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Unintended Consequences: Combat-related injuries lead to advances in facial plastic and reconstructive surgery

by Jennifer Decker Arevalo, MA •

The expertise gained by deployed otolaryngologists in OIF and OEF who have seen a large volume of HFNIs, has led to a renewed interest in HFNI trauma care by civilian otolaryngologists. “In fact, there is an effort underway, led by the military otolaryngologists, to refocus on our specialty’s experience and expertise in this aspect of trauma care,” Dr. Holt said.

More importantly, “as we become better educated and experienced in working with these technological advances, our service men and women are achieving better outcomes and reaping the benefits,” Dr. Laughlin added. ENTtoday

Infection Control

Infections in battlefield wounds have been an ongoing risk factor for years. According to a 2008 study, a high frequency of combat-related maxillofacial infections (7.1 percent) in theater, compared to other parts of the body (3.9 percent), was first observed in the Vietnam War, even with rapid evacuation, antibiotics, and early wound care (J Trauma. 2008;64(3):S265-S276). During the Iraq-Iran conflict in the 1980s, an 11 percent infection rate for maxillofacial injuries has been noted; delay in evacuation and lack of suitable fixation devices are listed as contributing factors.

Of the 52 patients in Dr. Lopez’s study who underwent ORIF in theater during OIF in 2005, none developed Acinetobacter baumannii infection. A. baumannii is a bacterium found in Iraqi soil that causes wound and prostheses infections, catheter-related sepsis and osteomyelitis. Although complex infection problems, including multiresistant microorganisms like A. baumannii, can still occur today, “infections are extremely rare and localized, because of the head and neck’s robust vascular supply,” said Dr. Lopez.

Additionally, deployed otolaryngologists/head and neck surgeons now have years of experience in which they have learned how to combat these bugs at an earlier stage in theater. “We quickly learned that standard empiric antibiotics used to treat civilian casualties did not work as well with combat casualties due to the indigenous bacteria of the theater,” Dr. Laughlin said.

“Dr. Lopez’s article was a valuable case series report and supported the prevailing opinion that head and neck combat injuries treated in theater are not at higher risk for A. baumannii infections,” said Lt. Col. Robert Hale, DDS, director of Craniomaxillofacial Research at the U.S. Army Institute of Surgical Research.

Dr. Hale and his colleagues now encourage physicians to use high-dose cefazolin, clindamycin, or ceftriaxone immediately upon identification of an HNFI and continue coverage during surgical interventions in a military setting. However, coverage should not extend beyond 24 hours post-op because long term antibiotic use may contribute to multidrug-resistant infections, such as A. baumannii, that have been found in military hospitals. Wounded service men and women are now automatically cultured for A. baumannii and placed in isolation if the results are positive, even though HNFIs have a lower incidence of this particular infection due to high oxygen tension levels.