Chronic sinonasal symptoms due to retained bullet fragments in the skull base





Abstract


Intranasal foreign bodies (FB) are a rare cause of chronic rhinosinusitis in adults. This report describes a unique case of bullet fragments embedded in the sphenoid bone and clivus for 34 years after a gunshot wound (GSW) to the face, leading to chronic rhinosinusitis. Recurrent acute infections were managed with antibiotics; however long-term cure required surgical intervention and removal of the largest bullet fragment. Surgery had been avoided on the patient for decades because of the proximity to critical neurovascular structures in the paracentral skull base, more specifically the sphenoid bone and clivus. Conservative endoscopic sinus surgery with left partial posterior ethmoidectomy and left maxillary antrostomy, followed by drilling of the sphenoid bone and clivus was performed to remove the FB. Bacterial cultures of surgical specimens revealed the presence of Proteus Mirabilis . The patient reported complete resolution of symptoms following surgery, which was maintained at six months follow-up.


This case presents a patient with a metallic foreign body in the skull base for greater than 30 years. Removal of the retained metallic fragment addressed the patient’s symptoms effectively. Despite the risks of the procedure related to the location of the foreign body, this case highlights the importance of addressing foreign bodies as underlying cause of chronic rhinosinusitis-like symptoms. Endonasal sinus surgery primarily for removal of a foreign body, also allows opening sinus outflow tracts and removing chronically infected bone and soft tissue.


Introduction


Intranasal or skull base foreign bodies are a rare cause of Chronic rhinosinusitis (CRS) in adult [ , ]. Foreign bodies could interfere with the drainage outflow tracts resulting in secondary mucous retention, mucocele formation and bacterial superinfection. Despite appropriate antibiotic treatment, symptoms could relapse as foreign bodies could remain a nidus of infection and biofilms could develop preventing long lasting response to antibiotics and relapse of acute exacerbation [ , ]. Retained fragments of non-fatal Gunshots to the head area are often embedded in bone, and seldom cause recurrent infections [ ]. In this case, we present a patient with previous gunshot wound (GSW) with retained bullet fragments in the skull base for which no intervention was originally recommended as it was close to the carotid artery. The foreign body caused recurrent sinus infections, which were treated with repeat antibiotic treatments for over three decades. Upon review of imaging and nasal endoscopy, it was thought that removal of the largest fragment likely causing the chronic infection was not unreasonably risky. Surgery offered the patient resolution of his symptoms, and in retrospect could have spared him numerous courses of antibiotics and significant impact of his sinonasal symptoms on his quality of life.


Case presentation


The patient is a 49-year-old male who was a victim of a GSW in 1986 requiring facial nerve and maxillofacial surgery. He underwent reconstructive surgery for his fractures but remained with several fragments of retained metallic foreign bodies in his craniofacial skeleton. Since the early period following accident as a teenager, he reported having suffered recurrent sinus infections over the years, with increasing frequency. He reported having 7 sinus infections in 6 years, 3 of which required antibiotics. The patient received recommendations against surgery because the risk of removing the retained bullet fragment was presumed to be greater than the benefit he would gain, mostly due to proximity to critical anatomical structures, specifically the carotid artery.


The patient presented to us after being referred from his otolaryngologist with complaints of intermittent thick mucous secretions expelled through the nose and throat as well as chronic sinus pressure and facial pain, consistent with CRS. He had received several rounds of antibiotics with limited improvement in the months preceding his visit. Computerized tomography (CT) scan revealed multiple metallic FB fragments along the course of the bullet that appeared to have traveled through the cheek on the left side, along the lateral wall of the maxillary sinus, and ended in the nasopharynx with multiple metallic fragments in the skull base ( Fig. 1 C). Coronal cuts ( Fig. 1 D) showed a defect in the lateral wall of the maxillary sinus connecting with the cavity. The bullet was lodged in the left aspect of the sphenoid bone under the nasopharyngeal mucosa. Nasal endoscopy confirmed the presence of mucosal inflammation and discolored secretions in the left sphenoethmoidal recess and superior aspect of the choana.




Fig. 1


(A) (B) Nasal endoscopy shows retained bullet in the left sphenoethmoidal recess with underlying purulence. (C) Axial cut shows the trajectory of the bullet through the left cheek along the lateral wall of the maxillary sinus with multiple metallic fragments situated in the skull base. (D) Coronal cut shows the largest retained ballistic fragment resides in the nasopharynx abutting the basisphenoid and clivus with tiny ballistic fragments in the sella turcica and dorsum sella. No evidence of intracranial bullet fragments.

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Jul 5, 2021 | Posted by in OTOLARYNGOLOGY | Comments Off on Chronic sinonasal symptoms due to retained bullet fragments in the skull base
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