Combat injuries to the head and neck region are very common, representing about 30% of all wounds seen in Iraq and Afghanistan. You will see a lot of it, so be ready. The two busiest surgeons in our Combat Support Hospital were the otolaryngologist and the orthopedic surgeons because most of the survivable trauma is inflicted to the areas of the body that are exposed: face, neck, and extremities. As opposed to civilian trauma which consists mostly of blunt trauma from motor vehicle accidents or low-velocity penetrating trauma, combat trauma is defined by high-velocity penetrating injuries and by blast injuries which combine penetrating, blunt, burn, and concussive trauma into one (Fig. 28.1). Whatever the mechanism, and no matter how devastating the injury appears, the same dogmatic principles of trauma and wound management still apply.

If the airway is compromised, nothing else matters until a definitive airway is obtained and secured. Many patients arrive already intubated in the field, but you may encounter your patient in the trauma bay without a definitive airway. Maxillofacial trauma, as seen in combat, can cause markedly distorted anatomy and make endotracheal intubation challenging or impossible. One of the biggest amateur mistakes is to jump to immediate intubation based on the appearance of the wound (peek and shriek) rather than an assessment of the airway. A patient that is moving air without distress and maintaining oxygenation is stable from an airway standpoint. If the airway is compromised in any way, the decision between endotracheal intubation versus a surgical airway must be quick and definitive. Anticipate a difficult intubation and the potential for airway obstruction with chemical paralysis, and have adjuncts available such as suction, a nasal trumpet, an oral airway, and a tracheostomy set ready for a surgical airway (Fig. 28.2). It is entirely appropriate to prep the neck during endotracheal intubation in anticipation of a potential failed airway. If your assessment (and your gut) tells you this patient needs a surgical airway, then make your decision and move forward with confidence and without delay.

Whether the patient was intubated in the field or in the trauma bay, it is paramount to confirm and secure the airway. Any patient that is intubated, either nasally or orally, is at risk for tube displacement during transfers and transport. Commercial tube-securing devices are generally adequate, but the movement of patients in theater is often less smooth than in CONUS environments and requires a more effective means of securing the tube. In the case of a nasal intubation, you can secure the endotracheal tube to the nasal septum in a pattern similar to securing a JP drain to the skin: take a 2-0 nylon suture and wrap it around the tube several times, and then pass the suture needle through the nasal septum and tie. If the patient has been orally intubated, the tube can be secured by wrapping a 24-gauge wire (or 2-0 nylon) around the adjacent teeth (circumdental), tightened by twisting, and then wrapping the wire around the endotracheal tube. These suturing and wiring techniques eliminate the need for circumferential tube taping and devices that may be detrimental to the skin and soft tissues of burn patients and can inadvertently hide facial injuries (Fig. 28.3). Keep in mind that these suturing and wiring are not intended to be used long term, due to secondary movement of the wired teeth and pressure necrosis of the nasal septal cartilage. Therefore, if the patient is expected to be intubated for several days, is repeatedly transferred during medevac or airevac, is taken to the operating room for multiple surgeries, or has facial polytrauma , then an elective tracheostomy should be considered. If a cricothyroidotomy was performed, it should be converted to a formal tracheostomy as soon as possible to avoid development of subglottic stenosis.

There are numerous techniques for entering the trachea: vertical incision (best for pediatrics), square resection of 1–2 tracheal rings, horizontal incision, or a Bjork flap. Regardless of the technique, it is helpful to place stay sutures with a 2-0 or 3-0 nylon through the tracheal cartilage and then secure the sutures to the skin with Mastisol or Steri-Strips . If the tracheostomy tube becomes dislodged or extrudes, the stay sutures are gently retracted upward and outward to keep the stoma patent and elevated for easy reinsertion of the tube. A tried and true tracheostomy technique is the Bjork flap creating an inverted “U” incision to facilitate entry into the trachea (Fig. 28.4). A horizontal incision is made between the 2nd and 3rd tracheal rings, and two lateral incisions are extended inferiorly through the 3rd tracheal ring creating an inferiorly based flap. Prior to making the inverted “U” incision, capture the tracheal flap with a 3-0 nylon suture, taking care to avoid perforating the cuff of the endotracheal tube. After removing the suture needle, the nylon suture can hold anterior traction on the wall of the trachea while the vertical incisions through the tracheal rings are made. Then, insert the tracheostomy tube over the flap, into the airway, and verify placement with end-tidal CO2 and chest rise. The nylon suture is then secured to the skin below the tracheostomy with Mastisol skin adhesive or Steri-Strips . The placement of this suture into the tracheal flap allows for control of the trachea in the event that the tube becomes displaced; it also prevents intubation of the pre-tracheal space in the face of edema or hemorrhage. Alternately, the free end of the Bjork flap can be directly sutured to the dermis of the inferior skin flap with 3-0 Vicryl. In the event of displacement of the tracheostomy tube, the tracheal cartilage has already been sutured open to the skin and retracted anteriorly, so replacement of the tracheostomy tube is relatively unencumbered. Be sure to suture the edges of the tracheostomy tube collar to the skin with 2-0 silk, and place a length of umbilical tape through the tracheostomy tube collar and around the neck for further protection against displacement. After a week the stoma is generally “matured” and the stay sutures can be removed, and the umbilical tape can be replaced with foam Velcro tracheostomy ties.

