Computed tomography navigation combined with endoscope guidance for the removal of projectiles in the maxillofacial area: a study of 24 patients


The aim of this study was to review recent records on the removal of projectiles in the maxillofacial area from patients with firearm wounds, and to summarize our experience in the use of computed tomography (CT) navigation combined with an endoscope in the treatment of these patients. Twenty-four patients injured by firearms and with projectile retention were identified. For surgical planning and intraoperative navigation, an iCT system integrating navigation with intraoperative CT scanning (iPlan) and an electronic endoscope were used. The records of the 24 patients were reviewed retrospectively. All projectiles in these cases were accessed and removed with CT navigation combined with endoscope guidance; no major complications occurred and the surgery time was reduced compared to conventional procedures. Additional incisions were used in 10 patients; removal of the retained projectile through the original wound is not appropriate in certain cases. There was no excessive intraoperative bleeding except in one case, and no patient experienced postoperative bleeding. In 29.2% of cases, the foreign projectiles involved occupied more than one space. CT navigation combined with endoscope guidance is a useful method for removing most projectiles retained in the maxillofacial and neck area.

In China, there has been a noticeable and substantial increase in firearm injuries to the maxillofacial area in recent years. Most of the firearm injuries treated in our department during the past 4 years have involved oral and maxillofacial wounds with retention of irregular fragments from low or middle velocity projectiles. These include small round projectiles made of iron or steel, lead shotgun pellets, and even sand. Projectile retention often leads to severe complications, such as foreign body reaction, secondary infections, and acquired defects, and has an aesthetic, functional, and/or psychological impact on the patient’s life. Knowing when and how to remove the fragments is essential to a successful procedure in the treatment of oral and maxillofacial firearm wounds.

Computed tomography (CT) navigation-assisted surgical procedures have provided an alternative for the surgical removal of metal fragments in oral and maxillofacial shotgun wounds. In recent years, the number of patients seen in our hospital with injuries to the maxillofacial area caused by automatic firearms, involving projectiles such as steel balls and lead bullets, has increased steadily. As a result of the poor penetration of these bullets, they are often retained in the maxillofacial soft tissue and bone. The treatment of this type of firearm injury has often been difficult and complicated when the operation has been performed with the use of traditional imaging modalities, including X-ray, ultrasound, and bar magnets, etc.

In this study, 24 patients suffering from projectile retention in the maxillofacial area were treated surgically under CT navigation combined with endoscope guidance. CT navigation combined with an endoscope for the removal of projectiles in the maxillofacial area can be carried out safely and accurately.

Patients and methods

Only patients who fulfilled all of the following criteria were included in this study: (1) The patient had experienced a firearm injury from a gun or explosion, etc. (2) The patient required a surgical procedure to remove the retained projectiles. (3) The retained projectiles could be detected by X-ray. (4) The patient presented to the hospital between January 2009 and September 2013 (the CT navigation system was introduced in the hospital in 2007; this method replaced the previous use of two X-ray machines). (5) The patient provided written informed consent to be included in the study.

Patients with retained projectiles in the craniocerebral area and thoracic cavity were excluded.

Of the 24 patients, 22 (91.7%) were male and two (8.3%) were female; the male-to-female ratio was 11:1. The mean patient age was 25.8 years (±15.5; range 17–39 years). The types of projectile retained in the face and neck region included, among others, iron balls, steel balls, and lead bullets, as shown in Table 1 .

Table 1
Detailed information of the 24 patients with firearm injuries.
No. Sex Age, years Intraoperative blood loss, ml Position Type Duration of surgery, min Results Year
1 Male 28 200 Skull base Five iron balls 197 Normal 2009
2 Male 20 150 Posterior wall of the maxillary sinus Copper bullets 81 Infection 2010
3 Male 18 120 The mandibular ramus Lead bullets 78 Normal 2012
4 Male 21 90 The anterior maxillary sinus Steel ball 64 Normal 2012
5 Male 19 20 Parapharyngeal Iron ball 23 Normal 2011
6 Male 25 30 Orbital wall Copper bullets 31 Normal 2013
7 Male 27 40 Inferior orbital rim Lead bullets 39 Normal 2009
8 Male 24 30 Inner maxilla Iron ball 45 Normal 2011
9 Male 35 50 Buccal space Steel ball 47 Normal 2013
10 Male 23 80 Skull base Copper bullets 59 Normal 2012
11 Male 21 40 The maxillary sinus Steel ball 51 Normal 2013
12 Male 30 30 Suborbital space Lead bullets 35 Normal 2010
13 Female 38 80 The trailing edge of the mandibular ramus Steel ball 69 Normal 2010
14 Male 26 60 Infratemporal fossa Steel ball 52 Normal 2013
15 Male 28 20 Chin muscle Sand 24 Normal 2013
16 Male 27 50 In front of the cervical vertebra Lead bullets 54 Normal 2011
17 Male 19 70 Pterygomandibular gap Steel ball 65 Normal 2013
18 Male 39 70 Nasal septum Lead bullets 44 Normal 2012
19 Female 22 30 Ethmoid Other 37 Normal 2013
20 Male 29 50 Posterior wall of the maxillary sinus Steel ball 51 Normal 2013
21 Male 21 70 Skull base Lead bullet 64 Normal 2013
22 Male 17 50 The surface of the mandible Glass 45 Normal 2011
23 Male 33 40 Skull base Steel ball 55 Normal 2013
24 Male 28 50 Anterior wall of the maxillary sinus Iron ball 48 Normal 2013
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Jan 17, 2018 | Posted by in Oral and Maxillofacial Surgery | Comments Off on Computed tomography navigation combined with endoscope guidance for the removal of projectiles in the maxillofacial area: a study of 24 patients
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