| Abstract|| |
A young male patient was shot from a revolver on his left temple from a close range, but surprisingly he survived. On imaging, a complete bullet was found occupying his left maxillary sinus and infratemporal fossa. The bullet, after hitting and breaking the neck of the mandible on the left side, ricocheted and entered the left maxillary sinus through its posterior wall. It was removed safely by a combination of sublabial antrotomy and endoscopic approach.
Keywords: Bullet, infratemporal fossa, maxillary sinus, paranasal sinuses
|How to cite this article:|
Goswami S. A bullet in the maxillary antrum and infratemporal fossa. Indian J Dent Res 2013;24:149
In our day-to-day practice, we frequently get patients with lodgment of foreign bodies in the nasal cavities. Sometimes we find foreign bodies in the paranasal sinuses (PNS) as well, but a bullet in the PNS is not common. Sharma et al.  reported a case of wooden foreign body in the periorbita of right eye, extending into the right sphenoid and ethmoidal sinuses. Mathews et al.  reported the base of a wristwatch in the left maxillary sinus and pterygopalatine fossa. Dutta et al.  reported a splinter (part of a bullet) in the right maxillary sinus. In this case, the patient had a complete bullet with its typical shape in the left maxillary sinus and infratemporal fossa. The reason behind reporting this case is its rarity and the surprising fact that the patient survived such a bullet injury in the temple from a close range.
| Case Report|| |
A male patient aged 25 years came to the emergency with the history of a firearm injury on his left temple from a close range. He became unconscious and was admitted in Malda District Hospital, West Bengal. He was treated conservatively there and regained consciousness after a few hours. On the next day, he was referred to N. R. S. Medical College, Kolkata. At first he was admitted under the Department of Surgery for head injury. Subsequently he was transferred to the Department of Otorhinolaryngology.
At the time of examination, the patient was conscious and his general condition was good. He was complaining of pain and swelling on the left cheek, mild nasal obstruction on the left side, and inability to open his mouth completely.
On examination, an entry wound was found in front of the left tragus. It was curved with concavity anteriorly. There was mark of smoked particles surrounding it. No wound of exit was found. There was edema and tenderness over the left cheek. The patient was unable to open his mouth completely. There was extreme tenderness over the temporomandibular joint on the left side.
On anterior rhinoscopy, the lateral wall of the left nasal cavity was found to be edematous and congested, but there was no breach in the mucosa. Blood-stained serosanguinous discharge was coming out from the middle meatus on the left side. Posterior rhinoscopy revealed no abnormality. Nasal airway was reduced on the left side.
On examination of the oral cavity, slight dental malocclusion was found. There was edema over the mucosa of the left cheek and left side of the palate, but the movement of the soft palate was normal. There was no abnormality in the oropharyx, hypopharynx, and larynx.
On examination of the ears, no abnormality was detected. The patient's hearing, smell, and vision were normal. The facial and other cranial nerves were not affected. General examination did not reveal any abnormality.
X-ray of the skull, anteroposterior [Figure 1] and lateral [Figure 2] views, revealed a bullet in the left maxillary sinus and infratemporal fossa. The base of the bullet was occupying the floor of the left maxillary sinus, whereas the tip was in the left infratemporal fossa. The long axis of the bullet was directed backward and outward. The neck of the mandible on the left side was broken. There was no break in the walls of the orbit.
|Figure 1: Preoperative X-ray of the skull anteroposterior view, showing the bullet on the floor of the left maxillary sinus. The major portion of the bullet including its base was inside the left maxillary sinus, whereas the tip was directed posterolaterally, occupying the left infratemporal fossa. The neck of the mandible on the left side was broken|
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|Figure 2: Preoperative X-ray of the skull lateral view, showing the bullet in the left maxillary sinus and infratemporal fossa|
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Computed tomography (CT) scan of the brain, which was done on the day of injury, revealed no intracranial injury. It too revealed the bullet in the left maxillary sinus and infratemporal fossa. But as only axial sections at wide intervals were taken, the quality of the images was not good.
A preoperative diagnostic nasal endoscopy was done under local anesthesia to assess the extent of damage to the soft tissue of the nasal cavities. It revealed no injury of the turbinates or the nasal mucosa. There was blood-stained serosanguinous discharge only in the left middle meatus. The nasopharynx and other structures were normal. However, the left maxillary sinus was not explored in the preoperative nasal endoscopy.
