EARLY MANAGEMENT OF CIVILIAN GUNSHOT WOUNDS TO THE FACE

We analyzed 54 civilian patients (1988-1992) with gunshot wounds (GSWs) of the face to review the management principles and results. Urgent airway control was needed in 18 cases (33%): by orotracheal intubation in 13, cricothyroidotomy in two, tracheostomy in two, and nasotracheal intubation in one. Central nervous system injury was seen in 12 (22%): 40% with orbital, 38% with mid-face, and 0% with lower face injuries. Two patients died of intracranial injuries (mortality, 4%). Vascular injury was present in five patients (9%), all detected by angiography. The local complication rate was 39% in the presence of intra-oral injury and 0% without intra-oral injury (p < 0.001). The maxilla was the most commonly fractured facial bone (41%) followed by the mandible in 28%. All maxillary, orbital, and zygomatic fractures were treated without reduction. One of the seven nasal fractures required open reduction for deformity. Six of the 15 mandible fractures were treated without reduction. Of eight patients treated with closed reduction, one developed nonunion. One patient treated with immediate open reduction developed osteomyelitis of the mandible and nonunion. Five patients (9%) had palate injuries. Two of them later developed intraoral fistulas following conservative treatment. The airway needs immediate attention in GSWs of the face. Computed tomographic scanning of the head or spine should be done when the bullet trajectory is above the lower face (the level of the mandible). Angiography is indicated when the trajectory of the bullet is suggestive. A conservative approach that effectively reduces the fractures is the procedure of choice. Open reductions should not be performed in the initial treatment. Palate injuries should be repaired early in an attempt to prevent intra-oral fistula formation.