13.1

Face and Neck Injuries

Chapter 13

Face and Neck Injuries

Introduction

Immediate recognition and appropriate management of

airway compromise is critical to survival.

 Face and neck injuries can be the most difficult-to-manage

wounds encountered by health care providers in the combat

zone. Focusing on ABC priorities is vital.

 During airway control, maintain cervical spine

immobilization in bluntly injured patients. (Unstable C-spine

injury is very rare in neurologically intact penetrating face

and neck wounds.)

 Bleeding should be initially controlled with direct pressure.

If bleeding cannot be controlled, immediate operative

intervention is necessary.

 Complete assessment of remaining injuries (fractures,

lacerations, esophageal injury, ocular injuries).

Immediate Management of Facial Injuries

 Airway.

ο Airway distress due to upper airway obstruction above

the vocal cords is generally marked by inspiratory stridor:

♦ Blood or edema resulting from the injury.

♦ Tongue may obstruct the airway in a patient with a

mandible fracture.

♦ A fractured, free-floating maxilla can fall back,

obstructing the airway.

♦ Displaced tooth fragments may also become foreign

bodies.

ο Maneuvers to relieve upper airway obstruction:
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Emergency War Surgery

♦ Remove foreign bodies (strong suction, Magill forceps,

among others).

♦ Anterior jaw-thrust maneuver.

♦ Place adjunctive airway device (nasal trumpet or

oropharyngeal airway).

♦ Endotracheal intubation and assisted ventilation.

♦ Cricothyroidotomy or emergent tracheotomy may

become necessary.

 Cervical spine.

ο Up to 10% of patients with significant blunt facial injuries

will also have a C-spine injury.

♦ In awake patients, the C-spine can be cleared clinically

by palpating for point tenderness.

♦ Obtunded patients with blunt facial trauma should be

treated with C-spine immobilization.

 Vascular Injury.

ο Injuries to the face are often accompanied by significant

bleeding.

ο Control of facial vascular injuries should progress from

simple wound compression for mild bleeding to vessel

ligation for significant bleeding.

Vessel ligation should only be performed under direct

visualization after careful identification of the bleeding

vessel. Blind clamping of bleeding areas should be

avoided, because critical structures such as the facial nerve

and parotid duct are susceptible to injury.

♦ Foley catheter inserted blindly into a wound may

rapidly staunch bleeding.

ο Intraoral bleeding must be controlled to ensure a patent

and safe airway.

♦ Do not pack the oropharynx in an awake patient due to

risk of airway compromise: first secure the airway with

an endotracheal tube.

♦ Copious irrigation and antibiotics with gram-positive

coverage should be used liberally for penetrating

injuries of the face.
13.3

Face and Neck Injuries

 Evaluation.

ο Once the casualty is stabilized, cleanse dried blood and

foreign bodies gently from wound sites in order to evaluate

the depth and extent of injury.

ο The bony orbits, maxilla, forehead, and mandible should

be palpated for stepoffs or mobile segments suggestive of

a fracture.

ο A complete intraoral examination includes inspection and

palpation of all mucosal surfaces for lacerations, ecchymosis,

stepoffs, and malocclusion as well as dental integrity.

ο In the awake patient, abnormal dental occlusion

indicates probable fracture.

ο Perform a cranial nerve examination to assess vision, gross

hearing, facial sensation, facial muscle movement, tongue

mobility, extraocular movements, and to rule out

entrapment of the globe.

ο Consult an ophthalmologist for decreased vision on gross

visual field testing, diplopia, or decreased ocular mobility.

ο If the intercanthal distance measures > 40 mm

(approximately the width of the patient’s eye), the patient

should be evaluated and treated for a possible naso-orbitoethmoid (NOE) fracture.

 If a NOE fracture is present, do not instrument the nose if

possible. There may be a tear in the dura, and instrumentation

may contaminate the CSF via the cribiform.

Facial Bone Fracture Management

The goals of fracture repair are realignment and fixation of

fragments in correct anatomic position with dental wire (inferior,

but easier) or plates and screws.