The patient was operated under local anesthesia with anesthesiologists on standby for administering general anesthesia if required. Injections pethidine (100 mg) and promethazine (50 mg) were given intramuscularly half an hour before the operation. The left nasal cavity was packed with 4% lignocaine with 1:30,000 adrenaline solution. Sublabial antrotomy on the left side was done after local infiltration with injection 2% lignocaine with 1:200,000 adrenaline solution. The left maxillary sinus was inspected with nasal endoscopes and was found to be full of necrotic material, which was removed by suction and irrigation. The bullet was found inside the left maxillary sinus. The posterior wall of the left maxilla was broken. The bullet was found to be strongly impacted within the left maxillary sinus. The base of the bullet was found to be lying on the floor of the left maxillary sinus, whereas the tip was directed posterolaterally and was protruding through the hole in the posterior wall of the left maxilla into the left infratemporal fossa. The bullet was carefully disimpacted from the surrounding tissues. It was not possible to remove the bullet through the antrotomy opening by gripping it with forceps without widening the opening to a greater extent which had risks of complications. The base of the bullet was gently mobilized toward the sublabial antrotomy opening with a little bit of difficulty. Once the base was outside the antrotomy opening, it was gripped with forceps and taken out of the maxillary sinus. The maxillary sinus was again inspected with nasal endoscopes. Residual necrotic tissue was removed from the sinus. The medial wall and the roof were found to be normal. The margin of the bony defect in the posterior wall was irregular. It was communicating with the left infratemporal fossa. Necrotic tissue was also removed from the left infratemporal fossa through the defect.
The entry wound in front of the left tragus was explored carefully. Necrotic tissue was removed from the tract. The margin of the wound was freshened and sutured.
The cavity was finally irrigated thoroughly with normal saline. Intranasal antrostomy for packing the maxillary sinus  was avoided. Instead, a small bore polythene tube drain was placed in the antrum and was taken out in between the stitches of the sublabial antrotomy closure. The drain was removed on the next day.
The patient was referred to the dental department for management of the fracture of the neck of the mandible on the left side [Figure 3] and [Figure 4] and was advised surgical treatment for that, but unfortunately he did not give consent. He was having mild difficulty in chewing and some restriction in opening his mouth, but was not bothering much about that. During follow-up, after 6 weeks, it was observed that the patient was having slight restriction in opening his mouth, but there was no significant malocclusion.
|Figure 3: Postoperative X-ray of the skull anteroposterior view. Note the fracture of the neck of the mandible on the left side|
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| Discussion|| |
Foreign bodies in the PNS are not common. They are usually traumatic and in some cases iatrogenic. Out of all foreign bodies in the PNS, about 50%  to 75%  are found in the maxillary sinuses.
Foreign bodies in the PNS include splinters,  gun pellets, woods,  etc., Radio-opaque foreign bodies can easily be detected by X-ray of PNS anteroposterior and lateral views. X-ray of PNS anteroposterior view is better than occiputo-mental view as it helps better in assessing the actual position of the foreign bodies. CT scan and magnetic resonance imaging (MRI) may be necessary in some cases.
Foreign bodies in the PNS should be removed as early as possible. A retained foreign body can lead to sinusitis, cutaneous fistula and foreign body granuloma formation. Metallic foreign bodies may even provoke malignant  transformations. In case of bullet, there may be lead poisoning. 
Sublabial antrotomy or Caldwell-Luc approach is the usual procedure for removal of foreign bodies from maxillary sinuses. This is particularly helpful in case of large or impacted foreign bodies. Bone flap technique  may be helpful in case of a large window in Caldwell-Luc approach. Endoscopic removal,  whenever possible, should be tried as it is associated with lesser morbidity and complications. Small foreign bodies can easily be removed endoscopically. Endoscopic approach has the advantage of better illumination and visualization. Chances of leftover fragments of foreign bodies are minimum in endoscopic approach. A combination of Caldwell-Luc and endoscopic approach is always better in case of a large or impacted foreign body, as in this case.
Mathews et al.  performed intranasal antrostomy for packing the sinus with a medicated ribbon gauze pack. We usually avoid intranasal antrostomy for packing the maxillary sinus as it interferes with the normal mucociliary clearance. Instead, we use a small bore polythene tube drain inside the antrum, which is taken out in between the stitches of sublabial antrotomy closure. In our experience, we found that there is no chance of fistula formation if the drain is removed within 24 hours.
Opinion from an expert in Forensic and State Medicine was sought for. According to him, the bullet [Figure 5] was fired from a rifled firearm from a range of less than 1 foot from the left side. The direction of the bullet was slightly forward and downward in relation to the inter-tragal line. As a result of this, the bullet ricocheted anteroinferiorly after hitting the condyle of the mandible and entered the left maxillary sinus through its posterior wall and the patient survived.
| Conclusion|| |
A variety of foreign bodies ranging from wooden objects to bullets can be found in the PNS. They can vary in size, shape, and location. Sometimes they can be found accidentally. Removal of a foreign body safely from the PNS is often a challenging task to the otolaryngologists. It is very important to know its exact size, shape, and location prior to the operation. Approach and technique of its removal depends upon its size, shape, and location. Use of nasal endoscopes can be very helpful for this purpose.
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Department of E.N.T., Midnapore Medical College, West Bengal
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]