplan RA, Barker SJ, et al.
Practice advisory for the prevention and management of operating room fires: an updated report by the American Society of
Anesthesiologists Task Force on Operating Room Fires. Anesthesiology. 2013;118(2):276. http://anesthesiology.pubs.asahq.org/article.aspx?art
icleid=1918685. Accessed August 28, 2017.
610
Figure 4. Surgical fire risk assessment score. Reproduced with
permission from Christiana Care Health System (PO Box 1668,
Wilmington, DE 19899) on September 13, 2017. Surgical fire risk
assessment. https://christianacare.org/forhealthprofessionals/educa
tion/fireriskassessment/. Accessed September 6, 2017.
(Surgical Fire Risk Assessment Score = 3), which involves
(1) a surgical site above the xiphoid process (2) with an open
oxygen source and (3) an available ignition source.26 A laser-
resistant endotracheal tube should be obtained for anticipated
laser surgery.1,4
In the OR, flammable skin-prepping agents should be
identified and allowed to dry prior to draping. Surgical
drapes should be appropriately configured. The anesthesiol-
ogist and surgeon must collaborate throughout the case to
minimize the OEA’s proximity to an ignition source.
Oxygen delivery should be stopped or the delivered oxygen
concentration reduced to the minimum necessary 1 to 3
minutes prior to activation of an ignition source in the surgi-
cal field. Gauzes and sponges should be moistened prior to
use in proximity to an ignition source. Surgical teams
should scavenge with suction to reduce the OEA as indi-
cated and appropriately manage electrosurgical devices,
including when not in use.1,4 Staff should be familiar with
examples of fuels, oxidizers, and heat sources in the OR
(Table 6).1 Recognizing human factors that predispose to
surgical fires is also important. According to Watson, these
include complacency, distraction, inattentiveness, slow reac-
tion, improper firefighting techniques, improper firefighting
tools, and feeling rushed.5 Further details concerning perio-
perative fire safety prevention are documented in the guide-
lines promulgated by the ASA and ECRI. Four common or
controversial scenarios resulting in surgical fires are dis-
cussed as follows.
Use an Appropriate Endotracheal Tube and Minimize Delivered
Oxygen Concentration before Using an Ignition Source in the
Upper Aerodigestive Tract: Safely Manage Fuel, Oxidizer, and
Heat Sources. Upper aerodigestive tract fires account for
69% of otolaryngologic fires according to the survey per-
formed by Smith and Roy and 72% of reported otolaryngo-
logic fires according to this review.3 Electrocautery or the
CO2 laser was used in 94% of these cases. Since use of a
heat source in surgery involving the upper aerodigestive
tract is common and in many cases necessary, safe manage-
ment of oxidizers and fuel is critical. In fact, oxygen deliv-
ery was reduced to 30% prior to use of an ignition source
in only 3% of non–nitric oxide upper aerodigestive tract
Otolaryngology–Head and Neck Surgery 158(4)
cases in this review, and laser-safe endotracheal tubes were
used in only 12% of indicated endoscopic laryngotracheal
cases. Roy and Smith demonstrated a decreased fire risk in
the setting of decreased oxygen concentrations in their
chicken model (no fire at \50% FiO2) and mannequin
model (no fire at room air) simulating oropharyngeal and
laser surgery, respectively.27,28 The results of this review sup-
port the recommendations promulgated by the ASA, ECRI,
JCAHO, and AORN: only 2 of 34 non–nitric oxide upper
aerodigestive tract cases (6%) recording O2 concentration and
type of endotracheal tube were guideline compliant. While
guideline adherence may drastically reduce upper aerodiges-
tive tract fires, compliance may not prevent all fires. Ilgner
et al reported a surgical fire during CO2 laser endoscopic
vocal fold granuloma ablation in which FiO2 was kept at
30% and a laser-safe tube was used.29 While no cuff
injury was described in this case, careful attention to cuff
integrity may be the next-most important practice in otolaryn-
gologic airway fire safety. Indeed, Sosis reported that a
Xomed Laser Shield cuff injury was responsible for a surgi-
cal fire during CO2 laser endoscopic vocal polyp removal.30
Roy and Smith confirmed the potential for airway fire despite
use of a laser-safe endotracheal tube and saline-soaked pled-
gets via cuff perforation.28 Further studies of other double-
cuffed laser safe endotracheal tubes are indicated. In surgery
involving the upper aerodigestive tract or airway and the 3
components of the surgical fire triangle, care must be taken
to minimize oxygen delivery, safely manage heat sources,
and utilize appropriate endotracheal tubes.