With the exception of fractures that significantly alter

normal dental occlusion or compromise the airway (eg,

mandible fractures), repair of facial fractures may be

delayed for two weeks.

 Fractures of the mandible.

ο Second most commonly fractured bone of the face.

ο Most often fractured in the subcondylar region.
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Emergency War Surgery

ο Multiple mandible fracture sites present in 50% of cases.

ο Patients present with limited jaw mobility or malocclusion.

ο Dental Panorex is the single best plain film (but is

unavailable in the field environment); mandible serves as

a less reliable but satisfactory study (might overlook

subcondylar fractures).

ο Fine cut (1–3 mm) CT scan will delineate mandibular

fractures.

ο Treatment is determined by the location and severity of

the fracture and condition of existing dentition.

♦ Remove only teeth that are severely loose or fractured

with exposed pulp.

♦ Even teeth in the line of a fracture, if stable, and not

impeding the occlusion, should be maintained.

ο Nondisplaced subcondylar fractures in patients with

normal occlusion may be treated simply with a soft diet

and limited wear of Kevlar helmet and protective mask.

ο Immediate reduction of the mandibular fracture and

improvement of occlusion can be accomplished with a

bridle wire (24 or 25 gauge) placed around at least 2 teeth

on either side of the fracture.

ο More severe fractures with malocclusion will require

immobilization with maxillary-mandibular fixation

(MMF) for 6–7 weeks.

ο Place commercially made arch bars onto the facial aspect

of the maxillary and mandibular teeth.

♦ The arch-bars are then fixed to the teeth with simple

circumdental (24 or 25 gauge) wires (Fig. 13-1).

♦ After proper occlusion is established, the maxillary arch

bar is fixed to the mandibular arch bar with either wire

or elastics.

♦ If the patient’s jaws are wired together, it is imperative

that wire cutters be with the patient at all times.

♦ If portions of the mandible have been avulsed or the mandibular fragments are extremely contaminated, an external

biphase splint should be placed to maintain alignment.
13.5

Face and Neck Injuries

Fig. 13-1. Arch bar applications.

ο Open reduction and internal fixation with a mandibular

plate across fracture sites may obviate the need for MMF.

 Nasal fractures.

ο Most common fracture.

♦ Control of epistaxis: anterior pack-gauze/balloon/

tamponade.

ο Diagnosed clinically by the appearance and mobility of

the nasal bones.

The patient’s septum should be evaluated for the presence

of a septal hematoma, which if present, must be

immediately drained by incision, followed by packing.

ο Treat by closed reduction of the fractured bones and/or

septum into their correct anatomic positions up to 7 days

after fracture.
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Emergency War Surgery

♦ Place a blunt elevator (Sayer) into the nasal cavity in

order to elevate the depressed bony segment while

simultaneously repositioning the bone with the

surgeon’s thumb placed externally.

ο The nose may then be fixed with tape or a splint in order

to maintain the reduction (Fig. 13-2).

a b

Fig. 13-2. (a) Anterior and (b) posterior packing of the nose.

 Maxillofacial Trauma.

ο Life-threatening due to loss of airway, hemorrhage, or

spinal injury.

ο Fragment wound of maxillary sinus is commonly seen and

requires surgical removal of retained fragments (can delay

until specialist is available).

 Bleeding.

ο Common from epistaxis, oral hemorrhage or combination

bleeding.

ο Nasal fracture—most common fracture.

♦ Control Epistaxis with Anterior Pack (gauze/balloon/

tampon).

ο Mandibular fracture fixation (wires/archbars, with wire

cutters at bedside).

ο Facial and scalp lacerations.

ο Mid-face fracture (Le Fort)—The most difficult bleeding

to control.
13.7

Face and Neck Injuries

♦ Requires “significant” trauma.

♦ Be aware of associated CNS and orbital injury.

♦ Significant hemorrhage due to laceration of IMA and

branches.

