The author has no funding, financial relationships, or conflicts of interest to disclose.
Head and neck trauma in Iraq and Afghanistan: Different war, different surgery, lessons learned
Article first published online: 1 APR 2013
Copyright © 2013 The American Laryngological, Rhinological and Otological Society, Inc.
Volume 123, Issue 10, pages 2411–2417, October 2013
How to Cite
Brennan, J. (2013), Head and neck trauma in Iraq and Afghanistan: Different war, different surgery, lessons learned. The Laryngoscope, 123: 2411–2417. doi: 10.1002/lary.24096
- Issue published online: 23 SEP 2013
- Article first published online: 1 APR 2013
- Manuscript Accepted: 19 FEB 2013
- Manuscript Received: 11 FEB 2013
- improvised explosive device;
- mass casualty
The objectives are to compare and contrast the head and neck trauma experience in Iraq and Afghanistan and to identify trauma lessons learned that are applicable to civilian practice.
A retrospective review of one head and neck surgeon's operative experience in Iraq and Afghanistan was performed using operative logs and medical records.
The surgeon's daily operative log book with patient demographic data and operative reports was reviewed. Also, patient medical records were examined to identify the preoperative and postoperative course of care.
The head and neck trauma experiences in Iraq and Afghanistan were very different, with a higher percentage of emergent cases performed in Iraq. In Iraq, only 10% of patients were pretreated at a facility with surgical capabilities. In Afghanistan, 93% of patients were pretreated at such facilities. Emergent neck exploration for penetrating neck trauma and emergent airway surgery were more common in Iraq, which most likely accounted for the increased perioperative mortality also seen in Iraq (5.3% in Iraq vs. 1.3% in Afghanistan). Valuable lessons regarding soft tissue trauma repair, midface fracture repair, and mandible fracture repair were learned.
The head and neck trauma experiences in Iraq and Afghanistan were very different, and the future training for mass casualty trauma events should reflect these differences. Furthermore, valuable head and neck trauma lessons learned in both war zones are applicable to the civilian practice of trauma.
Level of Evidence
Level 4. Laryngoscope, 123:2411–2417, 2013
During the past 10 years in Iraq and Afghanistan, several thousand head and neck trauma patients have been treated at American medical facilities in both war zones.[1, 2] The high incidence of head and neck trauma injuries is due to the lack of head and neck protection provided by the body armor currently used by the troops in the field.[3-6] The most common mechanism of injury, the improvised explosive device (IED), typically occurs at close range and results in multisystem high-velocity injuries that can be devastating to the head and neck.[7, 8] The objectives of this study are to compare and contrast the head and neck trauma experience in Iraq and Afghanistan and to identify trauma lessons learned that are applicable to civilian practice. [9, 10]
MATERIALS AND METHODS
Following Wilford Hall Medical Center Investigational Review Board approval, a retrospective clinical review of the operative logs of a single surgeon deployed to Iraq and Afghanistan were used to generate a case list of head and neck trauma patients treated in both combat zones.
The preoperative data included patient name, age, gender, nationality, and date of injury. Additionally, the level of medical care where the pretreatment of the head and neck trauma victims occurred and from where they were referred to the level III medical facility were determined. Level I treatment is immediate first aid delivered at the location of injury, generally by the Navy corpsman or the Army medic. Level II treatment provides surgical capability and limited inpatient bed space. Level III treatment provides the highest level of medical care in the war zone and contains the bulk of inpatient beds. Level IV facilities provide definitive medical and surgical care outside the combat zone.[11, 12] Finally, the number of mass casualty events, defined as greater than 40 trauma admissions in a 24-hour period, was recorded.
The perioperative data collected included the type of operation performed, the date of surgery, the mechanism of injury, the operative report and description, the number and type of plates used during facial fracture repair, and the triage category of the patient when taken to the operating room. The triage categories include the following four categories: immediate, delayed, minimal, and expectant. Immediate patients require life-saving surgery, and the patient should have a high chance for survival, such as those patients with acute traumatic airway obstruction. Delayed patients are those wounded whose condition allows a delay in surgical treatment without endangering their life. Minimal patients have minor injuries and can care for themselves or can be helped by nonmedical personnel. Lastly, expectant patients have devastating injuries whose survival would be unlikely, even with the benefit of massive medical resources.
Postoperative data included morbidity (complications) and mortality.
