Gunshot wounds to the head and neck By T. C. KENEFICK (Altnagelvin, Northern Ireland) THE cases presented in this paper have resulted from civil disturbances in the north of Ireland. The surgery of civil violence in this area mainly deals with the following types of injury. 1. Bullet wounds from rifles, pistols and automatic weapons. 2. Blunt injuries from stones, bricks and other blunt missiles. 3. The injuries produced by explosions which can be divided into two classes: (a) Those from the blast and the missiles it produces, particularly flying fragments of glass. (b) The crushing injuries of collapsing buildings. 4. Burns. 5. The psychological effects felt as much outside the riot areas as in them. It is with the first category of injury that this paper deals. The pattern has changed as the violence has escalated. The low velocity bullet wounds such as those fired from pistols are usually arrested in the tissues and often deflected by important structures during their passage. The high velocity bullet on the other hand passes through the body not only destroying structures in its path but also creating a zone of cavitation around it. The velocity is of much greater importance than the mass. The energy dissipated depends on the density of the tissues through which the bullet passes. Injuries of bone cause much greater damage and widespread destruction than those involving fat and muscle only. In this type of wound debridement is necessary far beyond the bullet track. The wound is loosely packed and referred for delayed primary suture five days later. Any bullet with a muzzle velocity of over 2,000 feet per second inflicting a wound at 200 yards or less may be considered to have caused a wound which may extend many centimetres from the permanent wound. The main difference between guerilla casualties and those in warfare such as the 1939-45 war lies in the very rapid evacuation to a fully staffed, fully equipped hospital with all that a modern teaching hospital should have, e.g. blood banks, radiology, laboratory services, departments of neurosurgery, plastic, thoracic, urogenital, ENT, vascular and paediatric surgery departments. 335
T. C. Kenefick Case presentation
Case i A male aged 18 received a gunshot wound to the neck. On admission the patient was conscious, talking and breathing comfortably. Pulse and BP were normal and there was no evidence of serious haemorrhage. An entry wound was noted on the right side of the upper neck and an exit wound on the left side. The following X-rays were done: (i) X-ray of chest—normal. (ii) X-ray of neck. X-ray of neck—notes surgical emphysema.
FIG. I.
X-ray of neck. Xote: Surgical Emphysema.
At operation The neck was explored by a transverse incision. The sternomastoids and strap muscles were divided to get good access. The bullet track was found to pass through the neck from right to left just anterior to the major vessels on both sides and just anterior to the oesophagus. It passed through the trachea at the level of its second and third rings causing an entry wound on the right lateral wall | in. in diameter in its posterior half and an exit wound f in. on the left side where it emerged. The structure of the larynx appeared intact. The thyroid isthmus was divided and a size 36 cuffed tracheostomy tube was 336
Gunshot wounds to the head and neck inserted below the site of penetration of the trachea. The area around the damaged part of the trachea was carefully debrided and any vital tissue resutured lightly over the defect. The wound was closed in the normal way, and a direct laryngoscopy performed post-operatively showed the larynx to be oedematous. The epiglottis was intact. The structure of the larynx appeared unharmed. The patient made a full and uneventful recovery and on discharge 21 days later both cords were moving normally and he had no difficulty with breathing or talking. Case 2 Male aged 20 received a gunshot wound to the face. On admission his general condition was good—pulse 84, BP 124/70. He was bleeding from the mouth and from an entry wound to the left side of the chin and from a laceration on the right side of the face. Intraorally there was extensive laceration to the buccal and lingual mucosa in the lower left molar region with bone and tooth loss between fa and jj. Lateral X-ray of face and neck showed the following:
FIG. 2. Lateral X-ray of face and neck. Note: Comminuted fracture of the body of the mandible on the left side, with a fragment of bullet lodged next to it. Also shown is a further larger fragment lying in the neck to the right of the midline and anterior to the body of C6 and the major vessels on the right side of the neck.
At operation The patient was intubated with difficulty because of bleeding and oedema of the epiglottis. A tracheostomy was performed. A bullet track was traced running down and back through the base of the tongue from left to right and a tear was noted in the posterior pharyngeal wall to the right of the endotracheal tube at the level of the arytenoids. 337
T. C. Kenefick A Boyle-Davis gag and tongue plate were inserted and thus the tear was explored and the bullet was seen to be just inside the tear and anterior to the major neck vessels on the light side of the neck. It was removed with a crocodile action laryngeal forceps without difficulty or bleeding. A nasogastric tube was then passed and the mandibular fracture was explored intraorally and a large foreign body was removed which proved, as aheady noted on the X-ray, to be part of the bullet. After debridement the wound was closed. The jaw fracture was reduced and immobilized using a combination of interdental wiring and external pin fixation. The entry wound was excised and sutured. The patient made a full and excellent recover}'. Case 3 A male aged 30 received a gunshot wound to the upper right chest. On admission the patient had stridor. Pulse 100 per minute, BP 100/60. On examination—the bullet entered the chest posteriorly on the right side about the level of the 5th rib. There was a massive swelling of the neck, bleeding from the mouth. An X-ray of face and neck showed the following. Fig. 3.
TIG. 3. A.P. view of neck and face. Note: Fractured right clavicle. Surgical Emphysema of neck and compression of trachea.
At operation The patient was transfused and taken immediately to theatre. He was intubated with difficulty and the neck was explored. A tracheostomy was performed and the haematoma was evacuated. All bleeding points were located and controlled. The bullet made its exit from the neck through the floor of the 338
Gunshot wounds to the head and neck mouth and hence to the exterior without fracturing the mandible or maxilla. The floor of the mouth was debrided and repaired with catgut. The haemopneumothorr.x was dealt with by the chest surgeons and the clavicle united satisfactorily. The patient made a full and complete recovery. Case 4
Male aged 14. Gunshot wound to the face. On admission general condition was good. Pulse 90, BP 120/70. On examination—bullet wound on right cheek just lateral to right nostril. Right cheek was swollen r.r.d tender. No ter.r was visible in the right vestibule. Bleeding from the right ear. This was cleared and it was noted that the meatus was torn, the patient also had trismus and the right facial nerve was paralysed. Lateral X-ray of skull. Fig. \.
FIG. 4. Lateral X-ray of skull. >Tote: Bullet lodged between mistoid process and ascending ramus of mandible on the right side. The pxth of the bullet is suggested by the debris seen in the antrum.
At operation The light ear was examined with the operating microscope and the bullet was seen to lie anteio-inferiorly just penetrating tiie merrtus. An incision was 339
T. C. Kenefick made in front of the ear and traced inwards until the bullet was discovered lying behind the head of the mandible. It was levered out without much difficulty. The right temporo-mandibular joint was unaffected. The meatus was reexamined and found to be torn infeiiorly. There was also a tear in the right tympanic membrane posterosuperiorly. The wound was repaired with catgut and silk. The entry wound was excised and sutured. Post-operatively it was noted that there was a profuse discharge of colourless fluid from the right ear. It was felt initially that this was saliva as the bullet had lodged in the vicinity of the right parotid gland and there was an entry from this position into the right external auditory meatus. Bilateral compression of the internal jugular veins increased the flow of colourless fluid—suggesting that the fluid was cerebro-spinal fluid. This was confirmed by analysis in the laboratory. The patient was put on prophylactic 'Ampicillin and Cloxacillin' i vial 6-hourly. The otonhoea continued unabated and ten days after the injury he developed a pyrexia of 1030, headache and photophobia. On examination—he had a positive Kernig's sign. A diagnosis of meningitis was made. This was confirmed by lumbar puncture. He was treated with sulphadiazine, crystapen and fluids. He gradually improved and the CSF otorrhoea stopped. Tomograms of the middle and inner ear did not show the site of CSF otorrhoea. An audiogram showed a severe right perceptive deafness with the left ear masked. He was discharged home well 18 days after admission—his right facia] palsy had improved. When last seen in out-patients two months after discharge the right T.M. had completely healed. The right facial palsy had almost completely recovered. The right perceptive deafness, however, remained unchanged. These four cases are each of particular clinical interest; the first in that a bullet passed through the patient's neck from one side to the other and missed hitting anything vital; in case 2 the patient was extremely fortunate that the bullet stopped before it had penetrated the common carotid artery or internal jugular vein on the right side; in case 3 the patient had an extremely lucky escape in that the bullet passed from the right chest up through the clavicle, causing a large right haematoma in the neck, but again not involving any vital structures to a serious degree; case 4 was of interest in that the bullet was discovered with the operating microscope in the floor of the right meatus. There was probably a concussion fracture of the right labyrinth causing the perceptive deafness and possibly the CSF otorrhoea. All the cases made a satisfactory recovery. Discussion The four years of fighting during the American Civil War provided an enormous experience of trauma of all kinds. It is not surprising that the first comprehensive study of penetrating wounds of the neck was based on this group of casualties. There were 4,895 cases recorded with an overall mortality of 12-6 per cent. I will deal first with shotgun wounds to the head and neck. May et al. (1971) describe the evaluation and treatment of 43 victims who sustained shotgun wounds to the head and neck—superficial in 30, massively destructive in 13. Moore (1965) stresses that massive 340
Gunshot wounds to the head and neck compound facial injuries create a sense of dismay which may lead to therapeutic inertia. The feeling of futility as in any disaster can only be overcome by an organized and disciplined approach. Prompt assessment of vital functions is the first requirement. An airway must be assured and shock treated and the condition allowed to stabilize. The extent of injury is dependent on muzzle/victim distance. When the distance was over 6 • 09 metres the wound consisted of many small superficial holes each corresponding with the point of entry of one pellet. When the distance was less than 6-09 metres the pellets and wadding entered the impact site in a solid mass producing a wound of entrance. Shell consists of paper or plastic tubing and a brass base in which primer, gunpowder, wadding and shotgun pellets are enclosed. After the charge has travelled over 6 • 09 metres the shell and wadding fall away, the wound created being caused by the spray of pellets. This is the type of injury which occurred in 30 of May's (1971) patients. The injury produced was usually simple, excepting eye injuries, and included the skin and subcutaneous tissues. Excluding eye injuries the length of stay in hospital was one to three days. In the remaining 13 the wound was massively destructive and involved major vessels, pneumothorax, intracranial injuries, multiple facial fractures, nerve injuries, e.g. of the facial nerve. Eleven of the 13 survived. They also stress that an ordered approach with immediate attention to those arriving and blood transfusions can save a large number of these patients; also thorough and meticulous exploration and debridement and all necessary repair must be undertaken. Sherman and Parrish (1963) saw 67 patients between 1953 and 1965 who received shotgun injuries to the head and neck—of these 14 had received shotgun wounds at very close range. The authors found that the most important factors determining the severity of the injury were the range, angle of shot and the presence or absence of a deflecting force such as a hand. They state that if the patient arrives in the emergency room alive a surprisingly good prognosis for survival exists if intracranial damage is absent. This is in contrast to similar injuries elsewhere in the body where haemorrhage and shock may be uncontrollable despite surgical intervention. Attention to the airway is stressed. In shotgun injuries the instances where primary closure can be carried out are relatively few and they have found that those which are left open with debridement do very well. Antibiotic cover and tetanus prophylactics are essential. The timing of nerve repair following high velocity projectile injuries has been well established with experience gained in World War II. Suturing is usually not carried out at the time of the initial debridement of the wound. If the nerve ends are found they can be tagged with a stainless steel suture to facilitate exploration and removed one month after healing. May et al. (1971) reviewed 100 patients initially surviving penetrating wounds of the neck. Six wounds were received in automobile accidents.
