A Military Otolaryngologist’s Experience Providing Medical Care in Iraq

Newswise — Operation Iraqi Freedom (OIF) has resulted in the largest number of United States military casualties since the Vietnam War more than 30 years ago. As of this September, more than 1,800 service members have been killed in action and approximately ten times that number have been wounded in action.

The highest level of care available in Iraq is located at the Army combat support hospital (CSH) and the Air Force Theater Hospital. Since the outset of the war, a multispecialty head and neck team consisting of neurosurgery, ophthalmology, and oral surgery has been caring for casualties at the combat support hospital. Several otolaryngologists, primarily from the Army, have been deployed to Iraq but members of this specialty have never been made a permanent member of the multispecialty head and neck team. Consequently, the full spectrum of otolaryngologic equipment and services had not been available in the Iraqi theater of operations.

In the summer of 2004, the Air Force Surgeon General and his readiness staff decided to deploy a fully equipped otolaryngology team to serve with the multispecialty head and neck team at the newly established Air Force Theater Hospital in Balad, Iraq. The hospital is located in the middle of the restive Sunni Triangle, 50 kilometers north of Baghdad along the Tigris River. The Air Force readiness personnel tasked this team with prospectively collecting all treatment data in an effort to determine if the otolaryngology team should continue as part of the multispecialty head and neck team.

The findings are made in a study, “Experience of First Deployed Otolaryngology Team in Operation Iraqi Freedom: The Changing Face of Combat Injuries,” authored by Joseph Brennan, MD, FACS, COL, USAF, MC, FS, Department of Otolaryngology/Head and Neck Surgery, Wilford Hall Medical Center, Lackland Air Force Base, TX. Their findings are being presented at the 109th Annual Meeting and OTO EXPO of the American Academy of Otolaryngology—Head and Neck Surgery Foundation, being held September 25-28, 2005, at the Los Angeles Convention Center, Los Angeles, CA.

Methodology: On September 2, 2004, the otolaryngology component of the head and neck team consisting of one otolaryngologist and one otolaryngology technician departed for Iraq. The team was accompanied by a full array of otolaryngology equipment consisting of two operating microscopes, two headlights, craniofacial and maxillofacial plating systems with external fixation, electric drills and saws, rigid and flexible endoscopy equipment (including sinus endoscopes, nasopharyngoscopes, esophagoscopes, and bronchoscopes), pediatric airway equipment, nerve integrity monitor, portable audiometer, and full otologic, head and neck, plastic, and maxillofacial equipment sets. The team prospectively collected patient data between September 7, 2004, and January 22, 2005. The study, including all accompanying figures, has been reviewed and approved through appropriate Air Force and hospital channels.

Patient data was collected over this four to five month period and separated into inpatient (surgical) and outpatient data. Inpatient data included patient name, age, military category (Army, Marine, Navy, Air Force, Iraqi National Guard/Police/Border Patrol, enemy prisoner of war, Iraqi civilian, coalition military, and coalition civilian), operative procedure(s), date of operation, intraoperative findings, and surgeons. Also, the postoperative condition and status of these patients were documented. Complex facial laceration repair was defined as a two-layer closure of a facial laceration typically performed in the operating room. Finally, special attention was paid to the multiple mass casualties, including the Fallujah offensive, seen at the Air Force Theatre Hospital during this period.

The outpatient demographic data consisted of patient name, age, military category, presenting complaint, examination findings including audiometric results, diagnosis and treatment, and disposition (admit, return to duty, aerovacuation to Germany).