The preoperative data showed that 142 patients underwent head and neck operations in Iraq over the 4-month time frame. Demographic data collected is shown in Table 1. The dates of surgical treatment occurred between September 13, 2004, and January 13, 2005. It should be noted that the surgeon was operating in Iraq for greater than 4 months, but this full-month time frame was chosen to facilitate comparison of data. Pretreatment at level II or level III medical facilities with surgical capabilities occurred in 10% of head and neck trauma patients in Iraq (12/116). Consequently, 90% of patients (104/116) were referred directly to the level III medical facility after receiving only level I treatment at the site of injury by navy corpsmen or army medics without any surgical capabilities. Lastly, during the 4-month time period in Iraq, two mass casualty events occurred. The first mass casualty event was the Fallujah battle in November 2004, during which the level III facility treated 381 wounded Americans and many Iraqi patients during the 10-day battle. The second mass casualty event was the Mosul dining hall suicide bombing in December 2004, during which 27 Americans were killed and more than 50 Americans were wounded.
|Gender||97% male (138/142)||98% male (153/156)|
|U.S. Servicemen||43% (58/136)||30% (45/150)|
|Number of Mass Casualties||2||0|
|1. facial laceration repair||33%||28%|
|2. surgical airways||23%||19%|
|3. neck exploration||13.3%||4%|
|4. intermaxillary fixation||5.7%||11%|
|5. ORIF facial fractures||3.3%||16.5%|
|2. reconstructive (2.4 mm)||0||3.5|
The perioperative data collected showed that the 142 patients underwent 241 surgical procedures over 4 months. The 10 most frequent head and neck surgical operations (211 procedures) included facial laceration repair, which comprised 33% of procedures (69/211); surgical airways (tracheotomy and cricothyroidotomy) in 23% (49/211); neck exploration for penetrating neck trauma in 13.3% (28/211); direct laryngoscopy in 10.4% (22/211); intermaxillary fixation (IMF) with arch bars in 5.7% (12/211); bronchoscopy in 4.3% (9/211); esophagoscopy in 4% (8/211); open reduction and internal fixation (ORIF) of facial fractures in 3.3% (7/211); emergent intubation by otolaryngologist in 2% (4/211); and emergent lateral canthotomy in 1.5% (3/211). The breakdown of the seven facial fracture ORIF repairs showed that tripod fracture repair comprised 2% of procedures (4/211) and that mandible fracture repairs comprised 1.5% (3/211). During these ORIF of facial fractures, 18 mandibular and craniofacial fracture plates (2 mm or less) were placed with a rate of 4.5 plates/month (18/4). No mandibular reconstruction plates (2.4 mm) were used in Iraq. Finally, the triage categories were immediate in 11% of patients (16/142), delayed in 66% (94/142), and minimal in 23% (32/142).
The postoperative data demonstrated that the mortality of the head and neck trauma patients in Iraq was 5.3% (6/114). The mortality status of the remaining 28 patients could not be determined. In addition, morbidity statistics could not accurately be determined since the majority of Iraqi patients had little or no follow-up.
The preoperative data collected showed that 156 patients underwent head and neck surgery in Afghanistan over a 6-month time frame. Demographic data collected is shown in Table 1. The dates of surgical treatment occurred between May 20, 2009, and November 15, 2009, a time frame of approximately 6 months. Pretreatment at level II or level III medical facilities with surgical capabilities occurred in 93% of head and neck trauma patients in Afghanistan (127/136). Consequently, 7% of patients (9/136) were referred directly to the level III medical facility after receiving only level I treatment at the site of injury by navy corpsmen or army medics without any surgical capabilities. During the 6-month time frame in Afghanistan, no mass casualty events occurred.
The perioperative data collected demonstrated that the 156 patients underwent 356 head and neck operations over 6 months. The 10 most frequent head and neck surgical operations (308 procedures) included facial laceration repair in 28% (87/308), surgical airways in 19% (58/308), ORIF of facial fractures in 16.5% (51/308), intermaxillary fixation with arch bars in 11% (34/308), esophagoscopy in 9% (27/308), direct laryngoscopy in 6.5% (20/308), neck exploration for penetrating neck trauma in 4% (13/308), parotid duct exploration in 2% (7/308), bronchoscopy in 2% (6/308), and oral tongue laceration repair in 1.6% (5/308). The breakdown of the 51 facial fracture ORIF procedures showed that mandibular fracture ORIF comprised 8% of procedures (25/308), Le Fort fracture repair 3% (10/308), tripod fracture repair 3% (10/308), and orbital floor repair 2% (6/308). During the ORIF of facial fractures, 115 mandibular and craniofacial plates were placed with a rate of 19 plates per month (115/6). Also, 21 mandibular reconstruction plates (2.4 mm locking) were utilized in Afghanistan with a rate of 3.5 mandibular reconstruction plates per month (21/6). Finally, the triage categories were immediate in 5% of patients (8/156), delayed in 69% (108/156), and minimal in 26% (40/156).
