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PhiliPPine Journal of otolaryngology-head and neck Surgery 2928 PhiliPPine Journal of otolaryngology-head and neck Surgery
ORIGINAL ARTICLES
ABSTRACT
Objective: To describe the incidence, pattern and severity of maxillofacial trauma among
patients who sustained gunshot and blast injuries of the maxillofacial region in a tertiary military
hospital.
Methods:
Design: Retrospective Case Series
Setting: Tertiary Military General Hospital
Participantss: All patients admitted under the otorhinolaryngology service with
gunshot and blast injuries to the face
Results: A total of 108 patients were admitted due to gunshot and blast injuries to the face from
January 2010 to December 2015. Most sustained gunshot injuries (73, 67.6%) compared to blast
injuries (35, 32.4%). Of 108 patients, 71 had maxillofacial fractures (65.7%) while the remaining 37
only had soft tissue injuries (34.3%). Majority of those with maxillofacial fractures had single bone
involvement (52, 72.2%); the rest had two or more bones affected (19, 27.8%) The most common
bone injured was the mandible (77.5%), followed by the maxilla (35.2%), zygoma (12.7%), and
others (frontal, nasal, and temporal bones) at 5.6%.
Conclusion: Gunshot injuries had a higher incidence than blast injuries among military personnel
with projectile injuries to the face seen during the study period. There were more fractures and
combinations of fractured bones affected in gunshot injuries, although the breakdown of soft
tissue injuries was similar among those with gunshot and blast injuries. However, the relation of
injury patterns and severity to gunshot or blast etiology, or to other factors such as protective
gear cannot be established in this present study.
Keywords: gunshot injuries; blast injuries; maxillofacial; projectile
Gunshot and blast injuries are commonly seen in a military hospital and patients come from
different areas of the country where insurgency and terrorism are rampant. These patients are
managed by multidisciplinary trauma teams including head and neck surgery, trauma surgery,
neurosurgery and ophthalmology.1 Injuries to the maxillofacial area pose a great problem
Maxillofacial Gunshot and Blast Injuries
Seen in a Tertiary Military Hospital
Julius France P. Garimbao, MD
Department of Otorhinolaryngology
Head and Neck Surgery
Armed Forces of the Philippines Medical Center
Quezon City, Philippines
Correspondence: Dr. Julius France P. Garimbao
Department of Otorhinolaryngology
Head and Neck Surgery
Armed Forces of the Philippines Medical Center
7th Floor, Armed Forces of the Philippines Medical Center
V. Luna Avenue, Quezon City 0840
Philippines
Phone: (632) 8426 2701 local 6172
Email: juliusgarimbao85@gmail.com
The author declared that this represents original material, that
the manuscript has been read and approved by the author, that
the requirements for authorship have been met by the author,
and that the author believes that the manuscript represents
honest work.
Disclosures: The author signed a disclosure that there are no
financial or other (including personal) relationships, intellectual
passion, political or religious beliefs, and institutional
affiliations that might lead to a conflict of interest.
Philipp J Otolaryngol Head Neck Surg 2019; 34 (2): 29-31 c Philippine Society of Otolaryngology – Head and Neck Surgery, Inc.
Creative Commons (CC BY-NC-ND 4.0)
Attribution - NonCommercial - NoDerivatives 4.0 International
PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 34 no. 2 July – december 2019
PhiliPPine Journal of otolaryngology-head and neck Surgery 3130 PhiliPPine Journal of otolaryngology-head and neck Surgery
ORIGINAL ARTICLES
because of close proximity to vital structures.1 They depend on the
speed and energy of the projectile and the damage is often very
difficult to repair.1,2
Institutional data on maxillofacial injuries is important for patient
care, as well as for preparation of plans and programs such as
procurement of supplies and implants necessary for the management
of these conditions. However, to the best of our knowledge there is
only one previous relevant study in our institution and it described
mandibular fractures only.3
This study aims to describe the incidence, pattern, and severity of
facial trauma among patients who sustained gunshot and blast injuries
to the maxillofacial region in a tertiary military hospital. This study also
aims to identify the facial bones commonly involved with these types
of injuries.
METHODS
With Ethics Review Board approval, this retrospective case series
reviewed records of all patients admitted to the otorhinolaryngology-
head and neck surgery (ORL-HNS) ward of the Armed Forces of the
Philippines Medical Center in Quezon City from January 1, 2010 to
December 31, 2015 who sustained gunshot and blast injuries to the
maxillofacial area. Data regarding sex, age, mechanism of injury (blast/
gunshot), and location and number of fractured bones of the face
were gathered from hospital in-patient and radiographic examination
records. The data was hand-searched, extracted and tabulated using
Microsoft Excel for Mac 2019 Version 16.3 (19101301), (Microsoft
Corp., Redmond, WA, USA). Descriptive statistics were used to describe
categorical data.
RESULTS
A total of 108 patients were admitted to the ORL-HNS ward due to
gunshot and blast injuries to the face during the study period from 2010
to 2015. All of the patients in this study were males. Ages ranged from
21 to 56 years old (median age 32 years old). Most (50) were aged 21 to
30 years old, followed by 41 patients aged 31 to 40 years old. Only 14
and 3 patients were aged 41 to 50 and 51 to 60 years old, respectively.
