'No zone' approach in the management of penetrating neck injuries - an Australian Tertiary Trauma Centre experience.

PURPOSE: Penetrating neck injuries (PNIs), defined as deep to the platysma, can result in significant morbidity and mortality. Management has evolved from a zone-based approach to a 'no zone' algorithm, resulting in reduced non-therapeutic neck exploration rates. The aim of this study was to examine PNIs and its management trends in an Australian tertiary trauma centre, to determine if a 'no zone' approach could be safely implemented in this population, as has been demonstrated internationally. METHODOLOGY: This was a retrospective observational study at a level 1 adult Australian tertiary trauma centre using prospectively collated data from January 2008 to December 2018. Observed data included age, gender, mechanism of injury, computed tomography angiography (CT-A) use and operative intervention. Patients were examined based on zone of injury and presenting signs - 'hard', 'soft' or 'asymptomatic'. Major outcomes were CT-A usage, positive CT-A correlation with therapeutic neck explorations and negative neck exploration rates. RESULTS: This study identified 238 PNI patients, with 204 selected for review. Most injuries occurred in zone 2 (71.6%), with soft signs accounting for 53.4% of cases. Over 10 years, CT-A utilization increased from 55% to 94.1%, with positive CT-As being more likely to yield therapeutic neck explorations. There was a general decreased trend in operative intervention but without a clear reduction in non-therapeutic neck explorations. CONCLUSION: Our data suggests similarities with results from around the world, demonstrating that the 'no zone' approach should be considered when managing PNIs, but with clinician discretion in individual cases.

Prognostic Significance of Multifactorial Analysis in Complex Cervical Aero-Digestive Trauma Cases.

Background and Objectives: In the context of complex aerodigestive cervical traumas, the prognosis and outcome heavily depend on risk factors, particularly injuries to the larynx, trachea, major digestive tissues, cervical vertebrae, and vascular structures. With the increasing prevalence of trauma as a public health concern, there is a pressing need for epidemiological research and the implementation of preventative measures. The purpose of this research is to establish the profile of the predictable impact factors that determine the prognosis of patients with complex cervical trauma. Methods and Methods: The study group consisted of 106 patients with complex cervical trauma pathology developed by various mechanisms such as car accidents, home-related accidents, aggression, gunshot wounds, and self-inflicted attempts, resulting in hospitalization in the E.N.T. Clinic at "St. Spiridon" Iași Hospital, from 2012 to 2016; medical records were the source of the collected data. Results: Hemodynamic instability upon admission associated with age, muscle and laryngeal injuries, and anemia were identified as negative prognostic factors. Additionally, the utilization of imaging-based paraclinical investigations for diagnosing traumatic lesions emerged as a positive prognostic factor in managing this pathology. The management of penetrating cervical trauma remains a subject of debate, with some advocating for surgical exploration beyond the platysma layer in all cases, while others argue for a more selective conservative approach due to a high rate of negative explorations. Conclusions: The statistical evaluation of epidemiological, clinical, lesion, paraclinical, and therapeutic parameters is needed to establish predictable risk factors in the prognosis of complex aerodigestive cervical trauma.

Displaced transverse laryngeal fracture from attempted hanging.

Laryngeal fractures are life-threatening injuries, frequently associated with long-term morbidity. We present a case of a man sustaining a displaced laryngeal fracture and rupture of supraglottic structures following attempted suicide by hanging from a bridge. His injuries included a tear of the thyrohyoid membrane, avulsed epiglottis and complete autopharyngotomy. All laryngeal functions were significantly impaired. Early tracheostomy, careful surgical repair, extensive multidisciplinary team (MDT) input and intensive rehabilitation all contributed towards a successful recovery. By 7 months following the initial injury, the patient had achieved excellent breathing and voicing, and a safe and competent swallow despite the extent of his initial injuries. This case demonstrates the importance of early airway management in laryngeal trauma and the role of surgical management in conjunction with swallow rehabilitation. Fundamentally, an MDT approach is essential for the holistic management of patients with laryngeal trauma.

[Surgical treatment of combined injuries of the neck and shoulder joints]. / Khirurgicheskoe lechenie sochetannykh porazhenii shei i plechevykh sustavov.