The postoperative data demonstrated that the mortality of head and neck trauma patients in Afghanistan was 1.3% (2/156). Due to the fact that there were no local national medical facilities with the equipment to manage craniofacial plating complications, the majority of the head and neck trauma patients returned for routine follow-up appointments at our level III facility. Surgical data and operative reports were examined from May 2009 through November 2010 to look for complications, most notably the need to remove craniofacial plates, in the patients treated during this study period. After up to 18 months of follow-up, only two craniofacial plates of the 115 plates placed in Afghanistan needed to be removed postoperatively (no mandibular plates were removed). Also, no wound infections requiring reoperation or readmission to the hospital occurred in the patients treated during this study period.
The most striking preoperative difference in both combat zones was the significantly lower percentage of wounded head and neck trauma patients in Iraq who were pretreated at level II or level III facilities with surgical capabilities. The Air Force Theater Hospital (AFTH) in Balad, Iraq, was located directly in the middle of the restive Sunni Triangle, where greater than 90% of the wartime trauma occurred. During the Fallujah mass casualty, helicopter crews were bringing wounded Americans and Iraqis directly to the surgeon's hospital from the Fallujah battlefield, which is only a 40-minute helicopter trip away.
Since the wounded in Iraq received only basic wound care after being hit, the head and neck injuries were “bleeding” wounds, and the head and neck surgeon was typically the first surgeon who would treat these patients. This is reflected by the increased incidence of head and neck trauma patients triaged to the immediate category in Iraq (11%) compared with those in Afghanistan (5%). Consequently, the perioperative mortality for head and neck trauma in Iraq (5.3%) was greater than the mortality in Afghanistan (1.3%). However, in Afghanistan the most common areas where head and neck patients are wounded are generally 1 to 3 hours away by helicopter, typically in the southern and eastern regions of the country. Consequently, level II and level III medical facilities are spread across these areas so that lifesaving surgery can be performed before they are sent to the Air Force Theater Hospital in Bagram, Afghanistan. The vast majority of head and neck wounded in Afghanistan, 93%, were pretreated by surgeons at level II and level III facilities before being seen by the head and neck surgeon in Bagram. Consequently, “bleeding” wounds in the head and neck were infrequently seen in Afghanistan. The “referral” or tertiary practice in Afghanistan is evident with the significantly increased number of facial fracture ORIF cases performed. Facial fracture repairs comprised 16.5% of the head and neck surgical volume in Afghanistan and only 3% of the surgical volume in Iraq. Furthermore, 19 facial plates per month, to include 3.5 mandibular reconstruction plates, were utilized in Afghanistan; while only 4.5 facial plates per month, but no mandibular reconstruction plates, were utilized in Iraq.
Facial laceration repair with soft tissue approximation was the most common head and neck operation performed in both Iraq and Afghanistan. The first lesson learned with traumatic soft tissue repair, typically due to high-velocity missile trauma, is that the soft tissue can be closed immediately after extensive irrigation and conservative debridement. Only grossly contaminated and devitalized tissue should be removed. The two primary goals of soft tissue reconstruction are to reapproximate the wound edges with primary closure and to achieve soft tissue coverage of the plates and exposed bone. The most important lesson learned is that the “home run” surgery should be avoided. After high-velocity injury to the facial soft tissues, the temporary cavity that results from the high kinetic energy of the missile may partially devitalize a large area surrounding the wound (Fig. 1). Even with the great blood supply to the face, “doing too much too soon” with extensive soft tissue undermining and flap rotation may result in dead tissue. With massive soft tissue injuries and a comminuted facial skeleton from high-velocity trauma (Fig. 2), it is recommend that the goals of the initial surgery be limited to reconstruction with soft tissue coverage of the exposed bone and plates with primary closure (Figs. 3 and 4). The surgical results in Afghanistan, with only 1.7% (2/115) of plates requiring removal due to loss of overlying soft tissue coverage after 51 facial/mandibular fracture repairs, support this recommendation.
