Could your next head and neck surgery spark a fire? BACO 2026 paediatric keynote speaker, Soham Roy, explains how understanding risk factors and prevention is key to patient and OR team safety.
Operating room fires are an uncommon but potentially catastrophic complication of surgery. Although the overall incidence is low, relative to the total number of surgical procedures performed annually, the consequences for both patients and operating room personnel can be severe.
Surgical fires are of particular concern in otolaryngology–head and neck surgery, where the operative field frequently contains the three components necessary for combustion: an ignition source, a fuel and an oxidising agent. This combination, often referred to as the ‘fire triad’, creates an environment in which even routine surgical manoeuvres may precipitate a fire [1–3].
"Head and neck procedures, especially airway surgery involving lasers, represent a particularly high-risk category because the operative field is located near the airway and anaesthesia delivery systems"
Procedures involving the head and neck are uniquely susceptible because supplemental oxygen is frequently delivered in close proximity to surgical instruments capable of generating heat or sparks. Numerous combustible materials are also present in the operative field, including endotracheal tubes, surgical drapes and skin preparation solutions. Fires have been reported during a variety of otolaryngologic procedures, including tracheostomy, endoscopic airway surgery, adenotonsillectomy and cutaneous surgery of the head and neck [1,4]. Awareness of these risks and implementation of preventive strategies are essential to improving patient safety.
Oral cavity fire simulated in a chicken model.
Damage assessment after simulated oral cavity fire.
The fire triad in the operating room
All fires require the presence of three elements: an ignition source, a fuel and an oxidiser. In the operating room, each component is commonly encountered in close proximity.
Potential ignition sources include electrosurgical devices, surgical lasers, heated probes, drills and fiberoptic light cables. These instruments are widely used in head and neck surgery and are capable of generating temperatures sufficient to ignite combustible materials [1,2].
Fuel sources are abundant in the surgical environment. Common examples include endotracheal tubes, nasal cannulae, surgical drapes, sponges, dressings, alcohol-based skin preparation solutions, gowns, gloves and the patient’s hair [1–5]. Although many operating room materials are designed to resist ignition, they may still melt or burn when exposed to high temperatures.
Oxidisers most commonly consist of oxygen and nitrous oxide administered during anaesthesia. These gases can accumulate beneath surgical drapes or within body cavities, producing an oxygen-enriched environment that facilitates combustion and flame propagation [2]. When all three elements of the fire triad coexist in close proximity, the potential for surgical fire increases substantially.
Incidence and risk in head and neck surgery
Although the true incidence of surgical fires is difficult to determine, several hundred events are estimated to occur annually in the United States [6]. Surveys of members of the American Academy of Otolaryngology–Head and Neck Surgery have demonstrated that approximately 25% of respondents have witnessed an operating room fire during their careers [5]. Electrosurgical units and lasers represent the most commonly implicated ignition sources, and the majority of events occur in the presence of supplemental oxygen.
Head and neck procedures, especially airway surgery involving lasers, represent a particularly high-risk category because the operative field is located near the airway and anaesthesia delivery systems. The configuration of surgical drapes may allow oxygen to accumulate around the face and neck, creating conditions that facilitate ignition when an electrosurgical device or laser is activated [2].
Endotracheal tube fire in mechanical model of laser laryngeal surgery.
Damaged endotracheal tube and larynx in mechanical model of laser laryngeal surgery.
Experimental studies of fire risk
Experimental investigations have provided important insights into mechanisms of surgical fire formation. Mechanical models simulating the human oropharynx have been used to evaluate ignition risk associated with commonly used surgical instruments.
In one such model, a cavity approximating the human oral cavity was exposed to 100% oxygen delivered through an endotracheal tube. Activation of a monopolar electrosurgical device resulted in ignition and sustained combustion within seconds [7]. In contrast, activation of a bipolar radiofrequency plasma ablation device (Coblation) did not produce ignition under the same conditions. These findings suggest that alternative surgical technologies may reduce the risk of fire in selected procedures.
Additional studies examining operating room drapes and towels demonstrated that while these materials may not ignite readily, they can melt when exposed to fiberoptic light cables and provide limited protection against burns caused by electrosurgical devices [5]. Such observations highlight the importance of understanding how commonly used materials behave in oxygen-enriched environments.
High-risk procedures
Laser airway surgery
Laser airway surgery represents one of the highest-risk scenarios for operating room fires. Carbon dioxide lasers used during laryngeal and airway procedures may ignite endotracheal tubes or surrounding materials when supplemental oxygen is present [8].
Laser-resistant endotracheal tubes have been developed to mitigate this risk, but they are not completely fireproof. If the cuff of a laser-resistant tube is compromised, oxygen leakage into the airway can create conditions favourable for combustion. Various protective strategies have been proposed, including the use of double-cuffed tubes and barrier materials; however, careful management of oxygen concentration remains the most critical preventive measure [9].
Cutaneous surgery of the head and neck
Cutaneous procedures involving the face and neck also present a potential fire risk, particularly when alcohol-containing skin preparation solutions are used. Alcohol lowers the ignition threshold and may act as a readily combustible fuel when exposed to electrocautery [10].