OBJECTIVE: To develop the algorithm for effective surgical restoration of shoulder joint and neck functions and acceleration of social and labor rehabilitation. MATERIAL AND METHODS: There were 116 patients with combined consequences of burns of the neck and shoulder joints between 2012 and 2021. These ones amounted to 29.4% of all patients with lesions of the neck or shoulder joints. Simultaneous surgeries with correction of post-burn cicatricial deformities and contractures were performed in 66 patients (56.9%). Age of patients ranged from 18 to 72 years, and 96% of them were employable. There were 89 (76.7%) women and 27 (23.3%) men. We assessed spread and localization of cicatricial process, as well as restriction of mobility of the neck and shoulder joint to select optimal surgical approach. Classification of neck deformities and contractures of shoulder joints considering severity of cicatricial lesion and functional impairment made it possible to systematize the approach to reconstructive procedures. Reconstructive surgery included repair with local tissues including skin-fatty flap, non-perforated split or full-thickness skin autograft, rotated flaps including those based on perforator vessels, as well as preliminary skin stretching. RESULTS: In general, 116 patients with combined lesions of the neck and shoulder joints underwent 314 surgeries. To accelerate rehabilitation, we performed simultaneous surgeries with correction of deformities and contractures in 66 patients (56.9%). Staged reconstructive surgeries were carried out in 50 patients. Acute dermotension and skin-fatty neck flap grafting were the most common for deformities and contractures of the neck. Skin-fatty axillary flap was used in most patients with contractures of shoulder joints. CONCLUSION: Simultaneous surgeries can accelerate rehabilitation. Correct algorithm of staged surgical treatment reduces rehabilitation period and eliminates functional disorders.

Surgical exploration for penetrating neck trauma - an audit of results in 145 patients.

BACKGROUND: Selective non-operative management (SNOM) is the current gold standard for the treatment of patients with penetrating neck trauma. The policy revolves around the liberal use of computed tomography angiography (CTA) in those patients who are haemodynamically stable, irrespective of the anatomical zone of injury, aiming at reducing the incidence of negative and non-therapeutic interventions and their potential complications. METHODS: A retrospective audit of results of patients who underwent immediate surgical exploration at the Chris Hani Baragwanath Academic Hospital in Soweto between January 2010 and December 2015 was performed. RESULTS: One-hundred and forty-five (145) patients, with a median age of 28 years (range 18-67 years), predominantly males (93.8%), underwent immediate exploration. Most injuries were caused by stab wounds (92.4%) and affected zone 2 (54.1%) on the left side of the neck (69.6%). The most common presentations were active haemorrhage (29.4%), shock (24.1%) and expanding haematoma (15.1%). A major vascular injury was found in 40%, and aero-digestive organ injury in 19.3%. The rate of negative-non-therapeutic exploration in this cohort was 4.1%. Complications were recorded in 7.6%, and the overall mortality was 9.6% secondary to early uncontrolled haemorrhage, sepsis and occlusive strokes. CONCLUSIONS: The utilisation of SNOM with strict criteria for selection of patients who require immediate surgical exploration versus investigations with CTA results in a low rate of non-therapeutic interventions.

Penetrating carotid artery injury by air rifle: a case report.

BACKGROUND: Air rifle injuries can cause significant vascular injuries. This air rifle injury has resulted in a penetrating neck trauma traversing the common carotid artery. There is debate around the need for radiological investigation, the most appropriate investigational modality, and the need for surgical exploration versus a conservative approach. This case report aims to exemplify a successful approach to managing Penetrating Carotid Injuries (PCI) while shedding light on the rationale behind the management decisions. PRESENTATION: An 18-year-old Caucasian man arrived at the hospital following an air rifle injury to the right side of the neck, with active bleeding and a moderate haematoma displacing the trachea. He was haemodynamically stable, with a Glasgow Coma Scale (GCS) of 15 and no evidence of bruit. Computed Tomography Angiography (CTA) showed Right common carotid (CCA) artery injury with associated post-traumatic pseudoaneurysm. The pellet trajectory traverses the right superior thyroid gland. A duplex ultrasound scan (USS) confirmed two areas of arterial blush at the right CCA. Management involved neck exploration under General Anaesthesia (G.A.), repair of right CCA, bullet extraction, and wound washout. He received antibiotics for ten days and a single agent of antiplatelets for three months and was discharged two days postoperatively with no complications. He was followed up for eight months with no evidence of any trauma sequelae. CONCLUSION: Penetrating carotid artery injuries are a serious concern. The small-sized pellets carry the risk of embolization. Therefore, neck exploration remains the gold standard treatment for PCI. Appropriate operative planning is crucial and can be optimised using radiological diagnostic modalities in haemodynamically stable patients. CTA is a non-invasive, swift, and adequate alternative to arteriography, providing valuable diagnostic information on vascular and aerodigestive injuries and bullet trajectory. This enables appropriate preparedness to achieve excellent outcomes in such critical cases.

