Surgical Fires in Otorhinolaryngology

August 12, 2009

Ronda Alexander, MD
Assistant Professor


The Wall Street Journal reported recently that approximately 650 surgical fires are reported in U.S. hospitals each year, and another three to four times as many are “near misses” or unreported events.1 The risk of surgical fires is a very real and legitimate concern for surgeons, anesthesiologists and OR staff alike. When considering the number of surgical fires that go unreported, the risk becomes even more significant.

Ignition Source + Fuel + Oxidizer = Fire

Surgical fires require a “classic triad” of elements to occur: an ignition source to create the spark, fuel (something to burn), and an oxidizer. Electrosurgical units, lasers, and light cords are all well-described ignition sources for surgical fires. Common sources of “fuel” in an operating room fire include endotracheal tubes, operating room drapes or towels, sponges and alcohol preparation solutions.2 The presence of an oxidizing agent, such as oxygen or nitrous oxide, is the final key factor in the triad. All three of these elements must be present in order to ignite a fire in an operating room.

Higher Risk in ENT Procedures

Intraoperative fires are a well-described and potentially devastating complication of surgery; head and neck or ENT surgical procedures are at the highest risk of operating room fire, due to the presence of exposed supplemental oxygen around flammable materials. Fires have been reported during tracheostomy, adenotonsillectomy, and skin surgery of the head and neck.3–5 My colleague Lee Smith, MD, (of Schneider Children’s Hospital in Long Island, New York) and I recently surveyed members of the American Academy of Otolaryngology-Head and Neck Surgery on their experience with surgical fires. We were surprised to learn that 25 percent of respondents had personally witnessed a fire in the operating room. The complete survey responses are currently being presented at an upcoming national meeting.6

Eliminating the Ignition Source

Our research team has conducted a series of scientific experiments to determine the risk factors of various surgical modalities, including electrocautery (Bovie), CO2 laser, and bipolar radiofrequency ablation (Coblation) over the past two years. We have examined the risk of fires and burns during endoscopic surgeries with halogen light sources, electrosurgery (2) and created mechanical models to study fire risk in oropharyngeal and airway surgeries.7

To replicate oropharyngeal surgery in a mechanical model, a 6.0 endotracheal tube was inserted into the cranial end of a degutted whole raw chicken, through which 100 percent oxygen was piped at 10 Liters per minute. A raw chicken was used because organic tissue is necessary to conduct electricity for electrocautery devices to work, and the volume and size of the chicken cavity approximates a human oral cavity and oropharynx. The mechanical model simulates the setup of free oxygen in the oropharynx that would be seen during a routine tonsillectomy. We then tested an electrocautery device (Bovie) on chicken tissue in the cavity and tested a bipolar radiofrequency plasma ablation device (Coblator) under the same circumstances.

While we were able to ignite a fire very quickly using an electrocautery device—in under 30 seconds in most trials (Figure 1 and Figure 2)—we were unable to create a fire in any of our mechanical models using the Coblator.

Our studies suggest that while electrosurgical devices and CO2 lasers (Figure 3 and Figure 4) present a significant risk of fire during open cavity surgery in oxygen-enriched environments, that risk appears to be eliminated with bipolar radiofrequency plasma ablation.7

We speculate that the Coblation technology does not produce the “spark” necessary to ignite a fire, preventing the ignition of fire. In addition, Coblation results in less thermal energy dissipation with lower surrounding temperatures in the tissues, further reducing the risk of ignition. By eliminating the ignition source, even in a 100 percent oxygen-enriched environment, the risk of oral cavity and oropharyngeal fire was eliminated in our mechanical model using Coblation.

Awareness is Key to Reducing Risk

As with any potential hazard, awareness is the first step to prevention. Last May, the American Society of Anesthesiologists (ASA) issued a practice advisory for the prevention and management of operating room fires. The advisory detailed several precautions for the OR team to follow to help avoid surgical fires.8

Before each surgical case, the OR team should determine if a case is at high risk for surgical fires. If a high-risk situation exists (i.e., the fire triad is present), the team should decide on a plan and roles for preventing and managing a fire. Communication between nursing staff, anesthesiologist, and surgeon is critical.

