Skip to main content

Orbito-Cranial Gunshot Injuries with Retained Sinonasal Bullets



Gunshot injuries to the sino-orbital region are rare. In South Africa, where gunshot injuries are common, sino-orbital gunshot injuries are encountered. Sino-orbital gunshot injuries are associated with trauma to surrounding facial and intracranial structures. Therefore, the management of these injuries may be complex and often requires an interdisciplinary approach.


To review the management of orbito-cranial gunshot injuries with retained sinonasal bullets.

Patients and methods

Three cases of orbito-cranial gunshot injuries with retained sinonasal bullets were reviewed. Two cases were complicated by cerebrospinal fluid leaks with ensuing meningitis. The retained bullets in all three cases were successfully removed via a transnasal endoscopic approach.


Sino-orbital gunshot injuries are rare, but may be encountered in areas with high frequencies of gun violence. An associated anterior skull base fracture with CSF rhinorrhoea poses a risk for meningitis and a low threshold for diagnosis and treatment of meningitis should be maintained. Retained bullets in the paranasal sinuses do not pose an immediate risk and may be removed on an elective basis.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3


  1. Collaborators TGB of D 2016 I. (2016) Global mortality from firearms, 1990–2016. JAMA. 320(8):792–814.

    Article  Google Scholar 

  2. Fowler KA, Dahlberg LL, Haileyesus T, Annest JL (2015) Firearm injuries in the United States. Prev Med (Baltim) 79:5–14.

    Article  Google Scholar 

  3. Blissitt PA (2006) Care of the critically Ill patient with penetrating head injury. Crit Care Nurs Clin North Am 18(3):321–332.

    Article  PubMed  Google Scholar 

  4. Bowen DI, Magauran DM (1973) Ocular injuries caused by airgun pellets: an analysis of 105 cases. Br Med J 1(5849):333–337

    Article  CAS  Google Scholar 

  5. Semple P, Domingo Z (2001) Craniocerebral gunshot injuries in South Africa—a suggested management strategy. South African Med J 91(2):141–145

    CAS  Google Scholar 

  6. Rosenfeld JV (2002) Gunshot injury to the head and spine. J Clin Neurosci 9(1):9–16

    Article  Google Scholar 

  7. Martins RS, Siqueira MG, Santos MTS, Zanon-Collange N, Moraes OJS (2003) Prognostic factors and treatment of penetrating gunshot wounds to the head. Surg Neurol 60(2):98–104.

    Article  PubMed  Google Scholar 

  8. Kuhn F, Morris R, Witherspoon CD, Heimann K, Jeffers JB, Treister G (1996) A standardized classification of ocular trauma. Ophthalmology 103(2):240–243.

    Article  CAS  PubMed  Google Scholar 

  9. Pieramici DJ, Sternberg PJ, Aaberg S et al (1997) A system for classifying mechanical injuries of the eye (globe). Am J Ophthalmol 123(6):820–831.

    Article  CAS  PubMed  Google Scholar 

  10. Sobaci G, Mutlu FM, Bayer A, Karagül S, Yildirim E (2000) Deadly weapon-related open-globe injuries: outcome assessment by the Ocular Trauma classification system. Am J Ophthalmol 129(1):47–53.

    Article  CAS  PubMed  Google Scholar 

  11. Bodanapally UK, Sours C, Zhuo J, Shanmuganathan K (2015) Imaging of Traumatic brain injury. Radiol Clin North Am 53(4):695–715.

    Article  PubMed  Google Scholar 

  12. Currie S, Saleem N, Straiton JA, Macmullen-Price J, Warren DJ, Craven IJ (2016) Imaging assessment of traumatic brain injury. Postgrad Med J 92(1083):41–50

    Article  Google Scholar 

  13. Dedini RD, Karacozoff AM, Shellock FG, Xu D, Mcclellan RT, Pekmezci M (2013) MRI issues for ballistic objects: information obtained. Spine J 13(7):815–822.

    Article  PubMed  Google Scholar 

  14. Dienstknecht T, Horst K, Sellei RM, Berner A, Nerlich M, Hardcastle TC (2012) Indications for bullet removal: overview of the literature, and clinical practice guidelines for European trauma surgeons. Eur J Trauma Emerg Surg 38(2):89–93.

    Article  CAS  PubMed  Google Scholar 

  15. Linden MA, Manton WI, Stewart RM, Thal ER, Feit H (1982) Lead poisoning from retained bullets. Pathogenesis, diagnosis, and management. Ann Surg 195(3):305–313

    Article  CAS  Google Scholar 

  16. de Madureira PR, De Capitani EM, Vieira RJ, Sakuma AM, Toledo AS, Mello SM (2009) Lead poisoning due to gunshot bullet in contact with cerebrospinal fluid: case report. Sao Paulo Med J 127(1):52–54

    Article  Google Scholar 

  17. Ben-David J, Fradis M, Podoshin L, Bartal AH (1981) Plasmacytoma arising in the vicinity of a foreign body in the nasal cavity. Laryngoscope 91(7):1150–1154.

    Article  CAS  PubMed  Google Scholar 

  18. Sifri ZC, Livingston DH, Lavery RF et al (2004) Value of repeat cranial computed axial tomography scanning in patients with minimal head injury. Am J Surg 187(3):338–342

    Article  Google Scholar 

  19. Brinson GM, Senior BA, Yarbrough WG (2004) Endoscopic management of retained airgun projectiles in the paranasal sinuses. Otolaryngol Neck Surg 130(1):25–30.

    Article  Google Scholar 

Download references


No funding was received from the institution or commercial sources.

Author information

Authors and Affiliations


Corresponding author

Correspondence to Gerrit Viljoen.

Ethics declarations

Conflict of interest

All authors declare that they have no conflict of interest.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Viljoen, G., Tromp, S., Goncalves, N. et al. Orbito-Cranial Gunshot Injuries with Retained Sinonasal Bullets. J. Maxillofac. Oral Surg. 20, 551–557 (2021).

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: