Context, objectives and hypotheses of the treatment of midfacial ballistic trauma

Gunshot injuries to the midface represent one of the most complex challenges in maxillofacial surgery, combining an immediate life-threatening emergency with major reconstructive imperatives. This anatomically dense region houses structures essential for respiratory, masticatory, and sensory functions. The transferred ballistic energy induces a unique pathophysiology: the proximity of the paranasal sinuses to the skull base increases the risk of cerebrospinal fluid leaks and intracranial sepsis, with complication rates exceeding 50% when the frontal sinus is involved.

This study details the multidisciplinary management of a 52-year-old male presenting with extensive panfacial laceration, dento-alveolar fracture, and minor frontal pneumocephalus following a self-inflicted gunshot wound. The objective is to evaluate the relevance of critical clinical decisions: the choice of conservative neurosurgical monitoring for the pneumocephalus, the principles of aggressive debridement coupled with stratified primary closure, and the efficacy of targeted antibiotic prophylaxis.

The hypothesis tested is that a structured approach, driven by Advanced Trauma Life Support (ATLS) principles and combining selective non-operative management of intracranial complications with immediate tissue reconstruction, achieves satisfactory healing without neurological or infectious sequelae, despite the violence of the ballistic impact.

Clinical approach and surgical protocol

This case report documents the multidisciplinary therapeutic strategy applied to a 52-year-old patient who suffered a self-inflicted mid-facial ballistic trauma. Initial management strictly followed the ATLS (Advanced Trauma Life Support) protocol, prioritizing airway securing via oropharyngeal cannula and fluid resuscitation (estimated blood loss exceeding 2 L).

The lesion assessment was based on a systematized clinical examination and a non-contrast craniofacial CT scan performed in an emergency setting. This imaging was crucial for identifying a right frontal pneumocephalus and an extensive dento-alveolar fracture (from tooth 12 to 22).

• Medical prophylaxis: Antibiotic therapy for 5 days (ceftriaxone 1 g, 2x/day; metronidazole 400 mg, 3x/day), short-term anticonvulsant prophylaxis and analgesic management (paracetamol 1 g, 3x/day; tramadol 100 mg, 2x/day).
• Surgical procedure: Aggressive debridement, massive irrigation with physiological saline and primary closure by anatomical layers (deep absorbable sutures and cutaneous non-absorbable monofilament).
• Follow-up: Evaluation of intracranial air volume resorption by follow-up CT scan at 24 hours.

The approach favoured a conservative neurosurgical strategy (watchful waiting) rather than invasive intervention for asymptomatic pneumocephalus.

Clinical and radiographic results

Upon admission, the initial examination revealed a state of compensated hypovolemic shock, with an estimated blood loss of more than 2 litres at the scene of the accident. Despite the severity of the trauma, the Glasgow Coma Scale (GCS) score was 15, with no focal motor or sensory deficits detected during the systematic neurological evaluation.

Imaging and lesional diagnosis

Non-contrast brain and maxillofacial computed tomography (CT) revealed critical lesions confirming the violence of the ballistic impact:

• Pneumocephalus: Presence of a small volume of intracranial air localized in the parenchyma of the frontal lobe. This radiological sign confirms a direct communication between the facial wound and the intracranial space.
• Bone lesions: Identification of a dento-alveolar fracture involving the entire anterior maxillary alveolar process.
• Absence of immediate complications: Imaging revealed no additional intracranial hemorrhage, no further skull fractures, and no intracranial tension physiology.

Postoperative evolution

Surgical management consisted of meticulous debridement followed by primary closure by anatomical layers. The clinical progression was marked by the following points:

• Intracranial air resorption: A follow-up CT scan performed at 24 hours demonstrated almost complete disappearance of the pneumocephalus.
• Infection follow-up: No signs of wound infection or intracranial sepsis were observed under prophylactic antibiotic therapy (Ceftriaxone and Metronidazole).
• Functional recovery: The patient achieved complete healing without neurological sequelae, with satisfactory soft tissue healing during the first postoperative follow-up visit.