Earlier Tracheostomy Reduces Complications in Complete Cervical Spinal Cord Injury in Real-World Practice: Analysis of a Multicenter Cohort of 2001 Patients.

BACKGROUND AND OBJECTIVES: It is believed that early tracheostomy in patients with traumatic cervical spinal cord injury (SCI) may lessen the risk of developing complications and reduce the duration of mechanical ventilation and critical care stay. This study aims to assess whether early tracheostomy is beneficial in patients with traumatic cervical SCI. METHODS: We conducted a retrospective cohort study using data from the American College of Surgeons Trauma Quality Improvement Program database from 2010 to 2018. Adult patients with a diagnosis of acute complete (ASIA A) traumatic cervical SCI who underwent surgery and tracheostomy were included. Patients were stratified into those receiving early (at or before 7 days) and delayed tracheostomy. Propensity score matching was used to assess the association between delayed tracheostomy and the risk of in-hospital adverse events. Risk-adjusted variability in tracheostomy timing across trauma centers was investigated using mixed-effects regression. RESULTS: The study included 2001 patients from 374 North American trauma centers. The median time to tracheostomy was 9.2 days (IQR: 6.1-13.1 days), with 654 patients (32.7%) undergoing early tracheostomy. After matching, the odds of a major complication were significantly lower for early tracheostomy patients (OR: .90; 95% CI: .88-.98). Patients were also significantly less likely to experience an immobility-related complication (OR: .90; 95% CI: .88-.98). Patients in the early group spent 8.2 fewer days in the critical care unit (95% CI: -10.2 to -6.61) and 6.7 fewer days ventilated (95% CI: -9.44 to -5.23). There was significant variability in tracheostomy timeliness between trauma centers with a median odds ratio of 12.2 (95% CI: 9.7-13.7), which was not explained by case-mix and hospital-level characteristics. CONCLUSION: A 7-day threshold to implement tracheostomy seems to be associated with reduced in-hospital complications, time in the critical care unit, and time on mechanical ventilation.

Penetrating Head and Neck Trauma: A Narrative Review of Evidence-Based Evaluation and Treatment Protocols.

Penetrating injury to the head and neck accounts for a minority of trauma but significant morbidity in the US civilian population. The 3-zone anatomical framework has historically guided evaluation and management; however, the most current evidence-based protocols favor a no-zone, systems-based approach. In stable patients, a thorough physical examination and noninvasive imaging should be prioritized, with surgical exploration of the head and neck reserved for certain circumstances. Diagnostic and management decisions should be tailored to the mechanism of injury, history, physical examination, experience of personnel, availability of equipment, and clinical judgment.

Surgical outcomes of basilar invagination type B without atlantoaxial dislocation through simple posterior fossa decompression: a retrospective study of 18 cases.

