|Year : 2014 | Volume
| Issue : 4 | Page : 198-203
Chemical burns of the head and neck following assault in Zaria, North West Nigeria: A demographic and clinical profile
Ibrahim Abdulrasheed1, Ijekeye O Ferdinand2, Asuku E Malachy1
1 Department of Surgery, Division of Plastic Surgery, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State, Nigeria
2 Department of Surgery, Division of Plastic surgery, University of Benin Teaching Hospital, Benin, Edo state, Nigeria
|Date of Submission||14-Apr-2014|
|Date of Acceptance||08-Sep-2014|
|Date of Web Publication||14-Nov-2014|
Division of Plastic Surgery, Department of Surgery, PMB 06, ABUTH, Shika Zaria, Kaduna state
Background: Chemical burns sustained following assault, represent a considerable medical and financial challenge for the society. These patients have poorer outcomes, are difficult to manage, and represent an economic drain on an already-strained health care system. This article explores the peculiar presentation and management of chemical burns of the head and neck in Zaria, North West Nigeria. Materials and Methods: The study was performed between April 2004 and June 2013. A retrospective medical records review was undertaken to select patients who had burn injuries to the head and neck from chemicals in the setting of an assault. Recorded information included details of the patient demographics, clinical presentation and treatment. Records with incomplete data were excluded. Results: The motive for the assault in three victims was revenge for perceived injustices at school and work, and in the setting of a relationship that had gone sour in one patient. The assailant was known to the victims in two of the chemical assault. The upper eyelids, nose and the scalp were most commonly injured. Two patients sustained chemical burns to the eyes with complete loss of vision, (no light perception) and three developed mentosternal contractures. Twenty six reconstructive procedures were carried out and these patients underwent an average of three operations each during admission in the hospital. The average hospital stay was 5 months with a range of 1-14 months. Conclusion: There was a preponderance of male patients and most of the perpetrators were men. Motive was reduced to three categories robbery, matters related to love or the lack of it and revenge. Majority of the patients in this study had burns <30% of the total body surface area, however more than half of the patients required three or more surgical procedures. A multidimensional approach will be required to prevent chemical assault through heightening awareness, legislation and enforcement.
Keywords: Assault, chemical burns, head and neck
|How to cite this article:|
Abdulrasheed I, Ferdinand IO, Malachy AE. Chemical burns of the head and neck following assault in Zaria, North West Nigeria: A demographic and clinical profile. Sub-Saharan Afr J Med 2014;1:198-203
|How to cite this URL:|
Abdulrasheed I, Ferdinand IO, Malachy AE. Chemical burns of the head and neck following assault in Zaria, North West Nigeria: A demographic and clinical profile. Sub-Saharan Afr J Med [serial online] 2014 [cited 2019 Aug 25];1:198-203. Available from: http://www.ssajm.org/text.asp?2014/1/4/198/144743
| Introduction|| |
Assault through the use of chemical agents, are a rare but profound medical and social problem of global reach and significance. They are reported to form up to 10.7% of total burns cases, and account for 2-6% of burns centre admissions. ,, The socioeconomic impact of this intentional trauma has received a great deal of interest because of the immense challenges of management and rehabilitation. 
Patients sustaining chemical burn injury represent a patient population with unique clinical presentations and outcomes. , The intent of the assailant is to disfigure and in an effort to maximize the impact of what is frequently an easy weapon to obtain and use, the target is often the head and neck, especially the face. ,, Small volumes of acid or alkali are capable of achieving this objective.  The costs are seen in poor patient outcome characterized by severe functional and aesthetic impairment and multiple reconstructive needs that are often difficult and limited. ,,, Survivors are driven to social isolation and the damage to their self-esteem forces them to leave work or school, which leads to illiteracy and poverty, thus further increasing the economic strain on the victims' scarce resources. 
