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

Abstract

Injuries caused by BB and pellet guns remain common among children. These guns fire low-velocity missiles that can cause considerable harm when fired at close range. Most injuries occur in adolescents as a result of accidental or careless shooting. Such injuries to head and neck sites are common, second only to injuries to the extremities. We report the case of a 10-year-old girl who was accidentally shot by a BB gun. The BB pierced the skin of her right cheek, traversed the right maxillary sinus walls, and lodged at the junction of the right ethmoid sinus and septum. Preoperative radiology combined with endoscopic surgery techniques and instrumentation allowed us to precisely locate and remove the steel ball from the paranasal sinus while the patient was under general anesthesia. We review the scope of maxillofacial injuries caused by BB and pellet guns, and we discuss their presentation, diagnosis, and management. Although these guns are easily bought and sold as toys, they are weapons capable of causing significant injury.

Introduction

BB and pellet guns use compressed air or gas to propel steel balls or lead pellets. These guns can be bought without a permit in all but a few states in the United States. The advent of the Internet has further facilitated the purchase of such guns, even in states with restrictive laws, and e-commerce has virtually brought the gun shop to the consumer's doorstep. An estimated 3.2 million BB and pellet guns are sold in the United States each year. (1,2)

Although most BB and pellet guns fire low-velocity missiles (muzzle velocity: <1,000 feet per second [fps]), they are still fast enough to penetrate the cranium, abdomen, thorax, and paranasal sinuses. (2-6) Approximately 80% of these weapons have muzzle velocities greater than 350 fps, and 50% have velocities of 500 to 930 fps. (1) A pellet velocity of only 150 fps is necessary to penetrate human skin, and a velocity of only 200 fps is necessary to fracture bone. (7)

It is not surprising, therefore, that such gun-related injuries cause a significant amount of morbidity, especially among children. Each year in the United States, an estimated 30,000 persons are treated in hospital emergency departments for BB and pellet gun-related injuries. (8) Approximately 90% of these injuries are inflicted on children by children) Injuries to the head and neck account for 31% of all cases. (1) Hospitalization is required in 5 to 6.5% of these injuries). (1,8)

In this article, we describe our management of a typical case of BB-gun injury to the paranasal sinuses. We also discuss the significant destructive potential of BB and pellet guns.

Case report

A 10-year-old girl had been playing with her male cousin when the boy accidentally shot her with a BB gun. The ball penetrated the skin just below the right zygomatic arch overlying the coronoid process of the mandible. She was brought to the emergency department. Plain x-ray revealed that an intact BB was lodged in her skull at the junction of the fight ethmoid sinus and septum (figure 1). The ball had traversed the skin of the cheek, both walls of the maxillary sinus (narrowly missing the orbital floor), and the right ethmoid sinus. Computed tomography (CT) demonstrated that the orbital floor was intact and that the injury was limited to the paranasal sinuses (figure 2). An air-fluid level was present in the right maxillary sinus.

[FIGURES 1-2 OMITTED]

On examination in our clinic, the patient indicated that she had mild bifrontal headache and nasal congestion. There was no evidence of mental status changes, cerebrospinal fluid (CSF) rhinorrhea, or epistaxis. Findings on examination of the eyes, ears, and oral cavity were normal.

The BB could not be visualized on flexible fiberoptic nasopharyngoscopy, and the patient was taken to the operating room nonemergently to have the ball removed under endoscopic guidance and general anesthesia. After the nasal cavity was vasoconstricted with oxymetazoline-soaked cottonoids, the right nasal cavity was examined with a 0[degrees] endoscope. The BB was located in the right posterior ethmoid sinus in the posterosuperior nasal cavity. It was removed intact and without complication. Mild granulation tissue was present where the BB had become lodged, and further examination of the nasal cavity detected no retained fragments.

The patient was discharged home the same day. Her postoperative course was uneventful, and she exhibited no evidence of CSF rhinorrhea or other complications on follow-up.

Discussion

This case is typical of most BB- and pellet-gun injuries. Almost all (80 to 90%) occur in persons younger than 19 years of age, and 50% occur in children aged 10 to 14 years. (1,8) Both victims and shooters are typically male (90% of cases), and most of these injuries occur while the children are playing unsupervised (90%) at home (60 to 75%). (9,10) Most shootings are accidental (60 to 75%), and in almost all instances they are self-inflicted or inflicted by a close relative or friend in the same age group as the victim. (8-10) The head or neck is involved in one third of cases. (1-8) Most victims (64%) are taken to an emergency department in a private vehicle; as many as 8% are transported by emergency medical services. Hospitalization is required for 5 to 6.5% of patients, particularly those who have incurred an ocular injury. (1,8)

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.

Although BB- and pellet-gun injuries are associated with low mortality, patient morbidity and the cost to society are high. Any significant decline in the incidence of these injuries may come about only after legislatures enact restrictions comparable to those that apply to standard firearms and after both parents and children become adequately educated on the potential dangers of BB and pellet guns.

References

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(9.) Damore DT, Ramundo ML, Hanna JP, Dayan PS. Parental attitudes toward BB and pellet guns. Clin Pediatr (Phila) 2000;39: 281-4.

(10.) Schein OD, Enger C, Tielsch JM. The context and consequences of ocular injuries from air guns. Am J Ophthalmol 1994:117: 501-6.

(11.) Lee D, Nash M, Turk J. Har-El G. Low velocity gunshot wounds Co the paranasal sinuses. Otolaryngol Head Neck Surg 1997;116: 372-8.

(12.) Lubianca Neto JF, Mauri M, Machado JR, et al. Air gun dart injury in paranasal sinuses left alone, Int J Pediar Otorhinolaryngol 2000;52:173-6

(13.) O'Connell JE, Turner NO, Pahor AL. all gun pellets in the sinuses. J Laryngol Otol 1995;109:1097-1100.

(14.) LaFrentz JR, Mair EA, Casler JD. Craniofacial ballpoint pen injury; Endoscopic managemennt. Ann Otol Rhinol Laryngol 2000; 109:119-22.

(15.) Wu MR. Shih CT, Yeh CW Transorbital penetrating injury of the paranasal sinuses. J Laryngol Otol 1998;112:1202-4.

>From the Division of Head and Neck Surgery, Department of Surgery, School of Medicine, University of California at Los Angeles.

Reprint requests: Nina L. Shapiro, MD, 62-132 CHS, Head and Neck Surgery, Mail Code 162418, UCLA School of Medicine, Los Angeles, CA 90095. Phone: [phone]; fax: [phone]; e-mail: [e-mail]

Originally presented at the annual meeting of the Society for Ear, Nose, and Throat Advances in Children (SENTAC); Nov. 29-Dec. 2, 2001; San Diego.