Reconstruction and Premorbid Occlusion Establishment Keys for HN Trauma Treatment

What are the most important lessons that can be learned for clinical application from head and neck trauma treatment in a war zone?

Background: During the last 10 years, several thousand head and neck trauma patients have been treated at American war zone medical facilities in Iraq and Afghanistan. This study compares and contrasts head and neck trauma characteristics and treatment in each locale and identifies trauma lessons that can be applied to civilian practice.

Study design: Retrospective review of operative logs and medical records of one head and neck surgeon’s operative experience in Iraq (Sept. 13, 2004, to Jan. 13, 2005) and Afghanistan (May 20, 2009 to Nov. 15, 2009).

Setting: Department of Surgery, San Antonio Military Medical Center, San Antonio, Texas; Iraq; Afghanistan.

Synopsis: Four treatment levels were identified: Level I (immediate first aid delivered at the injury location); Level II (surgical capability with limited inpatient bed space); Level III (highest level surgical capability with the bulk of inpatient beds); and Level IV (facilities with definitive medical and surgical care outside the combat zone). In Iraq, 142 patients underwent 241 surgical procedures. Ninety percent of patients were referred directly to Level III facilities after receiving only Level I treatment. The most frequent surgeries included facial laceration repair, surgical airways (tracheotomy and cricothyroidotomy), neck exploration for penetrating neck trauma and direct laryngoscopy. Mortality was 5.3 percent, with the majority of patients receiving little to no follow-up. In Afghanistan, 156 patients underwent 356 surgical procedures. Seven percent of patients were referred directly to Level III facilities after receiving only Level I treatment. The most frequent surgeries included facial laceration repair, surgical airways, open reduction and internal fixation of facial fractures, intermaxillary fixation with arch bars, esophagoscopy and direct laryngoscopy. Mortality was 1.3 percent, with the majority of patients returning for routine follow-up.

Bottom line: With massive soft tissue injuries and a comminuted facial skeleton from high-velocity trauma, initial surgery goals should be limited to reconstruction with soft tissue coverage of the exposed bone and plates with primary closure, with premorbid occlusion establishment as the single most important step in mandibular repair.

Citation: Brennan J. Head and neck trauma in Iraq and Afghanistan: different war, different surgery, lessons learned. Laryngoscope. 2013;123:2411-2417.

—Reviewed by Amy Eckner