◊ Is difficult to control.

◊ May be life-threatening.

◊ Treat by controlling airway, reducing fracture, and

placing a pressure dressing such as packing or

balloon.

♦ Edema may cause loss of airway, which may be

immediate or delayed.

♦ Can be difficult to diagnose. Criteria:

◊ Mobile hard palate and mid-face while stabilizing the skull.

◊ Penetrating injury may not follow classic Le Fort

patterns but may have a significant soft tissue injury

component (base of tongue, soft palate).

 Treatment.

ο ABCs.

ο Check CNS and vision.

ο Can immobilize maxilla by using the mandible as a splint

(wires/archbars, with wire cutters at bedside).

ο Control hemorrhage by tamponade.

♦ Nasopharynx, nasal cavity.

♦ Oropharynx.

 Surgical Repair.

ο Not an emergency once hemorrhage is controlled.

ο Requires ENT, oral, plastic, and ophthalmology surgical

expertise.

ο Time consuming.

ο Open and closed reductions with hardware that is usually

unavailable in the field.

 Fractures of Facial Bones.

ο Potentially life-threatening due to loss of airway,

hemorrhage, or spinal injury.

ο Fragment wound of maxillary sinus is commonly seen,

and requires surgical removal of retained fragments (can

delay until specialist available).

ο Mid-face fracture (Le Fort)—The most difficult bleeding to

control.

♦ Requires “significant” trauma.
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Emergency War Surgery

♦ Be aware of associated CNS and orbital injury.

♦ Significant hemorrhage due to laceration of IMA and

branches.

◊ Is difficult to control.

◊ May be life threatening.

◊ Treat by controlling the airway, reducing fractures,

and placing pressure dressings such as packing or

balloon tamponade.

♦ Edema may cause loss of airway, which may be

immediate or delayed.

♦ Can be difficult to diagnose.

◊ Mobilize the hard palate and mid-face while stabilizing

the skull. Place thumb and forefinger of one hand on

nasal bridge to stabilize, then with the other hand,

determine mobility of maxilla by placing the thumb on

alveolus and forefinger on the palate and attempting

gentle distraction in an anterior-posterior direction.

◊ Penetrating injury may not follow classic Le Fort

patterns but may have a significant soft tissue injury

component (base of tongue, soft palate).

◊ Apply principles of systemic palpation and

inspection, looking for crepitus, tenderness, internal

and external ecchymosis, and subconjunctival

hemorrhage that might suggest fractures.

ο Classification by Le Fort (Fig. 13-3).

a b c

Fig. 13-3. Le Fort facial fracture classifications.

I II III
13.9

Face and Neck Injuries

♦ I–Fracture separates the entire alveolar process from

maxilla.

♦ II–Separation of mid-face, including the nasal bone,

from the orbit (pyramidal).

♦ III–Detachment of the face from the skull (craniofacial

disarticulation).

ο Treatment.

♦ ABCs.

♦ If nasal intubation is used, extremely careful placement

is mandatory to avoid cribriform plate or anterior

cranial fossa penetration.

♦ Classification by Le Fort.

♦ Check CNS and vision.

♦ Can immobilize maxilla by using the mandible as a splint

(wires/arch bars, with wire cutters at bedside). It is much

easier to place patient into maxillomandibular fixation if

either a nasal airway or tracheostomy is employed.

♦ Control hemorrhage by tamponade as previously

described.

◊ Nasopharynx, nasal cavity.

◊ Oropharynx.

ο Definitive Surgical Repair.

♦ Not an emergency once hemorrhage is controlled.

♦ Requires expertise in ENT, oral and maxillofacial,

plastic, and ophthalmology surgery.

♦ Time consuming.

♦ Open and closed reductions require hardware usually

unavailable in the field.

Soft Tissue Injuries

 General principles.

ο Avoid injury to surrounding structures such as the facial

nerve or parotid duct.

ο Wounds should be gently cleansed with saline and light

scrub solutions; foreign bodies should be meticulously

cleaned from wounds prior to closure.