If the preparation solution has not fully evaporated before activation of an ignition source, combustion may occur. In addition, both oxygen and flammable vapours may accumulate beneath surgical drapes, further increasing the likelihood of ignition. Ensuring adequate drying time for alcohol-based preparations is therefore essential before electrosurgical instruments are used. However, recent data suggests that even waiting the manufacturer’s recommended drying time still poses risks for alcohol-based prep solutions, while iodine (non-alcohol) based solutions could not ignite under worst-case scenarios [10].
Tracheostomy
Tracheostomy is among the procedures most frequently associated with operating room fires. During tracheostomy, an oxygen-rich environment may exist within the airway while an endotracheal tube provides a potential fuel source [11].
If electrocautery is used to incise the trachea or control bleeding after the airway has been entered, a flash fire may occur. Recommended preventive strategies include avoiding electrocautery when opening the trachea, minimising inspired oxygen concentration and refraining from electrosurgical device use after the airway has been entered if supplemental oxygen is present.
Prevention strategies
Because surgical fires require all three components of the fire triad, prevention strategies typically focus on eliminating or minimising one of these elements. Control of the oxidiser is often the most practical intervention. Reducing the fraction of inspired oxygen to less than approximately 50% has been shown to significantly decrease the likelihood of ignition in open cavity procedures [7].
When oxygen concentrations greater than 30% are necessary, oxygen should ideally be delivered through a closed airway system, such as an endotracheal tube or laryngeal mask airway, rather than through open delivery systems, such as nasal cannulae. Open oxygen delivery allows oxygen to accumulate beneath surgical drapes and increases fire risk [2].
Substitution of ignition sources may also enhance safety. Radiofrequency plasma ablation devices have demonstrated a lower risk of ignition compared with traditional electrosurgical instruments in experimental models [7].
Institutional safety protocols are equally important. Many operating rooms incorporate a fire risk assessment or ‘fire time-out’ before procedures in which the fire triad may be present. This process facilitates communication between the surgical and anaesthesia teams regarding oxygen delivery, surgical instruments and potential fuel sources.
Management of operating room fires
Despite preventive measures, surgical fires may still occur. Rapid recognition and immediate intervention are essential to minimise patient injury.
When a fire is suspected, the surgical team should immediately stop the procedure, remove any burning materials and discontinue the flow of oxygen or other oxidising gases. In airway fires, the endotracheal tube should be promptly removed and the airway irrigated with saline to extinguish residual flames [12]. If surgical drapes or other materials ignite, they should be removed rapidly from the patient and surgical field.
"Reducing the fraction of inspired oxygen to less than approximately 50% has been shown to significantly decrease the likelihood of ignition in open cavity procedures"
Following fire extinguishment, the patient should be evaluated for airway injury, burns and inhalation injury. Reporting such events to institutional safety committees and national monitoring systems is critical to improving prevention strategies and patient safety.
Conclusion
Operating room fires remain a significant but largely preventable hazard in surgical practice. Otolaryngology procedures involving the head and neck are particularly susceptible because ignition sources, fuels and oxidisers frequently coexist in close proximity. A thorough understanding of the fire triad, careful management of oxygen delivery, appropriate selection of surgical instruments and effective communication among members of the operative team are essential components of fire prevention.
Through adherence to established safety guidelines and continued vigilance, the risk of surgical fires can be significantly reduced, thereby improving safety for both patients and operating room personnel.
Soham Roy will deliver a keynote talk on ‘Ethical Decision Making in Paediatric Otolaryngology’ at BACO 2026 in Glasgow, UK, in July.
For further information visit: www.entuk.org/baco
References
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2. Apfelbaum JL, Caplan RA, Barker SJ, et al. Practice advisory for the prevention and management of operating room fires. Anesthesiology 2013;118(2):271–90.
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4. Varcoe RL, MacGowan KM, Cass AJ. Airway fire during tracheostomy. ANZ J Surg 2004;74(6):507–8.
5. Smith LP, Roy S. Operating room fires in otolaryngology: risk factors and prevention. Am J Otolaryngol 2011;32(2):109–14.
6. Landro L. In just a flash, simple surgery can turn deadly. Wall Street Journal 2009.
7. Roy S, Smith LP. Device-related risk of fire in oropharyngeal surgery: a mechanical model. Am J Otolaryngol 2010;31(5):356–9.
8. Chou AK, Tan PH, Yang LC, et al. Carbon dioxide laser–induced airway fire during laryngeal surgery. Chang Gung Med J. 2001;24(6):393–8.
9. Roy S, Smith LP. Surgical fires in laser laryngeal surgery: are we safe enough? Otolaryngol Head Neck Surg 2015;152(1):67–72.
10. Jones EL, Overbey DM, Chapman BC, et al. Operating room fires and surgical skin preparation. J Am Coll Surg 2017;225(1):160–5.
11. Lin IH, Hwang CF, Kao YF, et al. Tracheostomal fire during elective tracheostomy. Chang Gung Med J 2005;28(3):186–90.
12. 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.
Declaration of competing interests: None declared.
