Traumatic airway management in Operation Iraqi Freedom.

OBJECTIVES: To examine the role of head and neck surgeons in traumatic airway management in Operation Iraqi Freedom and to understand the lessons learned in traumatic airway management to include a simple airway triage classification that will guide surgical management. STUDY DESIGN: Case series with chart review. SETTING: Air Force Theater Hospital at Balad Air Base, Iraq. SUBJECTS AND METHODS: The traumatic airway experience of 6 otolaryngologists/head and neck surgeons deployed over a 30-month period in Iraq was retrospectively reviewed. RESULTS: One hundred and ninety-six patients presented with airway compromise necessitating either intubation or placement of a surgical airway over the 30-month timeframe. Penetrating face trauma (46%) and penetrating neck trauma (31%) were the most common mechanisms of injury necessitating airway control. The traumatic airways performed include 183 tracheotomies, 3 cricothyroidotomies, 9 complicated intubations, and 1 stoma placement. Red or emergent airways were performed in 10% of patients, yellow or delayed airways in 58% of patients, and green or elective airways in 32% of patients. Lastly, surgical repair of the laryngotracheal complex was performed in 25 patients with 16 thyroid cartilage repairs, 4 cricoid repairs, and 8 tracheal repairs. CONCLUSIONS: The role of the deployed otolaryngologist in traumatic airway management was crucial. Potentially lifesaving airways (red/yellow airways) were placed in 68% of the patients. The authors' recommended treatment classification should optimize future traumatic airway management by stratifying traumatic airways into red (airway less than 5 minutes), yellow (airway less than 12 hours), or green categories (airway greater than 12 hours).

Penetrating neck trauma in Operation Iraqi Freedom.

OBJECTIVES: To examine the surgical outcomes of penetrating neck trauma patients in Operation Iraqi Freedom (OIF) and compare treatment and perioperative survival to historical data with low-velocity penetrating neck trauma seen in a noncombat clinical setting. STUDY DESIGN: Case series with chart review. SETTING: Air Force Theater Hospital at Balad Air Base, Iraq. SUBJECTS AND METHODS: The surgical management of penetrating neck trauma by 6 otolaryngologists deployed over a 30-month period at the United States Air Force Theater Hospital in Balad, Iraq, was retrospectively reviewed. The presenting signs and symptoms, operative findings, and outcomes of patients who underwent neck exploration for high-velocity penetrating neck trauma were determined. A treatment algorithm defining the management of both high-velocity and low-velocity penetrating neck trauma is recommended. RESULTS: One hundred and twelve neck explorations for penetrating neck trauma were performed in OIF over 30 months. Ninety-eight percent of these neck injuries were due to high-velocity projectiles. In patients, zone 1 injuries occurred in 10%, zone 2 injuries in 77%, zone 3 injuries in 5%, combined zone 1/2 injuries in 5%, and combined zone 2/3 injuries in 3%. The positive exploration rate (patients with intraoperative findings necessitating surgical repair) was 69% (77/112). The mortality of patients undergoing neck exploration for high-velocity penetrating neck trauma was 3.7%. CONCLUSIONS: The perioperative mortality and the positive exploration rate for high-velocity penetrating neck trauma by deployed surgeons in OIF are very comparable to those rates seen in civilian centers managing low-velocity penetrating neck trauma.

Facial trauma in Operation Iraqi Freedom casualties: an outcomes study of patients treated from April 2006 through October 2006.

This study investigates the postoperative complication rate in American military members treated for fractures of the facial skeleton with either immediate fixation in the Operation Iraqi Freedom combat theater or delayed fixation after transport out of the combat theater. Based on an army head and neck surgeon's case log, retrospective chart review was performed on 21 American active-duty patients evaluated for facial fractures in Balad, Iraq, between April 16, 2006, and October 30, 2006. Follow-up standardized patient interviews and review of electronic medical records were conducted to assess the postoperative clinical course and identify postoperative complications. Facial fractures involved the mandible (62%), the orbit (62%), nasal bones (48%), the midface (38%), the frontal bone (29%), the zygoma (24%), and the temporal bone (5%). Fourteen patients (67%) with facial fractures were treated definitively with open reduction and internal fixation surgery in Balad. Seven patients (33%) had delayed treatment. Overall, the major complication rate was 7% in the immediate fixation group, compared with 57% in the delayed treatment group (P < 0.04). Infectious complications occurred in 1 patient (7%) from the immediate fixation group requiring removal of exposed hardware, whereas 3 patients (43%) from the delayed treatment group experienced infectious complications requiring reoperation (P < 0.09). Although major complications were associated with both immediate and delayed definitive treatment, major complications were more likely to be associated with delayed treatment. The deployed surgeon should use clinical judgment in repairing facial fractures in theater. If treatment is delayed, every effort should be made to affect a timely repair of the fractures.

Innovations in military handling of facial trauma.

As the military medical treatment facilities of Operation Iraqi Freedom have transitioned from make-shift tent facilities to more formal fixed facilities, the capability to deliver more complex care has markedly improved. Using case presentations, the authors illustrate the integration of advances in surgical technology in managing complex and devastating craniofacial trauma at the 332nd Air Force Theater Hospital in Balad Iraq during Operation Iraqi Freedom 2006.

Primary branchiogenic carcinoma: the confusion continues.

As in many specialties, otolaryngology is not without diagnosis surrounded by controversy. This report discusses the entity known as the primary branchial cleft carcinoma, which has been argued by some to be no more than metastatic disease of the unknown primary. Although the disease is rare, the consideration of this diagnosis requires careful thought and analysis by the otolaryngologist, pathologist, and radiation oncologist so that a rational treatment plan can be offered to the patient.