ο Sharply debride devascularized wound edges minimally.

ο Facial lacerations should be closed in layers within 24 hours.

♦ Use 4-0 or 5-0 absorbable suture for subcutaneous/

dermal layers.
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Emergency War Surgery

♦ Use 5-0 or 6-0 nonabsorbable sutures on the skin of the face.

♦ Remove sutures in 5–7 days.

 Facial nerve injuries.

ο Carefully examine for facial nerve function in all five

branches (Fig. 13-4).

Fig. 13-4. Branches of the facial nerve parotid duct injury.

Facial nerve branches that are lacerated at a site anterior to

a vertical line drawn down from the lateral canthus of the

eye do not need to be surgically reapproximated because

these branches are very small and will spontaneously

regenerate with good return of facial function.

ο The severed ends of the nerve may be located in the wound

with a nerve stimulator, for up to 3 days.

ο Cut nerve ends should be reapproximated primarily with three

or four fine (9-0) nylon sutures placed through the epineurium.

ο If a gap exists between severed ends of the facial nerve due

to tissue loss, an interposition graft may be placed using a

section of the great auricular nerve to bridge the gap.

Temporal Branches

Zygomatic Branches

Buccal Branches

Marginal

Mandibular Branch

Cervical Branch
13.11

Face and Neck Injuries

ο If the wound is heavily contaminated and cannot be closed

primarily, the severed ends of the nerve should be located

and tagged for identification and repair at the time of

wound closure.

 Parotid duct injuries.

ο Evaluate penetrating wounds of the parotid/buccal

regions of the face for salivary leakage due to a lacerated

parotid duct (see Fig 13-5).

♦ The wound may be manually compressed and inspected

for salivary leakage.

♦ If the parotid duct is injured by a facial laceration, the

distal end of the duct may be identified by placing a

lacrimal probe through the intraoral opening of the duct

located near the maxillary second molar (see Fig. 13-4).

♦ The proximal end may be identified by compressing

the wound and identifying any areas of salivary

leakage.

ο Repair with absorbable (6-0) sutures (Fig. 13-5).

Fig. 13-5. Repair of parotid duct.

ο A stent may be placed into the duct to facilitate the closure

and prevent stenosis.

♦ Possible stents include lacrimal stents, large (size 0)

polypropylene sutures, or long angiocaths.

♦ Stents may be sutured to the buccal mucosa and

removed after seven days.
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Emergency War Surgery

Penetrating Neck Trauma

 Introduction.

ο Vascular injuries occur in 20% and aerodigestive tract in

10% of cases.

ο Mortality is primarily due to exsanguinating hemorrhage.

ο Esophageal injury, which results in mediastinitis and

intractable sepsis, may also be fatal.

 Anatomy.

The neck is divided into three zones to aid decision making for

diagnostic tests and surgical strategy. In each zone, the primary

structures at risk of injury are different (Fig. 13-6).

Fig. 13-6. Zones of the neck.

ο Zone 1 (clavicle to cricoid membrane): The structures of

concern include large vessels of the thoracic outlet

(subclavian artery and vein, common carotid artery), the

lung, and the brachial plexus.

ο Zone 2 (cricoid membrane to angle of mandible): Structures

of concern include the common carotid artery, internal

jugular vein, esophagus, and trachea.

ο Zone 3 (angle of mandible to base of skull): The structure

of concern is primarily the internal carotid artery.

Zone 3

Zone 2

Zone 1
13.13

Face and Neck Injuries

 Immediate management.

ο Initially, same as above.

ο Obtain chest and soft tissue neck radiographs.

ο Address tetanus and antibiotic prophylaxis.

 Operative strategy.

ο If no platysma violation, surgical intervention is not

indicated.

ο Zone 2 injuries that penetrate the platysma should undergo

routine exploration to rule out life threatening vascular,

esophageal or tracheal injuries via an incision along the anterior

border of the sternocleidomastoid muscle (Fig. 13-7).