Out of 108 patients, most sustained gunshot injuries (73 or 67.6%)
compared to blast injuries (35 or 32.4%). Most of the patients (71 or
65.7%) had fractures in the maxillofacial area while the remaining 37
(34.3%) only had soft tissue injuries. Of the 71 with fractures, most (54 or
76.1%) were among those with gunshot injuries than those with blast
injuries (17 or 23.9%), although the breakdown of soft tissue injuries
was similar among those with gunshot injuries (19 or 51.4%) and blast
injuries (18 or 48.6%).
Majority of patients with maxillofacial fractures had single bone
involvement (52 or 72.2%) compared to multiple bone involvement
(19 or 27.8%). Of the 52 with single bone involvement, 36 (69.2%) were
among those with gunshot injuries while 16 (30.8%) were among those
with blast injuries. Among the 19 with multiple bone involvement, 18
(94.7%) involved those with gunshot injuries while only one (5.3%)
involved blast injury.
Of the 71 fractures, the most common bone fractured was the
mandible (55 or 77.5%), followed by the maxilla (25 or 35.2%), zygoma (9
or 12.7%), and frontal, nasal or temporal bones, (4 or 5.6%). The majority
of fractures were from gunshot injuries: 40 of the 55 mandibular
fractures, 23 of the 25 maxillary fractures, all of the nine zygomatic
fractures, and three of the four frontal/nasal/temporal bone fractures.
DISCUSSION
In our military hospital, wounded personnel come in daily with
gunshot and blast injuries. Among them are patients with injuries in
the maxillofacial region. The management of maxillofacial gunshot
and blast injuries is multifaceted because it involves the facial skeleton,
orbit, cranium, airway and resulting deformities are usually disfiguring.4
All of the patients in this study were males. Similar to the previous
study in our institution on mandibular fractures, the predominant age
group in our study was 21 to 30 years old which could reflect the fact
that this age group makes up the fighting force of our soldiers engaged
in actual combat.3
Out of 108 patients, there were only 35 patients (32.4%) who
sustained blast injuries to the face compared to 73 patients (67.6%)
who had gunshot injuries in the same area. One explanation may be
that blast injuries due to land mines and grenades are more commonly
seen in the extremities especially in the lower limbs.5
Gunshot injuries compared to blast or shrapnel injuries are expected
to have more extensive damage due to their high velocity resulting in
greater energy transfer to soft tissues and bones.4-6 This may explain
why the breakdown of soft tissue injuries was similar among those with
gunshot injuries and blast injuries while there were more fractures with
the former than the latter.
As expected from other studies, in almost all the facial bones
included in our study, gunshots were still the leading cause of injury
with higher risk of resulting fracture.5 Furthermore, both single and
multiple-bone fractures were more common in gunshot than blast
injuries. High-velocity projectiles are more likely to cause unstable
fracture configurations with butterfly fragments and large amounts
of comminution.7 This might explain the higher occurrence of
both multiple and single-bone involvement (such as comminuted
mandibular fractures) in gunshot injuries in our study. On the other
hand, in blast injuries the blast wave loses velocity and magnitude
PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 34 no. 2 July – december 2019
PhiliPPine Journal of otolaryngology-head and neck Surgery 3130 PhiliPPine Journal of otolaryngology-head and neck Surgery
ORIGINAL ARTICLES
before decaying into an acoustic wave.8,9 This might explain less
fractures to the maxillofacial region from blast injuries in our study.
Similar to our findings, previous studies about penetrating and
blunt injuries to the maxillofacial region also showed that mandible
is the most frequent facial bone fractured in these types of injuries.4,10
On the other hand, we found that fractures in the nasal, frontal and
temporal bone were less common compared to the other facial bones.
One possible reason for this may be that the area is mostly covered by
protective gear. Another explanation may be the proximity of these
bones to the brain, such that patients with injuries in this area may
have been referred to neurosurgery and not included in this study. This
is a limitation of our study and also extends to patients with primary
injuries to the extremities being admitted under the orthopedic service.
Our only including patients admitted in the ORL-HNS ward also
excluded patients in other wards who may have had concomitant
maxillofacial injuries and future studies should account for these.
Another limitation of our study is the unavailability of data on the
number of deaths from these type of injuries to account for the
mortality rate among such patients.
In conclusion, gunshot injuries had a higher incidence than blast
injuries among military personnel with projectile injuries to the
face seen during the study period. There were more fractures and
combinations of fractured bones affected in gunshot injuries although
the breakdown of soft tissue injuries was similar among those with
gunshot and blast injuries. Despite possible initial trends and patterns,
the relation of injury patterns and severity to gunshot or blast etiology
or to other factors such as protective gear, cannot be established in this
present study.
ACKNOWLEDGEMENTS
The author wishes to thank Dr. Ma. Sheila P. Jardiolin who provided general support, Trisha Kay P.
Lumio for data collection and technical support and Dr. Grace Naomi G. Bravo and Dr. Kirby P. Jaramilla
for data encoding and assistance with manuscript revisions.
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