Management of Battlefield Injuries to the Skull Base

Abstract

High velocity skull base injuries on the battlefield are unique in comparison to most civilian sector trauma. With more than 43,000 United States military personnel injuries during Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF), the most recent conflicts in Iraq and Afghanistan have significantly expanded the understanding of the physiology of modern battlefield trauma and how to appropriately address these injuries. The acute care principles of effective triage, airway management, and hemorrhage control in these injuries can be life saving and are reviewed here. Specific injury patterns and battlefield examples are reviewed as well, with a review of some of the lessons learned while providing care in a deployed setting. Utilization of the knowledge learned in Iraq and Afghanistan, which have improved casualty care of deployed service members, can be used both in future military conflicts and in civilian trauma care.

Keywords

battlefield injuries - skull base trauma

Note

No sponsorships or competing interests have been disclosed for this publication.

The views expressed herein are those of the authors and do not reflect the official policy or position of Brooke Army Medical Center, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army, and Department of Defense, or the U.S. Government.

• References

• 1 Feldt BA, Salinas NL, Rasmussen TE, Brennan J. The joint facial and invasive neck trauma (J-FAINT) project, Iraq and Afghanistan 2003–2011. Otolaryngol Head Neck Surg 2013; 148 (3) 403-408
• 2 Champion HR, Holcomb JB, Young LA. Injuries from explosions: physics, biophysics, pathology, and required research focus. J Trauma 2009; 66 (5) 1468-1477 , discussion 1477
• 3 Ramasamy A, Hill AM, Clasper JC. Improvised explosive devices: pathophysiology, injury profiles and current medical management. J R Army Med Corps 2009; 155 (4) 265-272
• 4 Champion HR, Bellamy RF, Roberts CP, Leppaniemi A. A profile of combat injury. J Trauma 2003; 54 (5, Suppl) S13-S19
• 5 Kelly JF, Ritenour AE, McLaughlin DF , et al. Injury severity and causes of death from Operation Iraqi Freedom and Operation Enduring Freedom: 2003–2004 versus 2006. J Trauma 2008; 64 (2, Suppl) S21-S26 , discussion S26–S27
• 6 Brennan J. Head and neck trauma in Iraq and Afghanistan: different war, different surgery, lessons learned. Laryngoscope 2013; 123 (10) 2411-2417
• 7 Holt GR, Kostohryz Jr G. Wound ballistics of gunshot injuries to the head and neck. Arch Otolaryngol 1983; 109 (5) 313-318
• 8 Goldberg MS. Death and injury rates of U.S. military personnel in Iraq. Mil Med 2010; 175 (4) 220-226
• 9 Schenk E, Wijetunge G, Mann NC, Lerner EB, Longthorne A, Dawson D. Epidemiology of mass casualty incidents in the United States. Prehosp Emerg Care 2014; 18 (3) 408-416
• 10 Salinas NL, Eller RL, Davis MR, Rasmussen TE. Mass casualty response of a modern deployed head and neck surgical team. J Craniofac Surg 2010; 21 (4) 987-990
• 11 Brennan J. Experience of first deployed otolaryngology team in Operation Iraqi Freedom: the changing face of combat injuries. Otolaryngol Head Neck Surg 2006; 134 (1) 100-105
• 12 Cubano MA ed. Emergency War Surgery, Third United States Revision. Washington, DC: Department of the Army, Office of The Surgeon General, Borden Institute; 2004
• 13 Holt GR. Making difficult ethical decisions in patient care during natural disasters and other mass casualty events. Otolaryngol Head Neck Surg 2008; 139 (2) 181-186
• 14 Bellamy R. How people die in ground combat. Presented at: the Joint Health Services Support Vision 2010 Working Group. September 1996
• 15 Brennan J, Lopez M, Gibbons MD , et al. Penetrating neck trauma in Operation Iraqi Freedom. Otolaryngol Head Neck Surg 2011; 144 (2) 180-185