The role of oxygen and nitrous oxide are important factors to consider. The anesthesiologist should collaborate with all surgical team members throughout the procedure to minimize the presence of an oxidizer-enriched atmosphere in proximity to an ignition source. One of our recent studies evaluating the minimum oxygen requirements to obtain a fire in our mechanical model suggests that a fraction of inspired oxygen (FiO2) below 50 percent may eliminate the risk of fire ignition,9 and we are currently performing additional studies to quantify these risks.

Limiting any of the arms of the “fire triad” reduces the risk of surgical fires. Electrocautery and the CO2 laser may both serve as ignition sources when other arms of the triad are present. Even under “highest risk” circumstances in the presence of 100 percent pure oxygen, the Coblation wand does not present an ability to ignite and is therefore not considered an ignition source. This suggests that bipolar radiofrequency plasma ablation eliminates the risk of fire during open cavity surgery, even when oxygen and a fuel source are present.

What to do if a Surgical Fire Occurs

Medical professionals agree the most important thing to do in the case of a surgical fire is to eliminate the fire and protect the patient. When a surgical fire occurs, halt the procedure, remove whatever is on fire, and immediately cut the oxygen. These must occur essentially simultaneously to minimize the risk of patient injury.

In June 2003, The Joint Commission, a nonprofit group that accredits and certifies more than 15,000 healthcare organizations and programs in the United States, issued a Sentinel Event Alert on reducing surgical fires. In the alert, the group recommends that healthcare organizations help prevent surgical fires by:

  • informing staff members (including surgeons and anesthesiologists) about the importance of controlling heat sources by following laser and ESU safety practices
  • managing fuels by allowing sufficient time for patient prep to evaporate; and establishing guidelines for minimizing oxygen concentration under the drapes
  • developing, implementing, and testing procedures to ensure appropriate response by all members of the surgical team to fires in the OR

Organizations are strongly encouraged to report any instances of surgical fires as a means of raising awareness and ultimately preventing the occurrence of fires in the future. Reports can be made to Joint Commission, ECRI, the Food and Drug Administration (FDA), and state agencies, among other organizations.10 Airway fires are a significant risk in the OR, but with awareness, the proper tools, and preventive measures, they can be easily avoided.


  1. Landro, L. In Just a Flash, Simple Surgery Can Turn Deadly. Wall Street Journal, Informed Patient. February 18, 2009
  2. Smith LP, Roy S. Fire/burn risk with electrosurgical devices and endoscopy fiber optic cables. Am J Otolaryngol. 2008 May-Jun;29(3):171-6.
  3. Niskanen M, Purhonen S, Koljonen V, et al. Fatal inhalation injury caused by airway fire during tracheostomy. Acta Anaesthesiol Scand. 2007; 51(4): 509-13.
  4. Prasad R, Quezado Z, St. Andre A, et al. Fires in the operating room and intensive care unit: awareness is the key to prevention. Anesth Analg. 2006; 102(1): 172-4.
  5. Varcoe RL, MacGowan KM, Cass AJ. Airway fire during tracheostomy. ANZ J Surg. 2004; 74(6): 50.
  6. Smith LP, Roy S. Otolaryngologist’s Experience with Operating Room Fires. Survey of the membership of the American Academy of Otolaryngology–Head and Neck Surgery, 2008. To be presented at AAO-HNS annual meeting, October 2009
  7. Roy S, Smith LP. “Device-Related Risk of Airway Fire in Oropharyngeal Surgery” Abstracts of the AAO-HNS Annual Meeting, 2008; in press, American Journal of Otolaryngology
  8. Practice advisory for the prevention and management of operating room fires. Anesthesiology. 2008 May;108(5):786-801.
  9. Roy S, Smith LP: What does it take to start an Oropharyngeal Fire? Abstracts of the Society for Ear, Nose and Throat Advances in Children, 2008 meeting
  10. Preventing Surgical Fires. The Joint Commission. Sentinel Event Alert; Issue 29 – June 24, 2003. [Read more]