The operative lessons learned in Iraq and Afghanistan include the timing of surgery for American servicemen with facial fractures who are waiting for aerovacuation to a level IV medical facility outside the combat zone.[14, 15] Consideration should be given for IMF and possibly ORIF of facial fractures if the decision has been made to go to the operating room under general anesthesia. If no surgery is warranted, then consideration should be given to delaying the ORIF of facial fractures so that aerovacuation would not be delayed, and the critically short bed space in the level III facility can be opened for future casualties.
Lessons learned during mandibular ORIF occurred in Afghanistan during our treatment for the severely comminuted and displaced mandible. Three-dimensional computed tomography scans were ideal for preoperative planning (Fig. 5). The three most important goals of mandibular fracture repair are occlusion, occlusion, occlusion! The establishment of premorbid occlusion with Erich arch bars or IMF screws is the single most important step in mandibular repair. If ORIF of the mandible fracture is indicated, such as for comminuted and displaced fractures, all fracture sites should be exposed. If there is no severe comminution and displacement, ORIF is performed in the standard fashion with mandibular plates (2 mm or less) applied as needed. If there is severe comminution and displacement, the surgeon should preserve all bony mandibular fragments and preserve any soft tissue attachments to these fragments. Then a mandibular reconstruction plate, such as the 2.4-mm locking plate, was secured from the stable bone to the opposite stable bone on both sides of the intact mandible. Typically, these plates would span from one mandibular angle to the other angle, using the IMF obtained with the remaining dental contact points to estimate the curve of the plate. The reconstructive plates can be slightly recessed to facilitate soft tissue coverage at the end of the case. After placement of the reconstructive plate, the largest mandibular fragments, typically comprised of bone from the inferior border of the mandible with soft tissue still attached, were secured with screws into the reconstructive plate, with every effort made to achieve bone-to-bone contact and to preserve soft tissue attachments. After the mandibular body and symphysis were reconstructed, smaller mandibular fragments, typically from the occlusal surface of the mandible near the teeth, were replaced and fixed with smaller mandibular or craniofacial plates to the larger inferior bony segments (Figs. 6 and 7). Finally, soft tissue coverage was achieved (Fig. 8). Twenty-one patients in Afghanistan underwent this extensive mandible repair with reconstruction plates; all healed well without wound infections or plate removal.
The last sets of lessons were learned during the repair of multiple midface fractures to include severely comminuted high-velocity Le Fort 3 fractures. The first step is to “set the base” for the panfacial repair. Since the “base” is the mandible, IMF and ORIF of mandible fractures are performed first if indicated. IMF alone in patients without mandibular fractures may be needed to stabilize and set the “base” in patients with severely comminuted and displaced midface fractures with a mobile upper jaw. All midface fracture sites are then exposed. After the appropriate surgical approaches are made, the bony segments should be reduced and positioned into their premorbid position, ensuring that the midface height and projection are preserved. After fracture reduction, the midface needs to be built from stable points to unstable points. One can start at the stable zygomatico-frontal suture and proceed with fixation down the lateral orbital rim to the zygomatico-maxillary complex. Then one should start from the stable laterally intact zygomatic arch segment and proceed with fixation medially along the fractured zygomatic arch to the zyomatico-maxillary process. The zygomatic arch is normally flat and the zygomatico-maxillary process is the most prominent point of midface projection. Then, if indicated, one should plate from the stable frontal bone along the nasoethmoid complex to the inferior orbital rim and finally to the zygomatico-maxillary complex. Finally, plates are placed from the now stable upper midface along the medial and lateral maxillary buttresses, as indicated, and the soft tissue incisions are closed.
The head and neck trauma experience of a single surgeon in Iraq differed greatly from his experience in Afghanistan. The variability of this trauma experience supports our duty as head and neck surgeons to maintain skill sets that can effectively treat both acute “bleeding” trauma, such as traumatic airway compromise and penetrating neck trauma, and more complex craniofacial bony and soft tissue repair that will occur during mass casualty events. In addition, based on 600 trauma procedures performed in the combat zone, lessons that were learned have been described, which may allow our civilian partners to better treat patients if mass casualty events occur in their communities.
- 4Injury severity and causes of death from Operation Iraqi Freedom and Operation Enduring Freedom: 2003–2004 versus 2006. J Trauma 2008:64:S21–S27., , , et al.
- 10Combat injuries in Iraq and Afghanistan help rewrite the book on war surgery. JAMA 2009:301:1866–1867..
- 11Emergency War Surgery, Third United States Revision. Washington, DC: Department of Defense, United States of America; 2004.
- 13Wound ballistics of gunshot injuries to the head and neck. Arch Otolaryngol 1983:109:313–318., .