• 16 Kellman RM, Losquadro WD. Comprehensive airway management of patients with maxillofacial trauma. Craniomaxillofac Trauma Reconstr 2008; 1 (1) 39-47
• 17 Brennan J, Gibbons MD, Lopez M , et al. Traumatic airway management in Operation Iraqi Freedom. Otolaryngol Head Neck Surg 2011; 144 (3) 376-380
• 18 Salinas NL, Brennan J, Gibbons MD. Massive facial trauma following improvised explosive device blasts in Operation Iraqi Freedom. Otolaryngol Head Neck Surg 2011; 144 (5) 703-707
• 19 Owens BD, Kragh Jr JF, Wenke JC, Macaitis J, Wade CE, Holcomb JB. Combat wounds in Operation Iraqi Freedom and Operation Enduring Freedom. J Trauma 2008; 64 (2) 295-299
• 20 Lew TA, Walker JA, Wenke JC, Blackbourne LH, Hale RG. Characterization of craniomaxillofacial battle injuries sustained by United States service members in the current conflicts of Iraq and Afghanistan. J Oral Maxillofac Surg 2010; 68 (1) 3-7
• 21 Montgomery SP, Swiecki CW, Shriver CD. The evaluation of casualties from Operation Iraqi Freedom on return to the continental United States from March to June 2003. J Am Coll Surg 2005; 201 (1) 7-12 , discussion 12–13
• 22 Chambers LW, Rhee P, Baker BC , et al. Initial experience of US Marine Corps forward resuscitative surgical system during Operation Iraqi Freedom. Arch Surg 2005; 140 (1) 26-32
• 23 Thomas RF, Bothwell NE. Delayed management of paranasal sinus fractures. In Brennan JA, Holt GR, Thomas RW, eds. Otolaryngology/Head and Neck Surgery Combat Casualty Care in Operation Enduring Freedom. Fort Sam Houston, TX: Borden Institute; 2015
• 24 Maturo SC, Weitzel EK, Cowhart J, Brennan J. Isolated posterior table frontal sinus fractures do not form mucoceles in a goat model. Otolaryngol Head Neck Surg 2008; 139 (5) 688-694
• 25 Hale RG, Hayes DK, Orloff G, Peterson K, Powers B, Mahadevan S. Maxillofacial and neck trauma. In: Lenhart MK, ed. Combat Casualty Care: Lessons Learned from OEF and OIF. Fort Detrick, Maryland: Office of The Surgeon General, AMEDD Center & School, Borden Institute; 2012: 229-289
• 26 Kim DW, Yoon ES, Lee BI, Dhong ES, Park SH. Fracture depth and delayed contour deformity in frontal sinus anterior wall fracture. J Craniofac Surg 2012; 23 (4) 991-994
• 27 Coppit G. Midface fractures. In: Brennan JA, Holt GR, Thomas RW, eds. Otolaryngology/Head and Neck Surgery Combat Casualty Care in Operation Enduring Freedom. Fort Sam Houston, TX: Borden Institute; 2015
• 28 Kim JJ, Huoh K. Maxillofacial (midface) fractures. Neuroimaging Clin N Am 2010; 20 (4) 581-596
• 29 Ayala C. Orbital trauma and nasoethmoid fractures. In: Brennan JA, Holt GR, Thomas RW, eds. Otolaryngology/Head and Neck Surgery Combat Casualty Care in Operation Enduring Freedom. Fort Sam Houston, TX: Borden Institute; 2015
• 30 Ali MJ, Gupta H, Honavar SG, Naik MN. Acquired nasolacrimal duct obstructions secondary to naso-orbito-ethmoidal fractures: patterns and outcomes. Ophthal Plast Reconstr Surg 2012; 28 (4) 242-245
• 31 Cannon CR, Jahrsdoerfer RA. Temporal bone fractures. Review of 90 cases. Arch Otolaryngol 1983; 109 (5) 285-288
• 32 Dahiya R, Keller JD, Litofsky NS, Bankey PE, Bonassar LJ, Megerian CA. Temporal bone fractures: otic capsule sparing versus otic capsule violating clinical and radiographic considerations. J Trauma 1999; 47 (6) 1079-1083
• 33 Kilty S, Murphy PG. Penetrating temporal bone trauma. J Trauma 2009; 66 (3) E39-E41
• 34 Kumar AR, Tantawi D, Armonda R, Valerio I. Advanced cranial reconstruction using intracranial free flaps and cranial bone grafts: an algorithmic approach developed from the modern battlefield. Plast Reconstr Surg 2012; 130 (5) 1101-1109
• 35 Fisher H. A Guide to U.S. Military Casualty Statistics: Operation Inherent Resolve, Operation New Dawn, Operation Iraqi Freedom, and Operation Enduring Freedom. https://www.fas.org/sgp/crs/natsec/RS22452.pdf . Accessed January 12, 2015