Chemical burns of the head and neck certainly deserve increased recognition and attention. , Only through a determined collection and analysis of data related to chemical assault burn injuries can we become more efficient in the appropriate medical, psycho-social and judicial interventions.  The purpose of this study is to determine the motives, presentation and provide an account of our experience in the management of chemical burns.
| Materials and methods|| |
This study was conducted at Ahmadu Bello University Teaching Hospital Zaria. It serves a cosmopolitan city of about of about 408,198 (2006 census population) and receives tertiary referrals from other hospitals in Northern Nigeria. The inhabitants consist of government officials, clerks, petty traders and students. Outside Zaria, the suburbs are typically rural Nigeria, an agrarian society with clusters of villages inhabited by peasant farmers, self-employed laborers, artisans and shopkeepers. The study was performed between April 2004 and June 2013. A retrospective medical records review was undertaken to select patients who had burn injuries to the head and neck from chemicals in the setting of an assault. Recorded information included details of the patient demographics, clinical presentation and management. Exclusion criteria were patients with incomplete records.
| Results|| |
Twelve patients sustained chemical burns of the head and neck during the period under review, and nine patients fulfilled the inclusion criteria (Three patients had incomplete records). The median age was 31 years, with a range of 18-41 years. The male to female ratio of the victims was 2:1. The youngest victim was an undergraduate student and two were unemployed. The other six victims were engaged in some form of occupation, of which four were semi-skilled workers and two were lecturers in the university [Table 1]. Most of the assaults occurred at home in six of the victims. The other three victims were attacked at work, school and in a car. The majority of the assaults occurred at night while the victim was on the road or in the vicinity of their home and in three patients the attack was during the day [Table 1]. The motive for the assault in three victims was revenge and in the setting of a relationship that had gone sour in one. The assailant was known to the victims in two cases, and prehospital water irrigation was done in only three patients.
The upper eyelids, nose and the scalp were most commonly injured. Two patients sustained chemical burns to the eyes with complete loss of vision (no light perception) and three developed mentosternal contracture [Table 2]. Other complications included deformities of the auricle and postburn alopecia. The mean total body surface area (TBSA) burnt was 16% with a range of 7-39%. Majority of the patients had TBSA between 11% and 20%. Only one patient had TBSA burned over 30% [Table 2]. Twenty-six reconstructive procedures were carried out, and each of these patients underwent an average of three operations during admission. The commonest reconstructive surgeries were skin grafts, correction of ectropion of the eyelids and release of mentosternal contractures [Table 2]. Five patients had Class III facial impairment. (American Medical Association Criteria for Facial Impairment)  [Table 3]. The duration of hospital stay was 1-6 months in 7 patients [Figure 1]. None of the patients in this study spent <1-month in the hospital. Only one patient received consultation from a clinical psychologist in order to deal with the psycho-social impact of the injuries.
|Figure 1: Duration of hospital stay of patients with chemical burns of the head and neck|
Click here to view
|Table 1: Demographic characteristic of patients with chemical burns of the head and neck|
Click here to view
|Table 2: Clinical characteristics of patients with chemical burns of the head and neck|
Click here to view
|Table 3: American medical association criteria for facial impairment. Adapted from Yeong et al.|
Click here to view
| Discussion|| |
There are trends that accord to gender, identity of perpetrator and motive in chemical assault burns in the literature.  Majority of the victims are female, and most of the assailants are male. Psycho-social problems in the communities such as failed love affairs, marital disharmony, family disputes and issues related to land, money and business ventures, are some of the main root causes that trigger a chemical assault. 
The results of this study suggest similarities with the demographic trend described in earlier studies. ,, Although there was a preponderance of male patients in our study, most of the perpetrators were men. Motive was reduced to 3 categories in our study: Robbery (three patients); Matters related to love or the lack of it (two patients); and revenge (three patients). Familiarity with the assailant was established in only two patients. One for rejection of male sexual advances and the other for perceived injustices at work. The assailant was recognized and known in both patients. Globally, the exact explanation for the variation in gender and motive is not clear, some of it may be explained by socio-cultural differences, and the country where the studies originated. , In the setting of domestic disputes, including marital infidelity or rebuked romantic advances,  the use of chemicals in assault has been recognized as being typically a crime of passion.  Acid is used by an embittered acquaintance in an act of punishment or revenge with intent to inflict severe pain and cause permanent disfigurement.  In Bangladesh, the act of chemical assault has been aptly labeled a "gender crime" and there is a dominance of female victims. This is largely a representation of the uptake of acid by men, as means to disfigure women whom they believe have spurned their advances. ,, In Jamaica, the assailant was more likely to be female, who assaults another woman with whom her spouse has been unfaithful, , while, In Cambodia, the assailant is usually a woman who attacks her unfaithful husband.  Three patients were victims of chemical assaults during a robbery. In both motorcycle and car hijackings, acid is splashed on the face of the driver and the motorcycle or vehicle is stolen. Presumably, the acid acts as a convenient means of immobilizing the victim during a robbery - its consequences are devastating.  This is similar to the findings by Achebe et al. 