T. C. Kenefick Eighty-six remained and 8 were eliminated from the study as the platysma was not penetrated in 7 and 1 died shortly after admission. The 86 were divided as follows: 23 stab wounds and 53 gunshot wounds—the majority were inflicted with -22 calibre bullet. They came to the conclusion that management of penetrating wounds of the neck requires careful evaluation and treatment based on a logical approach rather than a routine policy. It would appear that the treatment pendulum after swinging to the extreme of observation and routine surgical exploration should now come to rest in the middle where exploratory operations are performed if there are positive preoperative indications for it. Their policy of selective exploration does not increase morbidity or mortality. Farley et al. (1964) studied 67 patients with serious trauma to the neck which had been admitted to their hospital over the previous ten years. The injuries included 20 gunshot wounds and 41 deep lacerations. The structures most commonly involved were either blood vessels or nerves. The oesophagus and respiratory structures were involved in 10 per cent of cases. There was a 6 per cent mortality in these cases. They state that the evidence indicates that if the wounds extend through the platysma muscle and enter or traverse the central vital area of the neck the wound should be formally explored even if there is no obvious injury to important structures. The treatment of penetrating wounds of the neck was largely non-surgical prior to World War II. During World War II the mortality rate from neck injuries declined and has remained at approximately 7 per cent since. Robert Jones, James Terrell and Salyer (1967) reviewed 274 cases of penetrating wounds of the neck treated between 1957-1964 to assess the validity of early and frequent exploration. There were 11 deaths yielding an overall mortality of 4 per cent. Five of the deaths were due to massive injury of the brain or spinal cord. There were 103 neck explorations in which no significant injuries were found. Included in the series were 15 patients with clinically negative neck wounds (i.e. no visible bleeding or haematoma and no shock or other evidence of significant injury) who had injury to 17 major structures including 13 major arteries. It is concluded that the policy of explorating all neck injuries where the platysma has been penetrated is justifiable. Fitchett et al. (1969) of Denver states that few surgeons, military or civilian, see enough such wounds to become expert in their management. They reviewed 75 cases, 62 military and 13 civilian. All the military cases were treated in the Republic of Vietnam and all but 4 were admitted to the hospital 30-90 minutes following the injury. Fifty per cent were from low velocity fragments and 50 per cent from high velocity missiles. Breakdown of the injuries was as follows: (1) Soft tissue only in 25 cases. (2) Internal jugular vein 7 cases. (3) Carotid artery 12 cases. 342
Gunshot wounds to the head and neck (4) Innominate artery 2 cases. (5) Injuries to larynx, trachea and cervical cartilages 10 cases. Subcutaneous emphysema may be the only reliable indication of underlying damage to the airway following penetrating injuries of the neck. Only 4 did not have emphysema on admission and these developed it soon afterwards. The structures injured corresponded roughly to their size and vulnerability. The trachea was violated in 5 patients, in one of whom there was also perforation of the oesophagus. In 5 others the thyroid cartilage was primarily injured. In 4 patients one or both vocal cords were directly damaged. The pharynx, pyriform fossa, hypopharynx and cricoid cartilages were injured in two cases. Laryngeal stents were placed in six wounds where there was appreciable destruction of thyroid cartilage. Every fragment of cricoid cartilage that could be salvaged was used to maintain this structure which is vital for a functioning airway and vocal apparatus. Gaps and tears in the pharyngeal or laryngeal mucosa were closed tightly and the wound widely drained. Every reasonable attempt was made to achieve skin coverage over the injured thyroid and cricoid cartilages and where oesophageal injury was suspected oesophagoscopy was performed.
Comment In World War II it was found by experience that early exploration of neck wounds reduced the mortality from 35 to 6 per cent. Factors which have effected improvement during the past 30 years have been: (1) Improved methods of establishing an airway. (2) Improved methods of resuscitation. (3) Early and thorough exploration of neck wounds. (4) Development of techniques for vascular repair. (5) Improved techniques for management of injuries to the larynx and trachea. (6) Prompt evaluation and definitive surgical care of both military and civilian casualties. They stress that the safest policy is to consider penetration of the neck in the same way as penetration of the abdominal wall—all should be explored. Summary The types of injury which occur as a result of the civil disturbances in the north of Ireland are described. Four cases of gunshot wounds to the head and neck are described, each of particular clinical interest. The recent literature on the subject is reviewed and the consensus of opinion appears to be that the safest policy is to explore all cases of penetrating wounds of the neck. 343
T. C. Kenefick Acknowledgements
I would like to thank Mr. Harvey and Mr. Emerson for allowing me to report these cases. I would like to thank Mr. O'Farrel for the preparation of the photographs. REFERENCES FARLEY, H. H., NIXON, R., PETERSON, T. A., and HITCHCOCK, C. R. (1964) American
Journal of Surgery, 108, 592. FITCHETT, V. H., POMERANTZ, M., BUTSCH, D. W., SIMON, R., and EISEMAN, B.