In the civilian setting, it is not instinctive to intubate or trach a patient with a stable airway because you have the luxury of admitting the patient to the hospital and closely monitoring their airway. However, in the combat setting, the circumstances are markedly different. These combat trauma patients may be stabilized and medevac’d to stateside within a few hours. Their airway may be fine at this moment, but you must anticipate whether the patient’s airway status has the potential to change. If so, better to obtain and secure the airway now rather than losing an airway en route. Besides the obvious head and neck trauma requiring airway interventions, here are a few injuries that should get a definitive airway prior to transport: penetrating injuries to the tongue, pharynx, or midface with the potential for significant swelling, burn injuries to the face and neck, inhalational injuries, and comminuted mandible fractures.

Following the initial evaluation of the airway, a comprehensive inspection of the head and neck is necessary while simultaneously addressing the areas of active hemorrhage. Most of the injuries to the face are not immediately life threatening, and treatment can be delayed until the patient is stable from an airway and hemodynamic standpoint. Facial bleeding can be controlled with pressure, packing, and then surgery when it is optimal. For more robust, superficial bleeding, a 2-0 or 3-0 silk suture on a straight Keith needle is invaluable in temporarily controlling actively hemorrhaging wounds. Secure the bleeding tissue by pinching it between the index finger and thumb of the non-dominant hand, then hold the straight Keith needle in the dominant hand (with or without a needle driver), and place a figure-of-eight or horizontal mattress suture through the tissue and tie. Once the bleeding is controlled, you can move on to the next part of your exam. If the bleeding can’t be controlled with these maneuvers, you need to transfer the patient to the OR and prepare for proximal and distal control.

Aside from the obvious airway concerns, injuries to the neck are serious. Vascular injuries can lead to immediate exsanguination and rapid hemodynamic compromise, while injuries to the aerodigestive tract can lead to delayed morbidity and mortality due to deep space neck infection and fistula formation. Unilateral or bilateral neck explorations are indicated in most patients with penetrating neck trauma and some with blunt neck trauma in theater. The head and neck trauma patients that do not require mandatory neck exploration must meet all of these criteria: (1) minimal or superficial injuries, (2) totally stable, and (3) normal CT of the head and neck.

Approach the neck exploration using the standard vertical neck incision over the anterior border of the sternocleidomastoid muscle. This approach provides excellent access to the carotid sheath and aerodigestive tract. The neck exploration includes opening the carotid sheath , obtaining proximal and distal vascular control, and identifying and then repairing injuries to the great vessels where indicated (Fig. 28.5). Once hemorrhage control has been established, take a deep breath and move on to a systematic examination of the vital neck structures. Start at the skull base and work inferiorly, including a visual and manual inspection of the entire head and neck region. Injuries to the aerodigestive tract including the pharynx, larynx, trachea, and cervical esophagus are identified and repaired as indicated. Small perforating injuries to the trachea can heal spontaneously and do not necessarily require an elective tracheostomy or primary repair . However, larger tracheal defects should be repaired using a 3-0 Vicryl through the cartilage, avoiding sutures through the mucosa as this may induce tracheal scarring and stenosis. Laryngeal and tracheal fractures need to be repaired, but the repair can be delayed for 2–3 days as long as the patient has a tracheostomy. Laryngeal fractures are reduced and stabilized with 26-gauge wire or microplates with 4 mm screws. Most massive laryngeal fractures require a laryngofissure to access the lumen. To prevent laryngeal stenosis, major laryngeal injuries with damage to the mucosa should get a soft stent. Prior to repair and closure of the laryngeal cartilage, make a soft stent by cutting the finger off of a sterile glove, loosely pack a sponge into the finger of the glove, and then close the opening with a 3-0 silk suture. This soft stent is then placed in the lumen of the larynx with the superior aspect above the level of the vocal cords. The stent is secured with 2-0 nylon brought through the tracheal cartilage inferiorly and then through the skin and secured externally. This stent can be removed in 2–3 weeks under direct visualization.