Minimize OEA during MAC Cases Involving an Ignition Source:
Safely Manage Oxidizing and Heat Sources. According to
Mehta et al, among 103 OR fires identified in the ASA
Closed Claims Database between 1985 and 2009, 78 (76%)
occurred during MAC, 99% of which involved the use of
supplemental oxygen.31 In the MAC and local cases
described in this review (Table 4), oxygen was being admi-
nistered in all but 1 of the cases involving surgical fires; in
the case involving a fire at room air, the patient had just
been preoxygenated. These unique surgical fires prompted
surgeons to investigate the genesis and prevention of these
fires. Laboratory studies evaluating OR material flammabil-
ity (especially surgical drapes) in the setting of increased
oxygen concentrations have consistently demonstrated a
decreased time to fuel ignition, increased total burn time,
and increased speed of fire propagation.32-34 According to
Barnes and Frantz, among mock patients receiving oxygen
by nasal cannula and draped for an ophthalmic procedure,
oxygen concentrations below the drapes rose up to 45%
with oxygen flow delivery by nasal cannula at 4 LPM.35
Minimization of oxygen delivery at all times and avoidance
of (1) drape tenting and (2) creation of an OEA beneath the
drapes that easily connects to the surgical field are broadly
accepted recommendations. Examples of other posited solu-
tions include a midfacial seal drape, discontinuation of nasal
cannula, supplemental oxygen delivery via a modified naso-
pharyngeal tube further sealed with an ipsilateral ear plug in
Day et al 611

Table 6. Examples of Fuels, Oxidizers, and Heat Sources in the Operating Room.
Source Examples
Heat Electrosurgical units, electrocautery units, laser, fiberoptic light sources and cables, sparks from high-speed surgical drills
and surgical burrs, defibrillators, glowing embers of charred tissue, other electrical hemostatic devices, ultrasonic
hemostatic or cutting devices, flexible endoscopes, tourniquet cuffs
Fuel Degreasers, flammable prepping agents (chlorhexidine gluconate, thimerosal, iodophor), drapes, towels, gowns, hoods,
masks, surgical sponges, dressings, ointments, petrolatum (petroleum jelly), tincture of benzoin, aerosols, paraffin, white
wax, patient’s hair, gastrointestinal tract gases (ie, methane), aerosol adhesives, alcohol (including alcohol in suture
packets), instrument and equipment drapes and covers, eggcrate mattresses, mattresses and pillows, blankets, adhesive
tape (cloth, plastic, paper), elastic bandages, stockinettes, collodion, disposable packaging materials, smoke evacuator
hoses, some instrument boxes and cabinets
Oxygen Oxygen-enriched atmosphere (ie, via nasal cannula or mask), nitrous oxide, petroleum-based jelly on eyes, flexible
endoscopes, anesthesia components (breathing circuits, masks, airways, endotracheal tubes, suction catheters, pledgets),
coverings of fiberoptic cables and wires (electrosurgery unit leads, electrocardiogram leads), blood pressure cuffs,
stethoscope tubing

the nares, supplying sub-100% oxygen-gas mixtures via
nasal cannula, air delivery at 5 to 10 LPM under the drapes
to dilute the OEA, and cessation of supplemental oxygen
for MAC cases altogether.36-41
Among patients scheduled for moderate to deep con-
scious sedation with an anticipated oxygen requirement and
ignition source, the ASA-PA, ECRI, and JCAHO have rec-
ommended the following: (1) reassess general anesthesia
preoperatively (ie, sealed gas delivery); (2) if MAC remains
unavoidable, start FiO2 delivery at 30% and increase only
as necessary; (3) discontinue oxygen or use the minimum
required to avoid hypoxia, and wait 1 to 3 minutes prior to
the use of an ignition source.1,4
Carefully Monitor Ignition Sources in the Operative Field: Safely
Manage Heat Sources. According to Smith and Roy, electro-
surgical instruments and fiberoptic light sources were the
respective sources of 71 and 25 fire and burn incidents
reported to the FDA between 1998 and 2006.42 In their own
experiment, a fiberoptic light source resulted in drape
damage even in the absence of oxygen. At the first and
senior authors’ past institution, an unattended fiberoptic
light source resulted in a smoldering fire involving an
approximately 2-cm area of the dry surgical drapes alone.
