World J. Surg. 25, 1021–1022, 2001 DOI: 10.1007/s00268-001-0053-0
WORLD Journal of
SURGERY © 2001 by the Socie´te´ Internationale de Chirurgie
World Progress in Surgery Head and Neck Trauma: Introduction Published Online: July 9, 2001
The treatment of extensive head and neck trauma has changed dramatically over the past quarter of a century. Airway compromise and exsanguination still pose the most immediate, yet potentially reversible threats to life, but neither is as lethal as it was previously. As a result of international development of organized regional emergency trauma care systems throughout most of the industrialized world and universal promulgation of standardized treatment protocols by first responders as afforded by the National Association of Emergency Medical Technicians’ Prehospital Trauma Life Support (PHTLS) and the American College of Surgeons Committee on Trauma Advanced Trauma Life Support (ATLS) course for physicians, many seriously injured trauma victims are now being salvaged who heretofore would have been declared dead at the scene or expired en route prior to ever having received any type of qualified prehospital emergency care. The net result has been an ever-increasing number of initially surviving critically ill trauma patients who now pose an entirely new set of challenges. With major head and neck trauma cases, managing devastating permanent disfigurement and impairment of important physiological functions has become almost as important as preserving life itself, especially where optimal patient care and the eventual quality of the patient’s life are concerned. The complexities of trauma to the head and neck are such that no one individual, let alone specialty, is capable of doing it all. Probably nowhere in all of medicine is there more of a need to simultaneously involve so many different disciplines and surgical subspecialties than when it comes to managing major head and neck trauma. However, it is important that a single person or specialty be identified as the primary service of record, if only to ensure holistic care. At most centers this role is delegated to a well-trained trauma or accident surgeon who would also be responsible for ensuring and coordinating the appropriate consultative input of other specialties that might be indicated as based upon the actual specific injuries incurred. Remember, it is usually errors of omission that get most clinicians into trouble, especially when they deal with areas or problems that go beyond their own specific interests and areas of expertise. At the same time, another problem commonly encountered with head and neck trauma is the significant competitive overlap among different specialties that might become involved: for example, plastic surgery, otolaryngology, oral surgery, and ocuplastics are all enthusiastic to handle maxillofacial fractures; while
neurosurgery, orthopedic surgery, and even microsurgery may all feel they are capable of managing cervical spine and brachial plexus injuries. At many academic health centers, under the guise of what has been referred to as “board blackmail” (specialty mandates requiring exclusive involvement of a subspecialty with all aspects of any head and neck injury in order to maintain Residency Review Committee (RRC) approval of their surgical residency training program), a commonly expressed comment by some specialties is, “Don’t worry, we can do it all.” Although such an approach can result in an acceptable outcome, the best and most satisfactory results are always obtained when all parties (subspecialties) with an interest in a particular type of injury participate in the development of a comprehensive and cooperative management plan. In turn all specialties maintain their skills and all the institutional training programs benefit from the clinical experience. Obviously who and what are actually available at any given facility will vary in accordance with the skills, reputation, and commitment of those involved. Whenever possible, however, cooperative subspecialty input ensures the best possible outcome. In the context of this symposium, several of the world’s leading authorities on different aspects of head and neck trauma have been kind enough to share their expertise. Hochberg et al., start off with the principles of managing soft tissue injuries of the face and neck, followed by Feliciano et al., of Grady Memorial Hospital in Atlanta, sharing their vast experience with penetrating carotid injuries. Biffl et al., next review their University of Colorado experience with blunt carotid and vertebral arterial injuries. Demetriades et al., from the University of Southern California, address the complex challenges associated with cervical pharyngoesophageal and laryngotracheal injuries. McNab, from Victoria, Australia, provides an excellent review on orbital and optic nerve trauma. Friedman and his neurosurgical colleagues at Mayo Clinic clarify much of the confusion surrounding cerebrospinal fluid leaks; and Albrecht et al., from the University of New Mexico, provide a commonsense approach to the often difficult problem of cervical spine clearance in obtunded and unresponsive intensive care unit patients following blunt trauma. The remaining contributions were selected for their innovative advancements, which have more or less revolutionized the management of certain types of head and neck trauma, including microsurgical neurotizations of brachial plexus root avulsions as championed by Terzis, from Eastern Virginia University, and co-authored in col-
1022
laboration with Vekris and Soucacos from Iorria University in Greece. One of the world’s largest experiences with free vascularized bone grafts for the reconstruction of traumatic bony effects of the mandible and maxilla is provided by Kildal, Wei, and Chang from Taipei. Finally, T. Honda et al. from Tokyo present their recent experiences with the application of endoscopic techniques in the facilitation of facial fracture repair. Overall, the preparation of this symposium proved to be a unique and gratifying experience. I am indebted to Ronald K. Tompkins, editor of World Journal of Surgery for the opportunity
World J. Surg. Vol. 25, No. 8, August 2001
to serve as Guest Editor, and I am especially appreciative of the contributors for their authoritative expertise and for their cooperative willingness to meet scheduled deadlines and complete all of the necessary, yet onerous, paperwork. I am confident that this updated multidisciplinary review will be informative and useful for anyone who is involved with managing major head and neck trauma. Peter Mucha, Jr., M.D. Guest Editor
