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 .
|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|
|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|
|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|
|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|