BACKGROUND: Basilar invagination (BI) is a common disease in the craniocervical junction (CVJ) area. Posterior fossa decompression with/without fixation is a controversial surgical strategy for BI type B. This study aimed to evaluate the efficacy of simple posterior fossa decompression in treating BI type B. METHODS: This study retrospectively enrolled BI type B patients who underwent simple posterior fossa decompression at Huashan Hospital, Fudan University between 2014.12 and 2021.12. Patient data and images were recorded pre- and postoperatively (at the last follow-up) to evaluate the surgical outcomes and craniocervical stability. RESULTS: A total of 18 BI type B patients (13 females), with a mean age of 44.2±7.9 years (range 37-62 years), were enrolled. The mean follow-up period was 47.7±20.6 months (range 10-81 months). All patients received simple posterior fossa decompression without any fixation. At the last follow-up, compared with preoperation, the JOA scores were significantly higher (14.2±1.5 vs. 9.9±2.0, p = 0.001); the CCA was improved (128.7±9.6° vs. 121.5±8.1° p = 0.001), and the DOCL was reduced (7.9±1.5 mm vs. 9.9±2.5 mm, p = 0.001). However, the follow-up and preoperative ADI, BAI, PR, and D/L ratio were similar. No patients had an unstable condition between the C1-2 facet joints that was observed in the follow-up CT and dynamic X-ray. CONCLUSIONS: In BI type B patients, simple posterior fossa decompression could improve neurological function and will not induce CVJ instability in BI type B patients. Simple posterior fossa decompression could be a satisfactory surgical strategy for BI type B patients, but preoperative CVJ stability assessment is crucial.

C1-2 Fusion in Atlantoaxial Dislocation and Basilar Invagination with and without Chiari Malformation: Clinical/Radiological and Craniometric Results.

OBJECTIVE: Patients with Chiari malformation (CM) associated with atlantoaxial dislocation (AAD) and basilar invagination (BI) may present with a small posterior cranial fossa, but data on the volumetric analysis are lacking. Additionally, whether additional foramen magnum decompression (FMD) is needed together with atlantoaxial fusion remains controversial. This study evaluated the volumetric alterations of the posterior cranial fossa in these patients and analyzed the radiological and clinical outcomes after posterior C1-C2 reduction and fixation plus C1 posterior arch resection. METHODS: Thirty-two adult CM patients with AAD and BI (CM-AAD/BI group) and 21 AAD and BI patients without CM (AAD/BI-only group) who received posterior atlantoaxial fusion plus C1 posterior arch resection were retrospectively studied. The clinical and radiological outcomes and volumetric measurements of the posterior cranial fossa were evaluated. RESULTS: The majority of CM-AAD/BI patients (94%) improved clinically and radiologically at 12 mo postoperatively, and none required additional FMD. Morphological analysis revealed a significant reduction in the bony posterior cranial fossa volumes of the CM-AAD/BI group (P < 0.01) and the AAD/BI-only group (P < 0.01) relative to those of the CM group. No significant differences were observed between the CM-AAD/BI and AAD/BI groups. CONCLUSIONS: Compared with patients with simple CM, patients with AAD/BI with or without CM demonstrated a considerably and equally reduced bony posterior cranial fossa volume. No additional FMD is needed in the treatment of CM-AAD/BI patients after posterior reduction and fusion plus C1 posterior arch resection.

Risk factors for sacral fracture following en bloc chordoma resection.

OBJECTIVE: The purpose of this study was to analyze risk factors for sacral fracture following noninstrumented partial sacral amputation for en bloc chordoma resection. METHODS: A multicenter retrospective chart review identified patients who underwent noninstrumented partial sacral amputation for en bloc chordoma resection with pre- and postoperative imaging. Hounsfield units (HU) were measured in the S1 level. Sacral amputation level nomenclature was based on the highest sacral level with bone removed (e.g., S1 foramen amputation at the S1-2 vestigial disc is an S2 sacral amputation). Variables collected included basic demographics, patient comorbidities, surgical approach, preoperative radiographic details, neoadjuvant and adjuvant radiation therapy, and postoperative sacral fracture data. RESULTS: A total of 101 patients (60 men, 41 women) were included; they had an average age of 69 years, BMI of 29 kg/m2, and follow-up of 60 months. The sacral amputation level was S1 (2%), S2 (37%), S3 (44%), S4 (9%), and S5 (9%). Patients had a posterior-only approach (77%) or a combined anterior-posterior approach (23%), with 10 patients (10%) having partial sacroiliac (SI) joint resection. Twenty-seven patients (27%) suffered a postoperative sacral fracture, all occurring between 1 and 7 months after the index surgery. Multivariable logistic regression analysis demonstrated S1 or S2 sacral amputation level (p = 0.001), combined anterior-posterior approach (p = 0.0064), and low superior S1 HU (p = 0.027) to be independent predictors of sacral fracture. The fracture rate for patients with superior S1 HU < 225, 225-300, and > 300 was 38%, 15%, and 9%, respectively. An optimal superior S1 HU cutoff of 300 was found to maximize sensitivity (89%) and specificity (42%) in predicting postamputation sacral fracture. In addition, the fracture rate for patients who underwent partial SI joint resection was 100%. CONCLUSIONS: Patients with S1 or S2 partial sacral amputations, a combined anterior-posterior surgical approach, low superior S1 HU, and partial SI joint resection are at higher risk for postoperative sacral fracture following en bloc chordoma resection and should be considered for spinopelvic instrumentation at the index procedure.

