A case of a BB-gun pellet injury to the ethmoid sinus in a child

Ear, Nose & Throat Journal,  March, 2004  by Dinesh K. Chhetri,  Nina L. Shapiro

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The initial management of pellet-gun injuries should be undertaken in accordance with institutional trauma guidelines, which include assessments of airway, breathing, and circulation status. Most injuries to the face are nonfatal and nonmutilating, and obtaining a history and performing a physical examination prior to treatment is possible. Although a low-velocity missile causes damage to tissues in immediate contact, it causes minimal damage from shock waves and temporary cavitation. (11) However, in some cases, a missile will ricochet after hitting bone and create secondary missiles from fragmented teeth or bone, thereby causing more injury than would normally be expected. The most common paranasal sinus injuries occur in the maxillary sinus (45% of cases) and the ethmoid sinus (35%). (11) The maxillary sinus is the most common site of missile entrance (60%).

Although plain x-rays of the head (anteroposterior and lateral views) can adequately localize metallic fragments, CT is better suited to fully evaluating the course of a projectile and assessing the damage to surrounding soft tissue and bone. In addition, CT provides essential preoperative anatomic details of the sinuses prior to endoscopic surgery. Angiography should be considered in patients with active bleeding, an enlarging hematoma, absent pulse, bruits, change in neurologic status, or an injury located close to known vascular structures. (11)

There has been some discussion as to whether BB and pellet fragments in the sinuses should be removed. (11-13) The potential complications of retained fragments include lead poisoning, fistula formation, recurrent infections, and secondary hemorrhage. Controversy also exists as to whether retained lead fragments cause a significant increase in blood lead levels. (12) However, because fragments left in the sinuses invariably become a nidus for infection and lead to sinusitis, we and others believe that all fragments in the sinuses should be removed if removal can be performed safely. (11)

Most foreign-body fragments in the paranasal sinuses can be removed endoscopically. (14,15) Improvements in endoscopic sinus surgery--such as superior illumination, better optical quality of endoscopes, and better instrumentation--have allowed us to perform even complex sinonasal operations endonasally. Open procedures such as Caldwell-Luc surgery and external sphenoethmoidectomy are rarely necessary.

Legislatures in at least 15 states in the United States have enacted some restrictions pertaining to the purchase, use, or possession of BB and pellet guns by minors. (8) However, the high number of injuries among minors clearly indicates that children still have easy access to these deadly weapons. BB guns involved in reported injuries are either owned by the victim or a sibling (39% of cases) or by a friend (32%). (9)

Parental attitudes appear to play a significant role in the high incidence of BB and pellet gun possession and use by minors. (9) Parents who allow their children to own these guns appear to misperceive their potential for injury. (9) Such injuries peak on weekends and during the month of January (just following the Christmas holiday). (8) Most of these children never receive proper training on gun use and safety.