In this study, 7 (78%) of the perpetrators were unknown to the victim. This is consistent with the findings in Jamaica where a large proportion of acid assault were perpetrated by unknown assailants.  However, in the study by Brodzka et al.  the assailant was known to the victim in 34 (62%) of the instances. In 20 of the 34 cases (37%), the assailant was a sex partner, most often the victim's wife. Other authors have reported that most of the victims were assaulted by their partners or family members.  These can be considered as a significant display of violence and traumatic interpersonal relationships in the society.  Regardless of gender or motive, the attacks fulfill their intended consequences, and the resulting scarring and deformities lead to disability, destitution, and social isolation. 
A literature review on facial mutilation after an assault with chemicals, speculates that concentrated acids especially sulfuric acid is the commonest chemical used.  Sulphuric acid is relatively easy to obtain, and a relatively common and cheap source is the car battery.  It is used to replete dry lead-acid batteries.  Dry lead-acid batteries form sulpuric acid in the process of "suphation" when the battery "dies." This is restored (desulfated) with sulphuric acid.  Branday et al.  observed that readily obtainable chemicals such as sulfuric acid have been used as weapons of assault or self-defense by those who cannot afford handguns. They were of the opinion that because the intent is to maim and scar but not to kill, chemicals are a preferable choice over more lethal weapons. , Injuries were usually sustained while patients were alone, and the chemical was commonly kept in a plastic basin or cellophane bag. The chemical was either poured on the face of the patient during an attack or while the patient was sleeping in one of the cases.  In the majority of the patients, the anterior aspect of the body was burnt compared with the back, highlighting the fact that most assaults were directed from the front, aiming at the face. 
Most of the patients in our study did not receive adequate prehospital water irrigation. Perhaps the lack of knowledge of first aid treatment and also the circumstances at the time of the assault appear to have contributed to the inadequate prehospital care. , These characteristics dictate the appropriate first aid which consists of prompt removal of all clothing and immediate lavage with copious volumes of water. Irrigation with ample amounts of water and removal of clothes soaked with acid eliminates the injuring agent. This dilution should begin as early as possible and continue until the acid is totally neutralized. , The effectiveness of immediate irrigation is substantiated both by experimental data and clinical studies, which have consistently demonstrated significantly less full skin thickness injury and shorter hospital stays in patients receiving appropriate first aid.  The extreme urgency of continued flushing should be stressed to all that provide first aid.  An increase in awareness among the population as to the need for prompt water irrigation of chemical burns will help reduce the morbidity from these injuries. 
Previous studies have reported that the TBSA in chemical assault patients varies between 13.7% and 24.8%.  About 80% of the patients in this study had burns <30% TBSA. Our study shows a similarity to the study by Tahir et al.  where 85% of the patients sustained burns ranging from 8% to 33% of their body surface area. Patients injured after a chemical assault to the head and neck usually have full thickness burns that lead to severe functional sequelae.  In this study, the commonest sequelae were stenosis of the nostrils and ectropion of the upper and lower eyelids. Four patients developed nasal stenosis. It was bilateral in one patient. The patient had excision of the obstructing cicatrix and replacement with full thickness skin graft with a stent in the nostrils postoperatively. A satisfactory improvement of the nostril aperture was achieved in the left nostril, but there was a re-stenosis of the right nostril. Two patients had evisceration and insertion of the prosthesis. The risk for blindness is relatively high, and its incidence varies from 14% to 63% in the literature.  The grading of facial appearance (disfigurement) is based on the evaluation of permanent impairment [Table 3].  55% of the patients in this study, sustained a Class III facial impairment. These patients remain severely impaired psychosocially. 
