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 nasotrachea l intubation in one. Central nervous system injury was seen in 12 (22% ): 40% with orbital, 38% with mid-face, and 0% with lower face injurie s. Two patients died of intracranial injuries (mortality, 4%). Vascula r injury was present in five patients (9%), all detected by angiograph y. The local complication rate was 39% in the presence of intra-oral i njury and 0% without intra-oral injury (p < 0.001). The maxilla was th e most commonly fractured facial bone (41%) followed by the mandible i n 28%. All maxillary, orbital, and zygomatic fractures were treated wi thout reduction. One of the seven nasal fractures required open reduct ion for deformity. Six of the 15 mandible fractures were treated witho ut reduction. Of eight patients treated with closed reduction, one dev eloped nonunion. One patient treated with immediate open reduction dev eloped osteomyelitis of the mandible and nonunion. Five patients (9%) had palate injuries. Two of them later developed intraoral fistulas fo llowing conservative treatment. The airway needs immediate attention i n GSWs of the face. Computed tomographic scanning of the head or spine should be done when the bullet trajectory is above the lower face (th e 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 sho uld not be performed in the initial treatment. Palate injuries should be repaired early in an attempt to prevent intra-oral fistula formatio n.