The fire was easily put out and no harm reached the patient.
No reported fires due to fiberoptic light sources were identi-
fied in this literature review.
Carefully Consider the Use of Alcohol-Based Skin Preparation
Agents: Safely Manage Fuel Sources. As evidenced in Table 6,
almost anything in the OR can be a fuel source. Among
these, alcohol and alcohol-based skin preparation agents
may be the most controversial. While skin preparation
agents were implicated in only 2 of 87 (2%; Tables 1-4)
otolaryngologic surgical fires, they have been deemed etio-
logic in many nonotolaryngologic surgical fires. In the
United Kingdom, the National Reporting and Learning
Service reported 13 OR fires over a 7-year period (March 1,
2004–March 1, 2011). Eleven of these fires were directly
related to the use of alcohol-based skin preparation: 4 were
attributed to not allowing the solution to dry, 4 to solution-
soaked swabs remaining in the field, and 3 to solution-
soaked drapes. Chlorhexidine was used in 8 cases and
povidone-iodine in 1 case; the type of alcohol-based solu-
tion was not detailed in the remaining 2 cases.43 Today, the
most common skin preparation agents include iodophors or
chlorhexidine gluconate (CHG) and are further classified by
their aqueous- or alcohol-based diluent: aqueous-iodophor
antiseptics (Betadine, Scrub Care), aqueous-CHG antiseptics
(Hibiclens), alcohol-iodophor (DuraPrep, Prevail-FX), and
alcohol-CHG (ChloraPrep).44 One case described a surgical
fire involving skin preparation agents in the absence of heat
or oxidizing sources: a patient’s right arm and hand were
being prepped with 83% ethyl alcohol solution when a fire
involving the patient’s right arm was suddenly noted. The
authors presumed that the fire started due to a static spark.45
A recent study evaluated the impact of skin preparation
agent choice (aqueous vs alcohol based) on the incidence of
OR fires in ex vivo clipped porcine skin models.46 The
models were exposed to an activated electrosurgical pencil
at 30 W for 2 seconds in room air. The authors found that
after allowing for 3 minutes of drying time, no flash fires
occurred after use of nonalcoholic-based preparation, whereas
flash fires occurred in 10% of cases (n = 6 of 60; P \ .001)
after alcohol-based preparations were used. As acknowledged
by the authors, however, the use of porcine cadaver skin
(which appeared hirsute in the included picture) is a poor sur-
rogate for living human tissue.46
In light of such cases and findings, some have gone so
far as to recommend banning the use of alcohol-based surgi-
cal antiseptics.47 However, other investigators demonstrated
that alcohol-based skin preparation agents are more effec-
tive at preventing surgical site infections as compared with
their aqueous-based counterparts.48 Furthermore, alcohol-
based skin preparation agents have rarely been implicated in
surgical fires when used according to manufacturer instruc-
tions.49 Hence, proponents encourage continued use of these
612
agents, emphasizing the importance of allowing sufficient
agent drying time and arguing the benefits outweigh the
risks.49 According to this review, 2 otolaryngologic surgical
fires occurred after application of DuraPrep (74% isopropyl
alcohol) and Prevail (59% ethanol) in an unshaved, hirsute
patient undergoing tracheostomy and in the unclipped scalp
of a patient undergoing a retroauricular mass excision,
respectively; in both cases, at least 3 minutes of drying time
was observed.50,51 Although otolaryngologic surgical fires
attributed to alcohol-based skin preparation agents are rare,
clinicians may consider avoiding the use of such agents in
unshaved, dense hair-bearing areas. Further studies on this
topic are needed.
Management
Appropriate fire management acknowledges the components
of the surgical fire triangle model. Fire response goals
include temperature reduction, fuel removal, and oxygen
dilution. The stepwise management of a surgical fire is
comprehensively documented in the OR fires algorithm of
the ASA-PA (see Figure 3)—this document should be
available in the OR.4,21 Additional attention to a few con-
cepts is warranted. Identification of early signs of a surgical
fire and prompt removal of fuel, oxidizers, and a heat
source from the field may minimize patient injury. A CO2
fire extinguisher should be used in the event of fire refrac-
tory to initial measures.