A Rare Self-Inflicted Stabbing to the Neck Injuring the Distal Trachea and Proximal Esophagus.

Penetrating neck trauma poses a significant risk to multiple vital structures, which if not treated immediately may lead to devastating consequences. Our patient presented after sustaining self-inflicted stab wounds to the neck. He was taken to the operating room for a left neck exploration and median sternotomy, revealing a distal tracheal injury. Following repair of the tracheal injury, an intraoperative esophagogastroduodenoscopy demonstrated a full-thickness esophageal injury 15 cm proximal to the tracheal injury. Both injuries were the result of separate stab entries originating from the same external midline wound. To our knowledge, this case report is unique in bringing this circumstance to the literature, demonstrating the importance of full intraoperative examination to assess for concomitant wounds in stab injuries after the initial pathology has been found and the initial stab trajectory understood.

Using an Expanded Cervical Flap With an Overlapping Tissue Expansion Technique to Resurface Middle and Lower Facial Defects.

BACKGROUND: Extensive facial burn scars are a tragedy for patients and often pose a great challenge to surgeons because of the high esthetic and functional demands. For patients with healthy skin in the neck region, a cervical flap is highly recommended for facial resurfacing; however, the skin on the midline of the neck often needs more expansion than that on either side, especially for the treatment of large facial defects. The sufficient longitudinal soft tissue in the anterior neck ensures a normal neck shape as well as a normal range of cervical extension, rotation, and lateral flexion. To overcome this, we developed an expanded cervical flap with an overlapping tissue expansion technique to gain more length centrally. METHODS: First, 2 tissue expanders were embedded in the anterior neck region overlapping each other at the midline of the neck. After adequate inflation of the expander, the expanded flap was dissected and rotated to repair defects in the middle and lower face. The anchor position of the flap was placed on the horizontal line of the thyroid cartilage to restore the cervicomental angle. RESULTS: Sixteen patients were treated with this method in this single-center study. All defects affected the middle and lower face, with an area ranging from 135 to 185 cm 2 , and were caused by a massive facial burn. Among them, 12 patients suffered ectropion of the lower lip, 3 suffered limited mouth opening due to scar contraction, and one patient had a cervicomental adhesion. The area of the expanded flap was approximately 163 to 266 cm 2 . The average period of expansion was 89.5 days. Patients were followed up after the operation, with the follow-up period ranging from 6 to 12 months. In all cases, good defect coverage was achieved, with primary closure of the donor sites and a good postoperative cervical configuration. CONCLUSION: We conclude that the expanded cervical flap with the overlapping tissue expansion technique proved to be a reliable method for facial skin reconstruction with functional and aesthetic improvement.

Microsurgical Clipping of a Ruptured Wide-Neck Basilar Tip Aneurysm by an Extended Transsylvian Transcavernous Approach: 2-Dimensional Operative Video.