Fig. 13-7. Neck exposure of zone 2.

ο Zone 1 and 3 injuries require selective management, based

on clinical signs and chest radiograph findings, making

an incision dependent on the vascular structure most

probably injured.

♦ Zone 1 and 3 penetrations without clinical signs of

injury (see below) may be evacuated without operative

intervention.

ο The most important clinical signs pointing to probable

injuries (pertinent to all 3 zones):
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Emergency War Surgery

♦ Signs of vascular injury.

◊ Current or history of significant bleeding.

◊ Expanding hematoma.

◊ Bruit or thrill in the neck.

◊ Hypotension.

◊ Dyspnea, hoarseness, or stridor.

◊ Absent or decreased pulses in neck or arm.

◊ Focal neurologic deficit or mental status change.

◊ Chest radiograph findings of hemothorax or

mediastinal widening.

♦ Signs of aerodigestive injury (esophagus, trachea,

larynx).

◊ Crepitus or subcutaneous emphysema.

◊ Dyspnea or stridor.

◊ Air bubbling from wound.

◊ Tenderness or pain over trachea; odynophagia.

◊ Hoarse or abnormal voice.

◊ Hematemesis or hemoptysis.

Surgical Principles

 The groin and upper thigh should be surgically prepped for

greater saphenous vein interposition graft or patch angioplasty.

 Exsanguinating hemorrhage from injured vessels at the base

of the skull (Zone 3) can often be controlled with inflation of

a directed catheter (Fogarty, Foley), left in place and inflated

for 48–72 hours, then deflated in the OR under controlled

visualization for rebleeding.

 Repair esophageal injuries in a single-layer and place closed

suction drains. The drain tip should not be placed near a

concomitantly repaired carotid artery. A muscle flap should

be interposed between repaired esophageal and tracheal

injuries to prevent fistula. Obtain an oral contrast swallow

radiograph seven days after repair before feeding.

 Repair laryngotracheal injuries with single-layer

monofilament absorbable suture. Must search for

concomitant esophageal injuries.

 Unreconstructable (significant segmental loss, or > 50%

diameter loss) tracheal injuries should be managed with an

endotracheal tube placed through the defect.
13.15

Face and Neck Injuries

 Vertebral artery injury.

ο Suspect if bleeding continues from a posterolateral neck

wound despite pressure on the carotid artery.

ο Preoperative angiography localizes site of injury and establishes the existence of a patent contralateral vertebral artery,

aplasia of which is most commonly located on the left side.

ο Exposure of vertebral artery may be difficult. When

contralateral vertebral artery is intact, ligation proximal

and distal to the injury will likely be necessary.

ο Bone wax or a Foley catheter may be useful for control of bleeding.

 Intraoral injuries

ο Penetrating injuries to the oral cavity LATERAL to the

tonsillar fossa are at a significant risk of causing occult

internal carotid injury. Neurologic testing/monitoring is

critical and CT scanning and/or angiography should be

considered. If after a penetrating lateral oral injury the

patient bleeds a small amount only to stop, this may signify

a “sentinel” bleed. A carotid blowout may follow.

 Internal carotid artery injury.

ο Should be repaired primarily unless there is profound

hemiplegia with deep coma Glasgow Coma Scale (GCS <

8). All other carotid branches can be ligated.

ο The use of carotid shunts during repair has no proven benefit.

ο In small perforations, debride minimally, and close with

6-0 polypropylene.

ο With loss of vascular tissue, vein angioplasty is required.

ο If there is extensive destruction, segmental resection and

restitution of flow is established by:

♦ End-to-end anastomosis (if the vessel is sufficiently

elastic to permit).

♦ Interposition vein graft.

♦ External carotid swing-over and interposition.

♦ Temporary (24–48 h) shunt as part of damage control

maneuver.

ο Themortality is high in patients with severe neurologic deficit;

carotid ligation is justifiable in complete occlusion of the entire

carotid system and depending on the triage situation.

