ENT - September 2020 - 505

Rhinoscopic Clinic

Guns n' Noses: Endoscopic Removal
of an Air-Gun Pellet Retained
in the Frontal Sinus

Ear, Nose & Throat Journal
2020, Vol. 99(8) 505-507
ª The Author(s) 2019
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DOI: 10.1177/0145561319850813
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Dylan A. Levy, MBBS1 , Andrew Y. Lee, MD2, Waleed M. Abuzeid, MD2,
and Nadeem A. Akbar, MD2

Endoscopic Foreign Body Removal From
the Frontal Sinus
A 16-year-old male was referred to our clinic for evaluation of
a penetrating foreign body (FB) retained in the right frontal
sinus. Five days earlier, he presented to a community emergency department after sustaining an injury to the right
eyebrow from an air gun (Figure 1). Computed tomography
(CT) scan revealed a metallic FB lodged in the right frontal
sinus recess associated with a nondisplaced fracture of the
frontal sinus anterior table (Figure 2).
Physical examination demonstrated a 4-mm well-healing
lesion at the right inferomedial eyebrow (Figure 1) associated
with a palpable step off just medial to the wound. Both vision
and extraocular muscle movements were intact. In-office nasal
endoscopy with a 30 rigid nasal endoscope did not reveal
evidence of trauma and no FB was visualized. There was no
evidence of cerebrospinal fluid (CSF) leak.
Surgery was performed 9 days later. Under CT guidance, the
right nasal cavity was visualized with a rigid 30 reverse sinus
endoscope. After completing an anterior ethmoidectomy and
frontal sinusotomy, the FB was visualized within the mucosa of
the posterior frontal sinus recess (Figure 3A). Upon further
dissection, the pellet was revealed and measured in situ (Figure
3B). The pellet was then removed successfully (Figure 3C).
The patient was discharged the same day and was doing well
at his 2-week follow-up.
Approximately 2% of penetrating head and neck traumas
result in retained FBs in the sinuses or skull base.1 Air-gun
injuries to the sinuses represent a small proportion of head and
neck penetrating trauma.1 Approximately 60% of air-gun pellets are retained in the tissue that is first struck as they do not
contain enough kinetic energy to penetrate through soft tissue
and bone.2 Reported sequelae of retained FBs in the sinuses
include sinocutaneous fistula, rhinolith formation, chronic
pain, sinusitis, abscess formation, meningitis, epilepsy, and
lead poisoning.3-6
The management of this unique entity is dictated by the
projectile's trajectory and the involved structures. The early
removal of sinus FBs is recommended to avoid detrimental
sequelae and intracranial complications.3,5 The choice of

Figure 1. Small entrance of the air-gun pellet concealed within the
right medial eyebrow.

therapy is influenced by the hemodynamic status of the patient,
the FB location, and the extent of involved anatomy and critical
structures such as the internal carotid artery, optic nerves, and
ethmoidal arteries.2,7,8

1

Frank H. Netter MD School of Medicine, Quinnipiac University, North
Haven, CT, USA
2
Division of Rhinology/Skull Base Surgery, Department of Otorhinolaryngology,
Albert Einstein College of Medicine, Bronx, NY, USA
Received: April 15, 2019; accepted: April 23, 2019
Corresponding Author:
Nadeem A. Akbar, MD, Division of Rhinology/Skull Base Surgery, Department
of Otorhinolaryngology, Albert Einstein College of Medicine, 3500 Bainbridge
Avenue, MAP 3rd Floor, Bronx, NY 10467, USA.
Email: nakbar@montefiore.org
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