The management of chemical burns of the head and neck requires a multidisciplinary approach with extensive surgical, psychological, and social support to improve outcome.  In-addition, the required number of reconstructive procedures in victims of assault is quite high. More than half of the patients in this study required three or more surgical procedures, which consisted of burn wound debridement and skin grafting. The current standard of care in the management of chemical burn injuries is early excision and grafting of the deep partial and full thickness injuries. Several studies have demonstrated that burn wound excision and the application of split-thickness skin grafts can significantly reduce contracture formation. ,, However, the availability of burn surgeons and blood transfusion services limit routine treatment in this fashion.  In this study, the longer stay in the hospital reflects the common practice of occlusive dressings, eschar separation and skin grafting. Subsequently, release of contractures and scar revision is undertaken.
Aesthetic restoration by surgical reconstruction is the primary goal in these patients. The criteria for "success" will include an undistracted "normal" look at a conversational distance, facial balance and symmetry. Others are fused inconspicuous scars in distinct aesthetic units, and a dynamic facial expression. These aesthetic results may not be possible in victims of chemical assault.  Thus, focusing on prevention rather than treatment cannot be over-emphasized. Multiple actions will be required to prevent chemical assault through heightening awareness, economic support, legislation and enforcement. ,, A significant barrier to prevention of chemical assaults is the reluctance of victims to press charges against the perpetrators. A detailed review notes that the victims are reluctant to report the identity of the assailant.  The victims' reluctance is due in part to their resignation regarding their perception of the inevitability of inaction on the part of the legal system. They, and others associated with the pursuit of justice, also dread the expenses associated with the process.  A policy of zero-tolerance for chemical attacks and strict regulation of sale would go a long way towards meeting the challenge posed by burns from chemical assault.  Acid attacks in Bangladesh have dropped by 75% since 2002, following the adoption of specific laws criminalizing chemical violence and limiting accessibility to acid through introduction of licenses. 
There are a few important limitations of this study. First is the nature of the study - a retrospective study. Retrospective studies are usually based on clinic records and are thus subject to underreporting. The true incidence may also be higher due to a poor adherence to health care delivery protocols that facilitate prompt and appropriate referrals to tertiary institutions. The interpretation and application of the results of this study must be considered from this standpoint. Secondly, the clinical and demographic profile of chemical burns varies not only from one country to another but also among institutions, depending on the geographic location and social environment.  A multi-institution population based analysis of the frequency of chemical burns of the head and neck in Nigeria is needed. The study should thus be replicated in more tertiary institutions to glean a larger sample size and facilitate the coordination of prevention strategies on a national level.
| Conclusion|| |
Chemical burns of the head and neck in Zaria showed the following characteristics: There was a preponderance of male patients and most of the perpetrators were men. Motive was reduced to three categories robbery, matters related to love or the lack of it and revenge. Majority of the patients in this study had burns <30% TBSA, however more than half of the patients required three or more surgical procedures. These patients remain severely impaired psychosocially. It is hoped, that the findings in this study will help to emphasize the magnitude of the problem and stimulate the development of preventive strategies.
| References|| |
Ahmadi H, Durrant CAT, Sarraf KM, Jawad M. Chemical burns: A review. Curr Anaesth Crit Care 2008;19:282-6.
Karunadasa KP, Perera C, Kanagaratnum V, Wijerathne UP, Samarasingha I, Kannangara CK. Burns due to acid assaults in Sri Lanka. J Burn Care Res 2010;31:781-5.
Yeong EK, Chen MT, Mann R, Lin TW, Engrav LH. Facial mutilation after an assault with chemicals: 15 cases and literature review. J Burn Care Rehabil 1997;18:234-7.
Theodorou P, Spanholtz TA, Amini P, Maurer CA, Phan TQ, Perbix W, et al.