(1969) Archives of Surgery, 99, 307. JONES, R. F., TERRELL, J. C , and SALYER, K. E. (1967) The Journal of Trauma, 7,
228. MAY, M., OGURA, J. H., L E E , C , SAPOTE, P., AMNUAC, C , and TUCKER, H. M. (1971)
Proceedings of the American Academy of Ophthalmology and Otolaryngology, 75, 496. MOORE, A. M., and WINSLOW, P. (1965) The American Surgeon, 31, 321. RODGERS, H. W., ROBB, J. D., RUTHERFORD, W. H., CROCKARD, H. A., MAGUIRK, C. J. F., JOHNSTON, S. S., SMYTH, G. D. L., STEWART, T. J., GRAY, R. C , COPPEL,
D. L., and LYONS, H. A. (1973) Recent Advances in Surgery, 321. SHERMAN, R. T., and PARRISH, R. A. (1963) Journal of Trauma, 3, 76. SPIRA, M., HARDY, S. B., BIGGS, T. E., and GEROW, F. J. (1967) Plastic and Recon-
structive Surgery, 39, 449. Inverell, Bishopstown, Cork, Eire.
344
T. C. Kenefick Case presentation
Case i A male aged 18 received a gunshot wound to the neck. On admission the patient was conscious, talking and breathing comfortably. Pulse and BP were normal and there was no evidence of serious haemorrhage. An entry wound was noted on the right side of the upper neck and an exit wound on the left side. The following X-rays were done: (i) X-ray of chest—normal. (ii) X-ray of neck. X-ray of neck—notes surgical emphysema.
FIG. I.
X-ray of neck. Xote: Surgical Emphysema.
At operation The neck was explored by a transverse incision. The sternomastoids and strap muscles were divided to get good access. The bullet track was found to pass through the neck from right to left just anterior to the major vessels on both sides and just anterior to the oesophagus. It passed through the trachea at the level of its second and third rings causing an entry wound on the right lateral wall | in. in diameter in its posterior half and an exit wound f in. on the left side where it emerged. The structure of the larynx appeared intact. The thyroid isthmus was divided and a size 36 cuffed tracheostomy tube was 336
Gunshot wounds to the head and neck inserted below the site of penetration of the trachea. The area around the damaged part of the trachea was carefully debrided and any vital tissue resutured lightly over the defect. The wound was closed in the normal way, and a direct laryngoscopy performed post-operatively showed the larynx to be oedematous. The epiglottis was intact. The structure of the larynx appeared unharmed. The patient made a full and uneventful recovery and on discharge 21 days later both cords were moving normally and he had no difficulty with breathing or talking. Case 2 Male aged 20 received a gunshot wound to the face. On admission his general condition was good—pulse 84, BP 124/70. He was bleeding from the mouth and from an entry wound to the left side of the chin and from a laceration on the right side of the face. Intraorally there was extensive laceration to the buccal and lingual mucosa in the lower left molar region with bone and tooth loss between fa and jj. Lateral X-ray of face and neck showed the following:
FIG. 2. Lateral X-ray of face and neck. Note: Comminuted fracture of the body of the mandible on the left side, with a fragment of bullet lodged next to it. Also shown is a further larger fragment lying in the neck to the right of the midline and anterior to the body of C6 and the major vessels on the right side of the neck.
At operation The patient was intubated with difficulty because of bleeding and oedema of the epiglottis. A tracheostomy was performed. A bullet track was traced running down and back through the base of the tongue from left to right and a tear was noted in the posterior pharyngeal wall to the right of the endotracheal tube at the level of the arytenoids. 337
T. C. Kenefick A Boyle-Davis gag and tongue plate were inserted and thus the tear was explored and the bullet was seen to be just inside the tear and anterior to the major neck vessels on the light side of the neck. It was removed with a crocodile action laryngeal forceps without difficulty or bleeding. A nasogastric tube was then passed and the mandibular fracture was explored intraorally and a large foreign body was removed which proved, as aheady noted on the X-ray, to be part of the bullet. After debridement the wound was closed. The jaw fracture was reduced and immobilized using a combination of interdental wiring and external pin fixation. The entry wound was excised and sutured. The patient made a full and excellent recover}'. Case 3 A male aged 30 received a gunshot wound to the upper right chest. On admission the patient had stridor. Pulse 100 per minute, BP 100/60. On examination—the bullet entered the chest posteriorly on the right side about the level of the 5th rib. There was a massive swelling of the neck, bleeding from the mouth. An X-ray of face and neck showed the following. Fig. 3.