Basilar tip aneurysms are difficult to treat due to their deep location, proximity to cranial nerves and brainstem, and risk of perforator stroke.1-3 A 49-year-old woman presenting to the emergency department with subarachnoid hemorrhage was found to have a wide-neck basilar tip aneurysm measuring 8.6 mm × 5.6 mm × 7.6 mm. The aneurysm had a 4.9-mm wide neck located at the level of the dorsum sellae.4,5 Microsurgical clipping was recommended to the patient due to the complexity of the aneurysm neck, the patient's young age, the expertise of the surgical-anesthetic team, treatment durability, and the low risk of recurrence.2,6-9 We used an extended transsylvian transcavernous approach to expose the aneurysm (Video 1). We preferred this anterolateral approach over the more lateral subtemporal transzygomatic approach because of its versatility in providing better visualization of the bilateral posterior cerebral arteries and superior cerebellar arteries.10 The surgical exposure to the proximal basilar artery was gained by drilling the posterior clinoid process and dorsum sellae. Two titanium clips were applied across the aneurysm neck, and indocyanine green angiography confirmed complete aneurysm obliteration. Protection of critical brainstem perforators was ensured using the rubber-dam technique. The patient tolerated the procedure well with no deficits at the 12-month follow-up. We review the microsurgical nuances of treating complex wide-neck basilar tip aneurysms that are not good candidates for endovascular treatment. Although endovascular tools are favored as the first-line treatment choice for most cerebral aneurysms, microsurgical clipping techniques remain an important tool in the contemporary cerebrovascular neurosurgeon's toolkit.2,6,11-15.

Facial Fractures and Their Relation to Head and Cervical Spine Injuries in Hospitalized Bicyclists.

Bicyclists are vulnerable road users. The authors aimed to characterise facial fractures and their association with head and neck injuries in bicyclists admitted to a Scandinavian Level 1 trauma center with a catchment area of ~3 million inhabitants. Data from bicycle-related injuries in the period 2005 to 2016 were extracted from the Oslo University Hospital trauma registry. Variables included were age; sex; date of injury; abbreviated injury scale (AIS) codes for facial skeletal, head and neck injuries; and surgical procedure codes for treatment of facial fractures. Anatomical injury was classified according to AIS98. A total of 1543 patients with bicycle-related injuries were included. The median age was 40 years (quartiles 53, 25), and 1126 (73%) were men. Overall, 652 fractures were registered in 339 patients. Facial fractures were observed in all age groups; however, the proportion rose with increasing age. Bicyclists who suffered from facial fractures more often had a concomitant head injury (AIS head >1) than bicyclists without facial fractures (74% vs. 47%), and the odds ratio for facial fracture(s) in the orbit, maxilla and zygoma were significantly increased in patients with AIS head >1 compared to patients with AIS head=1. In addition, 17% of patients with facial fractures had a concomitant cervical spine injury versus 12% of patients without facial fractures. This results showed that facial fractures were common among injured bicyclists and associated with both head and cervical spine injury. Thus, a neurological evaluation of these patients are mandatory, and a multidisciplinary team including maxillofacial and neurosurgical competence is required to care for these patients.

Surgical Decompression of Traumatic Cervical Spinal Cord Injury: A Pilot Study Comparing Real-Time Intraoperative Ultrasound After Laminectomy With Postoperative MRI and CT Myelography.

BACKGROUND: Decompression of the injured spinal cord confers neuroprotection. Compared with timing of surgery, verification of surgical decompression is understudied. OBJECTIVE: To compare the judgment of cervical spinal cord decompression using real-time intraoperative ultrasound (IOUS) following laminectomy with postoperative MRI and CT myelography. METHODS: Fifty-one patients were retrospectively reviewed. Completeness of decompression was evaluated by real-time IOUS and compared with postoperative MRI (47 cases) and CT myelography (4 cases). RESULTS: Five cases (9.8%) underwent additional laminectomy after initial IOUS evaluation to yield a final judgment of adequate decompression using IOUS in all 51 cases (100%). Postoperative MRI/CT myelography showed adequate decompression in 43 cases (84.31%). Six cases had insufficient bony decompression, of which 3 (50%) had cerebrospinal fluid effacement at >1 level. Two cases had severe circumferential intradural swelling despite adequate bony decompression. Between groups with and without adequate decompression on postoperative MRI/CT myelography, there were significant differences for American Spinal Injury Association motor score, American Spinal Injury Association Impairment Scale grade, AO Spine injury morphology, and intramedullary lesion length (IMLL). Multivariate analysis using stepwise variable selection and logistic regression showed that preoperative IMLL was the most significant predictor of inadequate decompression on postoperative imaging (P = .024). CONCLUSION: Patients with severe clinical injury and large IMLL were more likely to have inadequate decompression on postoperative MRI/CT myelography. IOUS can serve as a supplement to postoperative MRI/CT myelography for the assessment of spinal cord decompression. However, further investigation, additional surgeon experience, and anticipation of prolonged swelling after surgery are required.