Clinical analysis: the balance between vital urgency and reconstruction

This case illustrates the effectiveness of structured management according to ATLS principles for midfacial ballistic trauma. Success here relies on a key therapeutic decision: the choice of conservative neurosurgical management for minor frontal pneumocephalus. The absence of "tension physiology" allowed for the avoidance of immediate invasive intervention, validated by the near-disappearance of intracranial air on the 24-hour follow-up CT scan. Clinically, this demonstrates that the violation of the skull base, although indicated by pneumocephalus, does not systematically dictate a craniotomy if the patient remains neurologically stable.

Limits and perspective

As this is a single case report (n=1), the generalization of this approach remains cautious. Success depends closely on the projectile trajectory and the impact velocity. While the literature reports complication rates exceeding 50% for frontal sinus wounds (CSF leaks, sepsis), this patient benefited from early decontamination through abundant irrigation and targeted antimicrobial coverage. Short-term follow-up shows satisfactory healing, but the lack of long-term perspective on functional or aesthetic sequelae constitutes an inherent limitation of this type of report.

Implications for practice

The study highlights the importance of meticulous surgical debridement followed by primary closure by anatomical layers, even in a contaminated traumatic context. For the practitioner, managing these complex cases requires systematic radiographic monitoring to rule out any delayed cerebrovascular injury, the incidence of which is two to six times higher in self-inflicted ballistic trauma compared to other mechanisms.

Conclusion

This case confirms that a coordinated multidisciplinary approach optimizes the prognosis of high-energy craniofacial ballistic trauma.

Summary of results

The treatment of this ballistic trauma in a 52-year-old patient resulted in a complete recovery without neurological sequelae or infection. The strategy relied on aggressive debridement, stratified primary closure, and conservative neurosurgical monitoring of a frontal pneumocephalus, the near-total resolution of which was confirmed by CT scan as early as the 24th hour.

In concrete terms, for the practitioner:

• Non-tension pneumocephalus: In the absence of signs of intracranial tension, vigilant monitoring combined with targeted antibiotic therapy (ceftriaxone/metronidazole for 5 days) can constitute a viable alternative to immediate neurosurgery.
• Layered primary closure: Despite the contamination and projectile energy, an anatomical repair in layers is achievable immediately after copious irrigation with saline solution and meticulous debridement.
• Diagnostic vigilance: In the presence of a complex midfacial fracture, systematically look for pneumocephalus (a sign of skull base violation) and maintain a high index of suspicion for cerebrovascular lesions, which may sometimes be distant from the initial ballistic trajectory.

Technical lexicon of the study

Pneumocephalus: Presence of air inside the intracranial cavity, constituting a major radiological sign of a violation of the skull base. In this case, it is localized at the level of the frontal lobe and was subject to conservative neurosurgical monitoring.

Ballistic energy transfer: Process of kinetic energy dissipation from a projectile into anatomical structures, creating a shock wave responsible for complex tissue damage extending beyond the direct path of the projectile.

Dento-alveolar fracture: Traumatic lesion resulting in a disruption of the bone continuity of the alveolar segment supporting the teeth, clinically identified by segmental mobility during the maxillofacial examination.

Cavitation effect: Dynamic phenomenon where the passage of a high-velocity projectile causes a radial displacement of tissues, creating a temporary cavity and significantly increasing the risk of peripheral vascular or nerve lesions.

Cerebrovascular Injury (CVI): Traumatic injury to cerebral vascular structures (blunt-type lesions) that can occur at a distance from the primary injury path and requires systematic radiographic screening.

ATLS (Advanced Trauma Life Support): Protocolized framework for the initial management of severe trauma, prioritizing airway securing, hemorrhage control, and hemodynamic resuscitation.

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