TIG. 3. A.P. view of neck and face. Note: Fractured right clavicle. Surgical Emphysema of neck and compression of trachea.
At operation The patient was transfused and taken immediately to theatre. He was intubated with difficulty and the neck was explored. A tracheostomy was performed and the haematoma was evacuated. All bleeding points were located and controlled. The bullet made its exit from the neck through the floor of the 338
Gunshot wounds to the head and neck mouth and hence to the exterior without fracturing the mandible or maxilla. The floor of the mouth was debrided and repaired with catgut. The haemopneumothorr.x was dealt with by the chest surgeons and the clavicle united satisfactorily. The patient made a full and complete recovery. Case 4
Male aged 14. Gunshot wound to the face. On admission general condition was good. Pulse 90, BP 120/70. On examination—bullet wound on right cheek just lateral to right nostril. Right cheek was swollen r.r.d tender. No ter.r was visible in the right vestibule. Bleeding from the right ear. This was cleared and it was noted that the meatus was torn, the patient also had trismus and the right facial nerve was paralysed. Lateral X-ray of skull. Fig. \.
FIG. 4. Lateral X-ray of skull. >Tote: Bullet lodged between mistoid process and ascending ramus of mandible on the right side. The pxth of the bullet is suggested by the debris seen in the antrum.
At operation The light ear was examined with the operating microscope and the bullet was seen to lie anteio-inferiorly just penetrating tiie merrtus. An incision was 339
T. C. Kenefick made in front of the ear and traced inwards until the bullet was discovered lying behind the head of the mandible. It was levered out without much difficulty. The right temporo-mandibular joint was unaffected. The meatus was reexamined and found to be torn infeiiorly. There was also a tear in the right tympanic membrane posterosuperiorly. The wound was repaired with catgut and silk. The entry wound was excised and sutured. Post-operatively it was noted that there was a profuse discharge of colourless fluid from the right ear. It was felt initially that this was saliva as the bullet had lodged in the vicinity of the right parotid gland and there was an entry from this position into the right external auditory meatus. Bilateral compression of the internal jugular veins increased the flow of colourless fluid—suggesting that the fluid was cerebro-spinal fluid. This was confirmed by analysis in the laboratory. The patient was put on prophylactic 'Ampicillin and Cloxacillin' i vial 6-hourly. The otonhoea continued unabated and ten days after the injury he developed a pyrexia of 1030, headache and photophobia. On examination—he had a positive Kernig's sign. A diagnosis of meningitis was made. This was confirmed by lumbar puncture. He was treated with sulphadiazine, crystapen and fluids. He gradually improved and the CSF otorrhoea stopped. Tomograms of the middle and inner ear did not show the site of CSF otorrhoea. An audiogram showed a severe right perceptive deafness with the left ear masked. He was discharged home well 18 days after admission—his right facia] palsy had improved. When last seen in out-patients two months after discharge the right T.M. had completely healed. The right facial palsy had almost completely recovered. The right perceptive deafness, however, remained unchanged. These four cases are each of particular clinical interest; the first in that a bullet passed through the patient's neck from one side to the other and missed hitting anything vital; in case 2 the patient was extremely fortunate that the bullet stopped before it had penetrated the common carotid artery or internal jugular vein on the right side; in case 3 the patient had an extremely lucky escape in that the bullet passed from the right chest up through the clavicle, causing a large right haematoma in the neck, but again not involving any vital structures to a serious degree; case 4 was of interest in that the bullet was discovered with the operating microscope in the floor of the right meatus. There was probably a concussion fracture of the right labyrinth causing the perceptive deafness and possibly the CSF otorrhoea. All the cases made a satisfactory recovery. Discussion The four years of fighting during the American Civil War provided an enormous experience of trauma of all kinds. It is not surprising that the first comprehensive study of penetrating wounds of the neck was based on this group of casualties. There were 4,895 cases recorded with an overall mortality of 12-6 per cent. I will deal first with shotgun wounds to the head and neck. May et al. (1971) describe the evaluation and treatment of 43 victims who sustained shotgun wounds to the head and neck—superficial in 30, massively destructive in 13. Moore (1965) stresses that massive 340