There is a significant lack of data in the otolaryngologic
literature to guide patient management after a surgical fire
involving the upper aerodigestive tract. The ASA-PA recom-
mends tracheobronchoscopy after an airway fire to serve mul-
tiple purposes.4 From a diagnostic standpoint, tracheal tube
fragments and other foreign body fragments may be identi-
fied; furthermore, the degree of inhalation injury may be
ascertained by the presence of hyperemia, edema, ulceration,
or necrosis.52,53 The procedure holds therapeutic value, as
foreign bodies, debris, and soot may be removed and initia-
tion of medical treatment for inhalation injury delivered.
Surgeons may also prognosticate the need for mechanical
ventilation or additional procedures based on their findings.
While comprehensive management of the patient is beyond
the scope of this article, a cursory discussion of the burn and
inhalation injury literature is indicated. Multidisciplinary
management of the patient in an intensive care unit should be
considered. In the acute setting, emphasis should be placed
on continuous respiratory monitoring, humidification, conser-
vative fluid resuscitation, lung-protective mechanical ventila-
tion, pulmonary toilet, and identification and treatment of
carbon monoxide and cyanide poisoning; in addition, nitric
oxide and nebulization of beta-2 agonists, n-acetylcysteine,
anticoagulants, and anti-inflammatory agents may be help-
ful.54-59 Respiratory failure may occur 12 to 48 hours after
injury, and upper airway edema may take 3 to 6 days to
resolve.58,59 Patients should be monitored for tracheobron-
chial tree edema, mucosal sloughing, stenosis, tracheoesopha-
geal fistula, pneumonia, pulmonary congestion/edema, pleural
Otolaryngology–Head and Neck Surgery 158(4)
effusion, and pneumothorax. Lund et al recommended mini-
mizing the duration of endotracheal intubation and avoiding
tracheostomy, if possible.59 Serial fiberoptic tracheobroncho-
scopic examinations and spirometry should be considered over
the long term.29,55
Legal Implications
The legal implications of surgical fires are significant. In an
analysis of the ASA Closed Claims Database from 1985 to
2009, Mehta et al identified 103 OR fire claims and 5194
nonfire surgical anesthesia claims.31 Of the 103 claims, 78
(76%) occurred during MAC or regional anesthesia and 25
(24%) during general anesthesia or general/regional anesthe-
sia. Furthermore, 83 (81%) resulted in temporary or nondi-
sabling injury, 14 (14%) in permanent or disabling injury,
and 6 (6%) in death. These findings approximate the results
of our review, in which 22% of surgical fires resulted in
long-term complications. According to the Mehta et al
study, payments were made in 80 cases (78%).31 The
median payment was $120,166, with an interquartile range
of $43,861 to $280,000. Interestingly, when compared with
nonfire surgical anesthesia claims, OR fire claims resulted
in lower severity of injury and a higher percentage of pay-
ments made, with lower total payment amounts. Bhananker
et al analyzed the same database between 1990 and 2002.60
Of 121 MAC claims, 20 (17%) were due to surgical fires; in
contrast, of 1519 general anesthesia claims, only 10 (1%)
were due to surgical fires. Damages awarded can far exceed
the modest payments noted here. One newly ventilator-
dependent victim of an airway fire after elective laryngeal
laser surgery was reportedly awarded over $18,000,000.61
Conclusion
Surgical fires persist despite aggressive multiorganizational
initiatives to curb their incidence. Otolaryngology patients
are at increased risk. Guideline-adherent fire prevention
practices and individual and institutional fire safety prepara-
tion are needed to effectively prevent and manage surgical
fires.
Acknowledgments
The authors wish to acknowledge Donna Hesson, MLS and Stella
Seal, MLS.
Author Contributions
Andrew T. Day, data analysis, drafting, final approval, and
accountability; Erika Rivera, data analysis, drafting, final approval,
and accountability; Janice L. Farlow, data analysis, drafting, final
approval, and accountability; Christine G. Gourin, data analysis,
drafting, final approval, and accountability; Brian Nussenbaum,
data analysis, drafting, final approval, and accountability.
Disclosures
Competing interests: None.
Sponsorships: None.
Funding source: None.
Day et al
Supplemental Material
Additional supporting information is available in the online version
of the article.
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