WORLD Journal of
SURGERY © 2001 by the Socie´te´ Internationale de Chirurgie
World Progress in Surgery Head and Neck Trauma: Introduction Published Online: July 9, 2001
The treatment of extensive head and neck trauma has changed dramatically over the past quarter of a century. Airway compromise and exsanguination still pose the most immediate, yet potentially reversible threats to life, but neither is as lethal as it was previously. As a result of international development of organized regional emergency trauma care systems throughout most of the industrialized world and universal promulgation of standardized treatment protocols by first responders as afforded by the National Association of Emergency Medical Technicians’ Prehospital Trauma Life Support (PHTLS) and the American College of Surgeons Committee on Trauma Advanced Trauma Life Support (ATLS) course for physicians, many seriously injured trauma victims are now being salvaged who heretofore would have been declared dead at the scene or expired en route prior to ever having received any type of qualified prehospital emergency care. The net result has been an ever-increasing number of initially surviving critically ill trauma patients who now pose an entirely new set of challenges. With major head and neck trauma cases, managing devastating permanent disfigurement and impairment of important physiological functions has become almost as important as preserving life itself, especially where optimal patient care and the eventual quality of the patient’s life are concerned. The complexities of trauma to the head and neck are such that no one individual, let alone specialty, is capable of doing it all. Probably nowhere in all of medicine is there more of a need to simultaneously involve so many different disciplines and surgical subspecialties than when it comes to managing major head and neck trauma. However, it is important that a single person or specialty be identified as the primary service of record, if only to ensure holistic care. At most centers this role is delegated to a well-trained trauma or accident surgeon who would also be responsible for ensuring and coordinating the appropriate consultative input of other specialties that might be indicated as based upon the actual specific injuries incurred. Remember, it is usually errors of omission that get most clinicians into trouble, especially when they deal with areas or problems that go beyond their own specific interests and areas of expertise. At the same time, another problem commonly encountered with head and neck trauma is the significant competitive overlap among different specialties that might become involved: for example, plastic surgery, otolaryngology, oral surgery, and ocuplastics are all enthusiastic to handle maxillofacial fractures; while
neurosurgery, orthopedic surgery, and even microsurgery may all feel they are capable of managing cervical spine and brachial plexus injuries. At many academic health centers, under the guise of what has been referred to as “board blackmail” (specialty mandates requiring exclusive involvement of a subspecialty with all aspects of any head and neck injury in order to maintain Residency Review Committee (RRC) approval of their surgical residency training program), a commonly expressed comment by some specialties is, “Don’t worry, we can do it all.” Although such an approach can result in an acceptable outcome, the best and most satisfactory results are always obtained when all parties (subspecialties) with an interest in a particular type of injury participate in the development of a comprehensive and cooperative management plan. In turn all specialties maintain their skills and all the institutional training programs benefit from the clinical experience. Obviously who and what are actually available at any given facility will vary in accordance with the skills, reputation, and commitment of those involved. Whenever possible, however, cooperative subspecialty input ensures the best possible outcome. In the context of this symposium, several of the world’s leading authorities on different aspects of head and neck trauma have been kind enough to share their expertise. Hochberg et al., start off with the principles of managing soft tissue injuries of the face and neck, followed by Feliciano et al., of Grady Memorial Hospital in Atlanta, sharing their vast experience with penetrating carotid injuries. Biffl et al., next review their University of Colorado experience with blunt carotid and vertebral arterial injuries. Demetriades et al., from the University of Southern California, address the complex challenges associated with cervical pharyngoesophageal and laryngotracheal injuries. McNab, from Victoria, Australia, provides an excellent review on orbital and optic nerve trauma. Friedman and his neurosurgical colleagues at Mayo Clinic clarify much of the confusion surrounding cerebrospinal fluid leaks; and Albrecht et al., from the University of New Mexico, provide a commonsense approach to the often difficult problem of cervical spine clearance in obtunded and unresponsive intensive care unit patients following blunt trauma. The remaining contributions were selected for their innovative advancements, which have more or less revolutionized the management of certain types of head and neck trauma, including microsurgical neurotizations of brachial plexus root avulsions as championed by Terzis, from Eastern Virginia University, and co-authored in col-
1022
laboration with Vekris and Soucacos from Iorria University in Greece. One of the world’s largest experiences with free vascularized bone grafts for the reconstruction of traumatic bony effects of the mandible and maxilla is provided by Kildal, Wei, and Chang from Taipei. Finally, T. Honda et al. from Tokyo present their recent experiences with the application of endoscopic techniques in the facilitation of facial fracture repair. Overall, the preparation of this symposium proved to be a unique and gratifying experience. I am indebted to Ronald K. Tompkins, editor of World Journal of Surgery for the opportunity
World J. Surg. Vol. 25, No. 8, August 2001
to serve as Guest Editor, and I am especially appreciative of the contributors for their authoritative expertise and for their cooperative willingness to meet scheduled deadlines and complete all of the necessary, yet onerous, paperwork. I am confident that this updated multidisciplinary review will be informative and useful for anyone who is involved with managing major head and neck trauma. Peter Mucha, Jr., M.D. Guest Editor