Gunshot wounds to the head and neck compound facial injuries create a sense of dismay which may lead to therapeutic inertia. The feeling of futility as in any disaster can only be overcome by an organized and disciplined approach. Prompt assessment of vital functions is the first requirement. An airway must be assured and shock treated and the condition allowed to stabilize. The extent of injury is dependent on muzzle/victim distance. When the distance was over 6 • 09 metres the wound consisted of many small superficial holes each corresponding with the point of entry of one pellet. When the distance was less than 6-09 metres the pellets and wadding entered the impact site in a solid mass producing a wound of entrance. Shell consists of paper or plastic tubing and a brass base in which primer, gunpowder, wadding and shotgun pellets are enclosed. After the charge has travelled over 6 • 09 metres the shell and wadding fall away, the wound created being caused by the spray of pellets. This is the type of injury which occurred in 30 of May's (1971) patients. The injury produced was usually simple, excepting eye injuries, and included the skin and subcutaneous tissues. Excluding eye injuries the length of stay in hospital was one to three days. In the remaining 13 the wound was massively destructive and involved major vessels, pneumothorax, intracranial injuries, multiple facial fractures, nerve injuries, e.g. of the facial nerve. Eleven of the 13 survived. They also stress that an ordered approach with immediate attention to those arriving and blood transfusions can save a large number of these patients; also thorough and meticulous exploration and debridement and all necessary repair must be undertaken. Sherman and Parrish (1963) saw 67 patients between 1953 and 1965 who received shotgun injuries to the head and neck—of these 14 had received shotgun wounds at very close range. The authors found that the most important factors determining the severity of the injury were the range, angle of shot and the presence or absence of a deflecting force such as a hand. They state that if the patient arrives in the emergency room alive a surprisingly good prognosis for survival exists if intracranial damage is absent. This is in contrast to similar injuries elsewhere in the body where haemorrhage and shock may be uncontrollable despite surgical intervention. Attention to the airway is stressed. In shotgun injuries the instances where primary closure can be carried out are relatively few and they have found that those which are left open with debridement do very well. Antibiotic cover and tetanus prophylactics are essential. The timing of nerve repair following high velocity projectile injuries has been well established with experience gained in World War II. Suturing is usually not carried out at the time of the initial debridement of the wound. If the nerve ends are found they can be tagged with a stainless steel suture to facilitate exploration and removed one month after healing. May et al. (1971) reviewed 100 patients initially surviving penetrating wounds of the neck. Six wounds were received in automobile accidents.
T. C. Kenefick Eighty-six remained and 8 were eliminated from the study as the platysma was not penetrated in 7 and 1 died shortly after admission. The 86 were divided as follows: 23 stab wounds and 53 gunshot wounds—the majority were inflicted with -22 calibre bullet. They came to the conclusion that management of penetrating wounds of the neck requires careful evaluation and treatment based on a logical approach rather than a routine policy. It would appear that the treatment pendulum after swinging to the extreme of observation and routine surgical exploration should now come to rest in the middle where exploratory operations are performed if there are positive preoperative indications for it. Their policy of selective exploration does not increase morbidity or mortality. Farley et al. (1964) studied 67 patients with serious trauma to the neck which had been admitted to their hospital over the previous ten years. The injuries included 20 gunshot wounds and 41 deep lacerations. The structures most commonly involved were either blood vessels or nerves. The oesophagus and respiratory structures were involved in 10 per cent of cases. There was a 6 per cent mortality in these cases. They state that the evidence indicates that if the wounds extend through the platysma muscle and enter or traverse the central vital area of the neck the wound should be formally explored even if there is no obvious injury to important structures. The treatment of penetrating wounds of the neck was largely non-surgical prior to World War II. During World War II the mortality rate from neck injuries declined and has remained at approximately 7 per cent since. Robert Jones, James Terrell and