title: Unusual primary and secondary facial blast injuries.
abstract: OBJECTIVE
  To discuss unusual facial injuries resulting from a bomb blast.
  
  
  METHODS
  In March 1997, a bomb consisting of a bag of nails was detonated in a coffee shop in Tel Aviv. Two of the wounded were brought to our level 1 Trauma Center with unique facial injuries. Computed tomography (CT) scan and CT angiogram were performed.
  
  
  RESULTS
  The blast occurred to the immediate right of the victims who were sitting in an open cafe. Both had tympanic perforation. The first patient showed indirect damage to the facial nerve from a piece of shrapnel located anterior to the carotid artery and medial to the right mandibular angle. The second had a piece of shrapnel lodged in the parapharyngeal space that was initially missed and discovered only on reexamination 3 days later after the patient complained of pain in the temporomandibular joint; there was no facial nerve deficit. The port of entry was probably a small wound in the anterior wall of the external ear canal.
  
  
  CONCLUSIONS
  The wounds are probably attributable to the spalling effect of the shrapnel passing through the parotid gland, which has mixed-density tissue. These cases show that nerves are susceptible to damage even in the absence of direct engagement and that the emergency room physician should be alert to even small skin imperfections in blast victims to avoid missing penetrating wounds.
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, Rabin Medical Center, Petah Tiqva, Israel.
authors.forename: Ilan
authors.initials: I
authors.lastname: Koren
authors.forename: Mordechai
authors.initials: M
authors.lastname: Shimonove
authors.forename: Yaacov
authors.initials: Y
authors.lastname: Shvero
authors.forename: Raphael
authors.initials: R
authors.lastname: Feinmesser
mesh_terms: D000328:Adult; D001753:Blast Injuries / Q000000981:diagnostic imaging / Q000601:surgery*; D005151:Facial Injuries / Q000000981:diagnostic imaging / Q000601:surgery*; D005260:Female; D006801:Humans; D008875:Middle Aged; D012720:Severity of Illness Index; D014057:Tomography, X-Ray Computed