ο Distal clot may be removed by extremely gentle use of a

balloon catheter prior to shunt insertion or repair.
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Emergency War Surgery

 Internal jugular vein injury.

ο Preferably repaired by lateral suture.

ο Ligation OK, if the contralateral internal jugular is patent.

ο Larynx.

ο After immediate control of the airway has been achieved

by intubation or tracheotomy (not through the wound in

the larynx!), a complete airway evaluation by direct

laryngoscopy and bronchoscopy must be performed.

ο Debridement of laryngotracheal injuries must be careful

and conservative. A fragmented larynx or trachea should

be reapproximated and sutured with extraluminal,

absorbable sutures for tracheal injuries and nonabsorbable

sutures or micro-plates used for laryngeal fractures.

ο The management of laryngeal trauma includes accurate

reduction and stabilization of fractures, mucosa-to-mucosa

closure of lacerations, and use of a soft stent if there is

extensive cartilaginous damage and structural support is

decreased or the anterior commissure is involved. The stent

may need to be temporarily placed for 4–6 weeks to

maintain correct anatomic architecture and requires a

complementary tracheotomy.

ο The excessive removal of cartilage and mucosa must be

avoided to prevent tracheal or laryngeal stenosis.

 Laryngotracheal injuries.

ο If laryngotracheal separation is suspected (massive crepitis

over the larynx/trachea) in an otherwise “stable” airway,

endotracheal intubation should not be undertaken as this

may cause a partial separation to become a complete

separation and/or blind passage of the endotracheal tube

may occur with resulting impending airway emergency.

ο It is best to perform an awake tracheotomy/

cricothyroidotomy under local anesthesia without

paralysis. Good anesthesia can be achieved with a 4%

(40mg/cc) lidocaine nebulizer, 2cc in 3cc of saline, and

direct administration of 4% lidocaine into the trachea for

an awake tracheotomy (in addition to local anesthetic

infiltration into the skin and subcutaneous tissues). When

instilling anesthesia into the airway, aspirate and ensure

air enters the syringe before injecting.
13.17

Face and Neck Injuries

 Tracheal injury and reconstruction.

ο Small anterior wounds can have tracheostomy tube placed

through them after debridement.

ο Repair simple lacerations with absorbable monofilament

suture.

ο Up to 5 cm can be resected with proximal and distal

mobilization.

ο Mobilize anteriorly and posteriorly to preserve lateral

blood supply.

ο Remove endotracheal tube as soon as possible post-op.

ο May need to suture chin to chest for 10 days to avoid

extension injury.

 Esophageal injury and repair.

ο Difficult to diagnose.

ο 25% may be asymptomatic.

ο Missed injury is a major source of late morbidity/mortality.

ο Insufflation with air may aid in identification during

exploration.

ο Debride devitalized tissue.

ο Wound closure in two layers with absorbable sutures.

ο Viable muscle flap to protect repairs from leak.

ο Drainage with closed suction drain.

ο Barium swallow 7 days post-op, prior to oral intake.

ο Oral intake prior to drain removal.

ο Extensive injuries may require lateral cervical

esophagostomy.

ο Cervical esophagostomy is preferred to closure under

tension.

 Combined injuries.

ο All esophageal injuries combined with airway or vascular

injury require separation with healthy tissue. Strap muscles

are ideal, but can use pedicle of sternocleidomastoid if

straps are devitalized.

 Esophageal fistula.

ο 10%–30% incidence.

ο Due to inadequate debridement, devascularization of

remaining esophageal wall, closure under tension, or

infection.

ο Treatment.
13.18

Emergency War Surgery

♦ Maintain nutrition.

♦ Assure control with drains.

♦ Weekly barium swallow to assess closure.

♦ Oral intake prior to removing drain.

Skull Base, Temporal Bone and Otologic Injury

 Ensure that the facial nerve is assessed and documented on

an awake patient and at the earliest convenience in a patient

who has regained consciousness. Delineation between

delayed onset and acute facial paralysis is critical for

management and outcome of facial nerve injuries. Also critical

is delineation between a distal and proximal nerve injury. If

a distal injury is present, one or more branches may be

affected.