Salyer (1967) reviewed 274 cases of penetrating wounds of the neck treated between 1957-1964 to assess the validity of early and frequent exploration. There were 11 deaths yielding an overall mortality of 4 per cent. Five of the deaths were due to massive injury of the brain or spinal cord. There were 103 neck explorations in which no significant injuries were found. Included in the series were 15 patients with clinically negative neck wounds (i.e. no visible bleeding or haematoma and no shock or other evidence of significant injury) who had injury to 17 major structures including 13 major arteries. It is concluded that the policy of explorating all neck injuries where the platysma has been penetrated is justifiable. Fitchett et al. (1969) of Denver states that few surgeons, military or civilian, see enough such wounds to become expert in their management. They reviewed 75 cases, 62 military and 13 civilian. All the military cases were treated in the Republic of Vietnam and all but 4 were admitted to the hospital 30-90 minutes following the injury. Fifty per cent were from low velocity fragments and 50 per cent from high velocity missiles. Breakdown of the injuries was as follows: (1) Soft tissue only in 25 cases. (2) Internal jugular vein 7 cases. (3) Carotid artery 12 cases. 342
Gunshot wounds to the head and neck (4) Innominate artery 2 cases. (5) Injuries to larynx, trachea and cervical cartilages 10 cases. Subcutaneous emphysema may be the only reliable indication of underlying damage to the airway following penetrating injuries of the neck. Only 4 did not have emphysema on admission and these developed it soon afterwards. The structures injured corresponded roughly to their size and vulnerability. The trachea was violated in 5 patients, in one of whom there was also perforation of the oesophagus. In 5 others the thyroid cartilage was primarily injured. In 4 patients one or both vocal cords were directly damaged. The pharynx, pyriform fossa, hypopharynx and cricoid cartilages were injured in two cases. Laryngeal stents were placed in six wounds where there was appreciable destruction of thyroid cartilage. Every fragment of cricoid cartilage that could be salvaged was used to maintain this structure which is vital for a functioning airway and vocal apparatus. Gaps and tears in the pharyngeal or laryngeal mucosa were closed tightly and the wound widely drained. Every reasonable attempt was made to achieve skin coverage over the injured thyroid and cricoid cartilages and where oesophageal injury was suspected oesophagoscopy was performed.
Comment In World War II it was found by experience that early exploration of neck wounds reduced the mortality from 35 to 6 per cent. Factors which have effected improvement during the past 30 years have been: (1) Improved methods of establishing an airway. (2) Improved methods of resuscitation. (3) Early and thorough exploration of neck wounds. (4) Development of techniques for vascular repair. (5) Improved techniques for management of injuries to the larynx and trachea. (6) Prompt evaluation and definitive surgical care of both military and civilian casualties. They stress that the safest policy is to consider penetration of the neck in the same way as penetration of the abdominal wall—all should be explored. Summary The types of injury which occur as a result of the civil disturbances in the north of Ireland are described. Four cases of gunshot wounds to the head and neck are described, each of particular clinical interest. The recent literature on the subject is reviewed and the consensus of opinion appears to be that the safest policy is to explore all cases of penetrating wounds of the neck. 343
T. C. Kenefick Acknowledgements
I would like to thank Mr. Harvey and Mr. Emerson for allowing me to report these cases. I would like to thank Mr. O'Farrel for the preparation of the photographs. REFERENCES FARLEY, H. H., NIXON, R., PETERSON, T. A., and HITCHCOCK, C. R. (1964) American
Journal of Surgery, 108, 592. FITCHETT, V. H., POMERANTZ, M., BUTSCH, D. W., SIMON, R., and EISEMAN, B.
(1969) Archives of Surgery, 99, 307. JONES, R. F., TERRELL, J. C , and SALYER, K. E. (1967) The Journal of Trauma, 7,
228. MAY, M., OGURA, J. H., L E E , C , SAPOTE, P., AMNUAC, C , and TUCKER, H. M. (1971)
Proceedings of the American Academy of Ophthalmology and Otolaryngology, 75, 496. MOORE, A. M., and WINSLOW, P. (1965) The American Surgeon, 31, 321. RODGERS, H. W., ROBB, J. D., RUTHERFORD, W. H., CROCKARD, H. A., MAGUIRK, C. J. F., JOHNSTON, S. S., SMYTH, G. D. L., STEWART, T. J., GRAY, R. C , COPPEL,
D. L., and LYONS, H. A. (1973) Recent Advances in Surgery, 321. SHERMAN, R. T., and PARRISH, R. A. (1963) Journal of Trauma, 3, 76. SPIRA, M., HARDY, S. B., BIGGS, T. E., and GEROW, F. J. (1967) Plastic and Recon-
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