Cologne burn centre experience with assault burn injuries. Burns 2009;35:1152-7.
Modjarrad K, McGwin G Jr, Cross JM, Rue LW 3 rd
. The descriptive epidemiology of intentional burns in the United States: An analysis of the National Burn Repository. Burns 2007;33:828-32.
Reiland A, Hovater M, McGwin G Jr, Rue LW 3 rd
, Cross JM. The epidemiology of intentional burns. J Burn Care Res 2006;27:276-80.
Mannan A, Ghani S, Clarke A, Butler PE. Cases of chemical assault worldwide: A literature review. Burns 2007;33:149-54.
Asaria J, Kobusingye OC, Khingi BA, Balikuddembe R, Gomez M, Beveridge M. Acid burns from personal assault in Uganda. Burns 2004;30:78-81.
Peck MD. Epidemiology of burns throughout the World. Part II: Intentional burns in adults. Burns 2012;38:630-7.
Young RC, Ho WS, Ying SY, Burd A. Chemical assaults in Hong Kong: A 10-year review. Burns 2002;28:651-3.
Milton R, Mathieu L, Hall AH, Maibach HI. Chemical assault and skin/eye burns: Two representative cases, report from the Acid Survivors Foundation, and literature review. Burns 2010;36:924-32.
Farhad H, Naghibzadeh B, Nouhi AH, Rad HE. Acid burn violence in Iran. Ann Burns Fire Disasters 2011;24:138-40.
Theodorou P, Phan TQ, Maurer CA, Leitsch S, Perbix W, Lefering R, et al.
Clinical profile of assault burned victims: A 16-year review. S Afr J Surg 2011;49:178-81.
Guerrero L. Burns due to acid assaults in Bogota, Colombia. Burns 2013;39:1018-23.
Malic CC, Karoo RO, Austin O, Phipps A. Burns inflicted by self or by others - An 11 year snapshot. Burns 2007;33:92-7.
Das KK, Khondokar MS, Quamruzzaman M, Ahmed SS, Peck M. Assault by burning in Dhaka, Bangladesh. Burns 2013;39:177-83.
Brodzka W, Thornhill HL, Howard S. Burns: Causes and risk factors. Arch Phys Med Rehabil 1985;66:746-52.
Battery Basics: A Layman's Guide to Batteries. Available from: http://www.batterystuff.com/kb/articles/battery-articles/battery-basics.html. [Last assessed on 2014 Jul 21].
Branday J, Arscott GD, Smoot EC, Williams GD, Fletcher PR. Chemical burns as assault injuries in Jamaica. Burns 1996;22:154-5.
Olaitan PB, Jiburum BC. Chemical injuries from assaults: An increasing trend in a developing country. Indian J Plast Surg 2008;41:20-3.
Xie Y, Tan Y, Tang S. Epidemiology of 377 patients with chemical burns in Guangdong province. Burns 2004;30:569-72.
Singer A, Sagi A, Ben Meir P, Rosenberg L. Chemical burns: Our 10-year experience. Burns 1992;18:250-2.
Pitkanen J, Al-Qattan MM. Epidemiology of domestic chemical burns in Saudi Arabia. Burns 2001;27:376-8.
Tahir C, Ibrahim BM, Terna-Yawe EH. Chemical burns from assault: A review of seven cases seen in a Nigerian tertiary institution. Ann Burns Fire Disasters 2012;25:126-30.
Kraemer MD, Jones T, Deitch EA. Burn contractures: Incidence, predisposing factors, and results of surgical therapy. J Burn Care Rehabil 1988;9:261-5.
Sison-Williamson M, Bagley A, Palmieri T. Long-term postoperative outcomes after axillary contracture release in children with burns. J Burn Care Res 2012;33:228-34.
Prasad JK, Bowden ML, Thomson PD. A review of the reconstructive surgery needs of 3167 survivors of burn injury. Burns 1991;17:302-5.
Sharma DC. India promises to curb acid attacks. Lancet 2013;382:1013.
[Table 1], [Table 2], [Table 3]