Laryngotracheal and pharyngoesophageal traumatic injuries from US military operations in Iraq and Afghanistan, 2003-2017.

INTRODUCTION: Laryngotracheal and pharyngo-oesophageal trauma present military providers with especially difficult, life-threatening challenges. Although effective treatment strategies are crucial, there is no clear consensus. This study of combat injuries from Iraq and Afghanistan describes initial treatment outcomes. METHODS: US service members who sustained 'laryngotracheal' and 'pharyngoesophageal' injuries while deployed in military operations from 2003 to 2017 were identified from the Expeditionary Medical Encounter Database. Those with inhalation or ingestion injuries and an Injury Severity Score (ISS) <16 were excluded. Data on demographics, survival, mechanism and type of injury and diagnostic and therapeutic intervention were recorded. RESULTS: A total of 111 service members met inclusion criteria. Nearly one-third (32.4%) were killed in action (KIA) or died of wounds (DoW). Fatality was not significantly associated with age, theatre of operation, type of injury or mechanism of injury, but was associated with a higher ISS and those in the Marines. Although survival rates were not significantly different, the frequency of these injuries decreased after the introduction of cervical collar protection in 2007. Of those who DoW or survived, 41.1% required a surgical airway. Tracheobronchoscopy was performed in 25.6%, oesophagoscopy in 20.0% and oesophagram in 6.7%. Of the 85 with penetrating neck injuries, 43 (50.6%) underwent neck exploration, in which 31 (72.1%) required intervention. CONCLUSIONS: Severe laryngotracheal and pharyngo-oesophageal injuries have a high fatality rate and demand prompt treatment from skilled providers. Further work will elucidate preventive measures and clear management algorithms to optimise outcomes.

[Management of blunt and penetrating laryngeal trauma]. / Management von stumpfen und scharfen Kehlkopfverletzungen.

Patients presenting with laryngotracheal trauma can be in a life-threatening situation. Early recognition of the severity of the injury and, if necessary, surgical intervention within the first 24-48 h increases the chance of achieving a good functional late result. Preservation or restoration of voice and swallowing function is the long-term therapeutic goal. Precise assessment of the extent of the injury can be achieved using a combination of computed tomography and flexible laryngotracheoscopy. Symptoms often do not reflect the extent of the injury, which can vary from endolaryngeal hemorrhage to complete laryngotracheal separation. Conservative treatment consists of observation with symptomatic therapy. On the other hand, surgery may include endolaryngeal repair and/or transcervical reconstruction; securing the airways is of utmost importance.

Head Face and Neck Surgeon Deployment in the New French Role 2: The Damage Control Resuscitation and Surgical Team.

INTRODUCTION: High-intensity conflict is back after decades of asymmetric warfare. With the increase in the incidence of head, face, and neck (HFN) injuries, the French Medical Military Service has decided to deploy HFN surgeons in the new French Role 2: the Damage Control, Resuscitation, and Surgical Team (DCRST). This study aims to provide an overview of HFN French surgeons from their initial training, including the surgical skills required, to their deployment on the DCRST. MATERIALS AND METHODS: The DCRST is a tactical mobile medico-surgical structure with several configurations depending on the battlefield, mission, and flux of casualties. It represents the new French paradigm for the management of combat casualties, including HFN injuries. RESULTS: The HFN's military surgeon training starts during residency with rotation in the different subspecialties. The HFN surgeon follows a training course called "The French Course for Deployment Surgery" that provides sufficient background to manage polytrauma, including HFN facilities on modern warfare. We have reviewed the main surgical procedures required for an HFN military surgeon. CONCLUSION: The systematic deployment of HFN surgeons in Role 2 is a specificity of the French army as well as the HFN surgeon's training.Currently, the feedback from an asymmetric conflict is encouraging. However, it will have to innovate to adapt to modern warfare.