Results: Between September 7, 2004, and January 22, 2005, 159 patients underwent 257 operative procedures by the otolaryngology team at the Air Force Theater Hospital at Balad Air Base, Iraq. Key findings are:

• Each patient had an average of 1.6 procedures performed in the operating room. During the first two months of deployment (October-November 2004), all patients operated on by the multispecialty head and neck team were tracked. Some 170 patients had life/sight-saving surgery over this two-month period. The otolaryngologist was the busiest member of the head and neck team and operated on 37 percent of these patients (63/170), followed by ophthalmology with 26 percent (44/170), neurosurgery with 22 percent (37/170), and oral surgery with 15 percent (26/170).
• The most common otolaryngology procedures were complex facial laceration repair (70 patients), tracheotomy (53), neck exploration for penetrating neck trauma (27), direct rigid laryngoscopy (22), arch bars/intermaxillary fixation (15), control of facial bleeding (13), flexible bronchoscopy (10), flexible esophagoscopy (9), excision of head and neck mass (5), orbital enucleation (4), open reduction/internal fixation (ORIF) tripod fracture (4), ORIF mandible fracture (3), lateral canthotomy (3), and orbital exenteration (3).
• The three most commonly performed procedures were examined in more detail. Complex facial lacerations were typically caused by improvised explosive devices (IED), which consisted of artillery shells or other explosives buried in the ground, or carried in a motor vehicle (vehicle born IED or VBIED). These complex facial lacerations usually occurred with multiple other extremity and torso injuries and were often associated with extensive blood loss. Surgical treatment consisted of airway management, stopping the active bleeding, and then restoring the tissue/boney integrity of the injury.
• The second most common procedure performed was tracheostomy, a procedure that was subdivided into emergent and elective surgical airways. Four emergent/urgent surgical airways were performed. Forty-nine elective tracheostomies were performed, typically for United States troops with major head and neck trauma pending aerovacuation and for Iraqis who were ventilator dependent. Lastly, the otolaryngology team emergently intubated three patients after failed attempts by other services.
• The third most common procedure was neck exploration for penetrating neck trauma. The physicians reported 27 patients underwent neck exploration with a mortality of four percent (1/27). The location of the penetrating neck trauma was zone I in six cases, zone II in 20 cases, and zone III in one case. The incidence of major intraoperative pathology found on exploration in the operating room was 78 percent (21/27).

525 outpatient visits were recorded at the otolaryngology clinic. The 10 most common outpatient diagnoses were hearing loss after acoustic trauma (59), superficial shrapnel wounds with simple one-layer repair or observation (53), tympanic membrane perforation (47), chronic (nontraumatic) otitis media (46), otitis externa (30), blunt head and neck trauma (26), parotid/neck masses (25), sinusitis (15), facial abscess (14), and chronic (nontraumatic) hearing loss (13). Several mass casualties occurred during our deployment to Iraq. The busiest mass casualty occurred during the Fallujah offensive between November 8 and November 18, 2004. During this 10-day period, 381 combat injured personnel were admitted to author’s hospital, including 52 patients admitted on November 9, 2004. The otolaryngology service performed 34 head and neck procedures on 26 patients during this mass casualty. Also, the otolaryngology service participated in many orthopedic and general surgical cases during this time frame.

Conclusions: The author states that outpatient care of soldiers in the field was exceedingly important. First, by treating the many common head and neck diseases seen, they were able to maximize the quality of life for these patients and maximize their effectiveness in the field. Second, ear, nose, and throat specialists were able to safely and effectively treat many patients in theater who otherwise would have been aerovacuated to Germany for an otolaryngology consult. This helped maintain unit strength and morale since these soldiers were extremely reluctant to leave their comrades. Third, they were able to identify early several potential head and neck tumors that needed advanced care in Germany and the United States. Lastly, the otolaryngology providers were able to have a very positive impact on the Iraqi military patients, Iraqi civilians, and enemy prisoners of war. By offering care that was difficult to find in the local medical system, they greatly improved the quality of life for these Iraqis. All wounded patients of every nationality and military affiliation (friend versus foe) were treated the same within the author’s hospital.

The author concludes that the otolaryngology team proved to be a valuable and indispensable member of the multispecialty head and neck team deployed during Operation Iraqi Freedom. Otolaryngologists possess the key airway skills, endoscopy skills, and neck exploration skills needed to maximize the quality of care of the wounded patients. Otolaryngologists also provide outpatient treatment that further maximizes the quality of care for the patients and allows otolaryngologic consultation in theater, thus preventing many needless aerovacuations to Germany.