Air gun pellet remaining in the maxillary sinus for 50 years: a relevant risk factor for the patient?

Abstract

The authors report the case of a 62-year-old man referred to the department of oral and maxillofacial surgery because of a clinical suspicion of palate carcinoma. Incidentally, diagnostic radiology showed a metallic foreign body in the left maxillary sinus. Anamnestic data revealed that a shot from an air gun accidentally hit the patient’s left cheek in 1957. The lead-containing air gun pellet was removed by endoscopic antrostomy and the diagnosis of squamous cell carcinoma was confirmed by histopathological examination. 50 years after the pellet’s impact, toxicological blood analysis showed no increased blood lead level. It remains unclear whether the air gun pellet has a potential toxicological effect or is related to the development of the patient’s oral carcinoma. In this context the article reviews the literature and discusses the necessity of removing metal-containing foreign bodies, the role of lead in chronic toxicity and its possible carcinogenic effect in humans.

Foreign bodies in the paranasal sinuses are rare. Typically, air gun injuries occur in adolescent males . Most are associated with trauma in the maxillofacial region followed by dislodgement of teeth or surgical intervention for dental problems . Infrequently, gunshot injuries are responsible for foreign particles in the paranasal sinuses. Maxillofacial gunshot injuries are rare and generally presented in case reports ( Table 1 ). Air gun pellet injury may cause major damage to soft tissue or bone or other severe problems. Some metals, embedded in body tissue, can be a source of potential exposure to toxic effects . Little is known about the health effects of lead-containing air gun pellets after internalisation in body cavities. There is ambiguity in the literature about whether to remove metal-containing foreign bodies, particularly air gun pellets, or to leave them in situ. Microinvasive techniques (e.g. endoscopy) have reduced the surgical stress and comorbidity of surgical intervention, so the decision to remove foreign bodies is now made earlier and more often. The aim should be the prevention of long-term sequelae for the patient.

Table 1
Summary of reports on low-velocity gun injuries in paranasal sinuses.
References Age/gender Type of pellet Sinus Signs of infection, toxicity, tumor Surgical approach Period in situ Outcome
Ogale et al. 3 year/female air gun sphenoid chemosis, eye congestion transnasal unknown uneventful
Murthy et al. 1 year/male air gun ethmoid Unknown endoscopic failed/extern.ethmoidectomy unknown uneventful
ÓConnell et al. 1. 12 year/male air gun 1. maxillary Unknown 1. Caldwell.Luc unknown 1. uneventful
2. 16 year/male 2. maxillary 2. Caldwell.Luc 2. unknown
3. 14 year/male 3. sphenoid 3. transethmoidal 3. eye damage
Lubianca Neto et al. 15 year/female air gun dart ethmoid/sphenoid visual problems, ocular pain no removal 34 months moderate visual loss
Mahajan and Shah 6 year/female air gun maxillary asymptomatic sinusitis no removal unknown chronic sinusitis
Strek et al. 15 year/male air gun sphenoid endoscopic uneventful
Badran et al. 17 year/male air gun ethmoid brief epistaxis endoscopic 1-2 hours uneventful
Hyckel et al. unknown air gun maxillary Unknown endoscopic unknown unknown
Cohen et al. unknown low-velocity maxillary 2 cases Unknown unknown unknown unknown
Chhetri and Shapiro 10 year/female BB gun ethmoid Unknown endoscopic unknown unknown
Akhtar et al. 41 year/male missile sphenoid Unknown transmaxillary unknown unknown
Lee et al. 6-63year/ low-velocity maxillary:27 vascular injuries:4 removed:16 unknown death:3
33male,2female ethmoid:20 ocular injuries not removed:5 eye injury:9 (blindness:3)
frontal:6 unknown:14 nerve injury:15
sphenoid:5 sinusitis:4
Brinson et al. 1. 8 year/female air gun 1. maxillary 1. hypesthesia 1. endoscopic 1. 2 weeks 1. uneventful
2. 15 year/male BB gun 2. ethmoid 2. headache, 2. antrostomy, 2. 3 weeks 2. uneventful
3. 8 year/male BB gun 3. sphenoid epistaxis ethmoidectomy, 3. several 3. enucleation
3. no light sphenoid sinustomy, weeks
perception, stereotactic guidance
headache 3. sphenoidotomy,
stereotactic guidance
Donald and Gadre 19 year/female air gun ethmoid neuralgia-like symptoms endoscopic unknown uneventful
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Feb 8, 2018 | Posted by in Oral and Maxillofacial Surgery | Comments Off on Air gun pellet remaining in the maxillary sinus for 50 years: a relevant risk factor for the patient?
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