Third‐Degree Burns of the Upper Aerodigestive Tract Caused by a Flare Gun: A Case Report

ABSTRACT

Flare gun‐related injuries of the upper aerodigestive tract are extremely rare and can result in life‐threatening third‐degree burns with deep thermal damage and foreign body complications. Early recognition and multidisciplinary care are crucial, yet prognosis remains poor, underscoring the need for awareness of this devastating injury pattern.

1. Introduction

Although gunshot‐related injuries, including intraoral cases [1], can frequently be found in the literature, burn injuries—especially those involving the upper aerodigestive tract—caused by flare guns are exceptionally rare [2, 3]. To the best of our knowledge, there is only one case report of oral burns caused by fin the literature, involving a 15‐year‐old male who accidentally suffered flare gun‐related burn injuries to the oropharynx while playing with a friend [3].

Flare guns have been utilized by the military as well as in civilian use for signaling and illumination. The flares are mainly made of strontium nitrate, strontium peroxide, potassium perchlorate, and magnesium. After being discharged, they can reach temperatures of up to 1600°C. If injuries caused by flare guns occur, they can result in major trauma, which might be complicated by burns, fractures, lacerations, and foreign bodies [3].

2. Case History/Examination

An 83‐year‐old man was brought into the emergency trauma room of the university hospital in Innsbruck by ambulance with flare gun‐related injuries. After a thorough third‐party anamnesis, it was revealed that the patient had shot himself in the mouth with a flare gun with suicidal intent a few hours prior to arrival. The gun was determined to be from 1941.

Initial clinical examination revealed third‐degree burn injuries of the upper aerodigestive tract, extending from the lips to the oropharynx, as well as burns to the face and both hands. The total body surface area burned was estimated to be approximately 7%. Lacerations of the tongue and soft palate were also noted.

3. Differential Diagnosis, Investigations, and Treatment

For further evaluation, a computed tomography (CT) scan was performed, revealing extensive soft tissue injury of the tongue with foreign body impaction (Figure 1), extending into the floor of the mouth and the posterior pharyngeal wall, reaching as far as the anterior arch of the atlas. Additionally, the CT demonstrated basal lung consolidations with a patchy ground‐glass appearance, as well as foreign bodies within the right bronchi.

FIGURE 1.

CT scan on the day of admission showing an extensive soft tissue injury of the tongue with foreign body invasion.

Based on the findings, the patient was referred to the Department of Otorhinolaryngology—Head and Neck Surgery for consultation, where additional injuries to the larynx were revealed, which made orotracheal intubation impossible. Hence, an emergency tracheostomy and wound exploration were performed immediately. During this procedure, multiple foreign bodies could be removed and debridement as well as a wound adaptation of the tongue were carried out. In a bronchoscopy that was also performed promptly, a metal foreign body of the right lower lobe could be removed. Furthermore, it showed an edematous and slightly bloody mucous membrane and a burned area in the trachea. As a result, an antimicrobial therapy with ampicillin/sulbactam and metronidazole was initiated.

The following day, additional foreign bodies in the right lower lobe were removed during a bronchoscopy. Additionally, metronidazole was stopped after 3 days in the absence of anaerobic evidence. Since Pseudomonas aeruginosa could be detected in a throat swab and methicillin‐susceptible Staphylococcus aureus in tracheal secretion, the antibiotic treatment was escalated to piperacillin/tazobactam on day four of hospitalization. Following this therapy, the inflammatory parameters showed a continuous decline. An esophagogastroduodenoscopy was performed on the fourth day and demonstrated marked burns in the upper third of the esophagus. On day six of hospitalization, a percutaneous endoscopic gastrostomy tube was placed. Moreover, the second‐degree burns of the hands were managed by the colleagues of the Department of Plastic and Reconstructive Surgery.

One week after admission, a CT scan showed numerous foreign bodies in the nasopharynx, oropharynx, tongue, and bronchi. Moreover, at this time, a pharyngoscopy and wound exploration were performed (Figure 2), which showed progressive fibrin coatings and necroses from the oral cavity reaching down to the larynx. A repeat esophagoscopy on the same day now showed massive liquefaction necroses from the upper esophageal sphincter to the middle third of the esophagus. On the ninth day, inhalational tobramycin therapy was started, as P. aeruginosa was detected repeatedly in the respiratory tract.