ο Be as concise as possible in describing facial motion even

if not technically accurate; be complete in the description.

A more proximal injury (proximal to the Pes Anserinus)

will most likely result in all branches being equally

affected. Accurate documentation may spare the patient

from unwarranted surgical intervention to explore the

entire length of the facial nerve. It is desirable to accurately

describe the motion of EACH branch of the facial nerve.

Eyelid movement does not ensure that the facial nerve is

intact since the levator palpebrae is innervated by the

occulomotor nerve and will remain intact despite facial

nerve injury.

ο If there is no contraindication for systemic steroids, they

should be administered for suspected facial nerve

paralysis. Crush injuries to the facial nerve may present

with delayed onset paralysis and the severity and course

of the paresis may be improved with systemic

administration of steroids.

 Skull base fractures are often occult. Assess the patient for

evidence of basilar skull fractures (Battle’s sign, raccoon eyes).

 Ensure that the external auditory canal is examined. Do not

instrument the external auditory canal, however. If a temporal

bone fracture is present and the dura is not intact,

instrumentation may introduce bacteria and/or a foreign

body into the CSF.
13.19

Face and Neck Injuries

 The external auditory canal should be inspected for a tear of

the lining of the canal. A tear of the lining of the canal suggests

a temporal bone fracture.

ο If a temporal bone fracture is suspected, it is critical that

the facial nerve be assessed.

 Tympanic membrane perforations can be managed

expectantly. The vast majority of them will heal

spontaneously, but the patient should be followed for

evidence of cholesteatoma formation from traumatic

implantation of the squamous epithelium. This may occur

months to years after the injury. Acutely, application of otic

antibiotic drops will prevent the perforation from desiccating,

but this is not required. The patient should be instructed to

keep the ears dry (avoid water contamination).

 Hemotympanum may be seen with acoustic & temporal bone

trauma. These patients will have hearing loss. If available,

perform a gross audiological evaluation with tuning forks.

Hemotympanum with hearing loss (conductive) should

resolve in about 6 weeks.

ο Examination for hearing in the field can be accomplished

with a single 512 tuning fork.

♦ With the tuning fork placed on the mastoid tip and then

alternately in front of the external canal (Rinne).

Documentation as A>B (air > bone) or B>A is sufficient

– do not report as “positive” or “negative”:

◊ Air conduction greater than bone conduction with a

512 tuning fork is normal.

◊ Bone conduction greater than air is suggestive of a

conductive hearing loss.

♦ With the 512 tuning fork on the frontal bone/ nasal

dorsum/ or central incisors (best) (Weber):

◊ If the Rinne test suggests a conductive hearing loss –

the 512 should lateralize to the side with the

conductive loss.

◊ If the Rinne is NORMAL (A>B) – the 512 should

lateralize to the ear with a sensorineural loss

 Any otologic blast injury or injury to the temporal bone may

result in tinnitus. Management is expectant and it may resolve
13.20

Emergency War Surgery

spontaneously. Accurate documentation is critical for future

management of these patients, however.

 If sensorineural hearing loss is suspected and documented

after a blast injury or noise trauma, steroids are indicated.

1mg/kg of prednisone is appropriate. If after five days there

is no improvement, the patient can be taken off of the steroids.

If improvement is noted, a taper over 3–4 weeks is indicated.

Be mindful that steroids may affect a patient’s affect and

impair judgment.

 Dizziness and vertigo may result from acoustic trauma. If

true vertigo exists after an otologic injury (observed

nystagmus), the patient may have a perilymphatic fistula

from depression of the stapes into the oval window or

rupture of the round window. These patients may have

tinnitus and hearing loss with vertigo. If a perilymphatic

fistula is suspected, this patient should be seen by an

Otolaryngologist as soon as possible to prevent further

damage to the inner ear.