Otolaryngologists on the Front Lines

Otolaryngology is not just another specialty in the wars of the twenty-first century. It is one of—if not the—most crucial subspecialties in the care of the injured. In Iraq one out of six troops wounded in combat needs to see an otolaryngologist. Today’s effective body armor means that most serious injuries are to the extremities—which are rarely fatal—and to the head and neck, where they can be grave indeed.

Insurgents and terrorists specifically target the major means of human communication, including the ears and the nasopharyngeal complex. For example, many attacks attempt to maximize noise, because a deafening blast disorients and confuses, as well as injures. Bombs aimed at soldiers and civilians are “super-sized” with shrapnel and toxins. They are meant to kill, but if they fail to kill, they are intended to cause maximum panic, pain, and disfigurement.

In the course of the conflicts in Iraq and Afghanistan, the US military has deployed increasing numbers of otolaryngologists, and moved them closer to the battlefield. In Israel, an otolaryngologist was stationed 24/7 at the trauma hub to which military and civilian wounded were evacuated during the 2006 war with Hizbollah. Wherever terror strikes, from Bali to Britain, otolaryngologists have become indispensable.

There are still snipers, precision-propelled grenades, heavy machine guns, and shoulder-fired rockets in the field, but the greatest number of injuries is caused by improvised explosive devices (IEDs). IEDs cause a disproportionate number of ear, nose, and throat injuries, even in civilians without body armor, because the shrapnel tends to spray upward. Moreover, the propelled shards can be minute, causing occult injuries that take time and medical sophistication to detect.

Otolaryngologic Injuries in War

In an Air Force study, Colonel Joseph Brennan, MD, one of the US military’s most seasoned otolaryngologists, found the most common otolaryngologic procedures performed in Iraq to be complex facial laceration repair, tracheotomy, and neck exploration for penetrating neck trauma.

Tympanic puncture is very common, as it is in everyday practice. But even if most heal spontaneously, the conditions of war make intervention imperative. In the bombing of the US embassy in Kenya, a study showed, five of 14 untreated membranes failed to heal, while all of those that were treated did heal.

Sensorineural hearing loss and the resultant balance disorder are more problematic, says Commander Michael E. Hoffer, MD, of the Naval Medical Center in San Diego. “Neurocognitive dysfunction—temporary or permanent—is almost universally present, and it’s not as obvious as other injuries.”