FIGURE 2.

Intraoperative images on day seven of hospitalization showing: (a) wound exploration of the tongue; and (b) wound adaptation following exploration.

The patient underwent multiple surgical procedures throughout the hospital stay, including wound debridements and endoscopies. As part of this, necrotic tissue was sharply excised until viable, bleeding tissue was observed. The main reason for a repeat exploration was the presence of retained foreign bodies. Furthermore, the antibiotic therapy was escalated to cefepime, because P. aeruginosa could be detected again on day 17 of hospitalization, but now was resistant to piperacillin/tazobactam.

4. Conclusion and Results (Outcome and Follow‐Up)

Despite all efforts, the local findings continued to worsen. Analgosedation was required throughout the patient's stay, and catecholamine support was needed for most of the time. Given the overall situation—marked by a poor prognosis and the expectation of severe, permanent impairment of quality of life—an interdisciplinary decision was made, with the consent of the relatives, to transition to comfort care 18 days after the flare gun injury. The patient died in the intensive care unit 1 day later.

5. Discussion

Flare gun‐related burns of the upper aerodigestive tract are extremely rare, with only one prior case reported in the literature [3]. In their paper, Sljivic et al. demonstrate the case of a 15‐year‐old male who sustained intraoral burn injuries by a flare gun while he was playing with a friend. Similar to our case, this young patient presented with third‐degree burns of the oral cavity and oropharynx as well as second‐degree burns of both hands. Moreover, a laceration of the tongue was found. Contrary to the case of our patient, however, the burn injuries were limited to the oral cavity and oropharynx, and the 15‐year‐old male made a full recovery after having undergone multiple procedures, including multiple debridements [3].

In our case, the patient suffered marked burns not only to the oral cavity and oropharynx, but also to the airways and esophagus. Although airway involvement was present, this case does not represent a classic “inhalation injury,” which typically refers to exposure to gases, smoke, chemicals, or fumes, often in the context of fire‐related burns [4]. Instead, the mechanism appears to be a direct thermal and chemical injury of the aerodigestive tract from flare discharge within the oral cavity, with secondary involvement of the tracheobronchial tree. Yet, it should be noted that the presence of inhalation injury exacerbates the prognosis of burn patients, with mortality increasing by up to 20% compared to isolated skin burns. If pneumonia develops in combination with inhalation injury, mortality rates can rise to approximately 60% [5]. Given the known composition of flare‐gun pyrotechnics (e.g., strontium nitrate, magnesium, potassium perchlorate) and their extremely high thermal output, it is plausible that both thermal injury and chemical oxidizing damage contributed to the deep tissue necrosis we observed. While no published case definitively documents this dual mechanism in aerodigestive tract burns, the features of progressive necrosis and liquefaction in our patient support a combined mechanism. In addition, multiple foreign bodies were found, leading to a further burden for the patient and his healing process. This complex case underscores that, despite access to contemporary medical interventions and optimal interdisciplinary care in a tertiary hospital, the severity and distribution of injuries sustained are scarcely compatible with survival.

Flare gun‐related injuries can lead to massive burns, which might be complicated by foreign bodies and ultimately require multiple surgical interventions, creating a major challenge in treatment. Therefore, it seems of utmost importance to report these types of injuries, as they can lead to a high patient morbidity and mortality despite intensive interdisciplinary treatment.

Author Contributions

Lukas Schmutzler: conceptualization, data curation, formal analysis, investigation, writing – original draft, writing – review and editing. Matthias Santer: conceptualization, data curation, writing – original draft, writing – review and editing. Johanna Leitgeb: data curation, writing – review and editing. Benedikt Hofauer: supervision, validation, writing – review and editing. Daniel Dejaco: conceptualization, supervision, writing – review and editing.

Funding

The authors have nothing to report.

Consent

Written informed consent was obtained from the individual's next of kin for the publication of this case report and any accompanying images.

Conflicts of Interest

The authors declare no conflicts of interest.

Schmutzler L., Santer M., Leitgeb J., Hofauer B., and Dejaco D., “Third‐Degree Burns of the Upper Aerodigestive Tract Caused by a Flare Gun: A Case Report,” Clinical Case Reports 14, no. 1 (2026): e71751, 10.1002/ccr3.71751.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.