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Year : 2021  |  Volume : 7  |  Issue : 3  |  Page : 261-264

Removal of Bullet from Infratemporal Fossa Through Endoscopic Approach

Department of ENT & Head and Neck Surgery, Maulana Azad Medical College, New Delhi, India

Date of Submission31-Mar-2021
Date of Decision13-May-2021
Date of Acceptance26-Jul-2021
Date of Web Publication03-Dec-2021

Correspondence Address:
Dr. Mohamed Riyas Ali
Senior Resident, Department of ENT and Head & Neck Surgery, Maulana Azad Medical College, New Delhi 110002
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mamcjms.mamcjms_33_21

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Head and neck wounds account for a large majority of gunshot and firearm-related injuries. The morbidity and mortality associated with such injuries are high due to the presence of various vital structures in the vicinity, such as trachea, esophagus, carotid and vertebral artery, brachial plexus, and so on. Damage to any of these can lead to devastating results. However, in rare cases, there can be unusual trajectories of the bullet bypassing these structures. Here, we present one such case of a 35-year-old man where the bullet got lodged in the infratemporal fossa and it was successfully removed by trans-maxillary endoscopic approach. Transmaxillary endoscopic approach for infratemporal fossa is a minimally invasive technique with low morbidity, better acceptability, and quicker postoperative recovery than traditional approaches.

Keywords: Bullet, endoscopic, infratemporal fossa

How to cite this article:
Meher R, Wadhwa V, Ali MR, Ahmad S. Removal of Bullet from Infratemporal Fossa Through Endoscopic Approach. MAMC J Med Sci 2021;7:261-4

How to cite this URL:
Meher R, Wadhwa V, Ali MR, Ahmad S. Removal of Bullet from Infratemporal Fossa Through Endoscopic Approach. MAMC J Med Sci [serial online] 2021 [cited 2022 Aug 19];7:261-4. Available from: https://www.mamcjms.in/text.asp?2021/7/3/261/331738

  Introduction Top

Gunshot injuries are known to produce severe morbidity and mortality when the head and neck regions are involved, due to potential damage to vital neurovascular structures.[1] The complex anatomy of the facial skeleton has multiple surgical challenges.[2] Here, we present the successful management of a patient with gunshot injury from a close range with a bullet lodged in the infratemporal fossa (ITF), which was subsequently removed by a minimally invasive trans-maxillary endoscopic approach.

Case Report

A 35-year-old male patient with a history of gunshot injury from a very close range presented to ENT emergency with history of bleeding from wound and loss of consciousness. There was no history of any headache, seizures, vomiting or facial asymmetry.

On examination, a lacerated entry wound 2 × 1 × 1 cm was present over the left zygomatic region with ragged and inverted margins with no active bleeding but no exit wound could be identified [Figure 1]. Visual acuity was within normal limits and extraocular movements were not restricted. Patient had mild trismus and facial nerve function was normal. Nose, ear and oral cavity examination was within normal limits.
Figure 1 Clinical picture showing lacerated wound over the left zygomatic region

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Non Contrast Computed Tomography (NCCT) head with Paranasal Sinuses (PNS) cuts revealed a foreign body in left infratemporal fossa with fracture of left zygomatic arch, greater wing of sphenoid and depressed comminuted fracture of squamosal part of left temporal bone [Figure 2] and [Figure 3]. There was also an adjacent extra cranial hyperdensity in left temporal region suggestive of minimal extradural haemorrhage and mild hyperdensity in left Sylvian fissure and sulci suggestive of subarachnoid haemorrhage.
Figure 2 Coronal CT showing the location of the bullet in the left infratemporal fossa

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Figure 3 Axial CT showing the location of the bullet

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The patient was consequently evaluated by neurosurgeons and was managed conservatively.

The patient complained of mild periorbital oedema on day 2 of hospital stay and was taken up for surgery of day 4. The bullet was removed by trans maxillary endoscopic approach under general anaesthesia. An incision was given in left gingivolabial sulcus from lateral incisor to the second molar and the maxillary sinus was entered after creating an antrostomy in the canine fossa [Figure 4]. Next, a zero-degree nasal endoscope with cameral attachment was introduced through the opening to visualize the posterior wall of the maxillary sinus. The bony posterior wall and lateral wall was removed endoscopically using Freers elevator, Kerrison’s bone punch and mastoid drill. The infratemporal fossa was thus exposed and the fat and soft tissue there was dissected carefully to expose the bullet [Figure 5]. A bullet measuring around 3 cm × 1 cm was identified in the infratemporal fossa [Figure 6]. The bullet was removed gently using a Blakesley forceps through the canine fossa. Haemostasis was achieved. Entry wound at the left zygomatic region was sutured after debridement. The patient made uneventful recovery in the postoperative period.
Figure 4 Intraoperative image of canine fossa bony window

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Figure 5 Intraoperative endoscopic view of the bullet

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Figure 6 Bullet after removal

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  Discussion Top

Firearm injuries in the head and neck have a potential for fatal complications and in cases where the damage is not fatal, the bullet may still retain enough energy to penetrate the tissue and travel in a nonlinear trajectory.[1]

A bullet’s ability to wound is directly related to its kinetic energy at the moment of impact. Tissue damage produced by high-velocity bullets is disproportionately higher than a bullet of ordinary muscle velocity. Tissue density and hydrostatic forces are other factors determining the severity of the injury. The greater the tissue density, the greater is the energy discharged by the bullet passing through it, and consequently, the greater is the damage. Hydrostatic forces, for example, in fluid-filled hollow organs cause extensive destruction due to excessive displacement of fluid in all directions.[3] Moreover, the larger size of the bullet was a significant factor associated with an increased risk of the retained ballistic fragment in a study conducted by Vorrasi.[4]

Many unusual routes of bullets have been described. A bullet entering from the right posterior scapular region and leaving the body from the right orbit through the eye with no vital structure damage is described.[5] In another case report, the bullet entered near the right lateral alar cartilage of the nose, descended through, and ended up in the left side of the neck.[6]

In the present case, the bullet entered through the left side of the face; then after fracturing the zygomatic arch it hit over the squamous part of the temporal bone and got deflected downward to finally lodge in the ITF.

In the late 19th century, surgical care for gunshot wounds to the cranium was based upon the depth and involved finding the bullet, controlling the bleeding, and preventing further injury.[7] Presently, retained bullet/fragments in the head and neck can either be removed endoscopically or by an open approach.[8]

Endoscopes in ENT facilitate accessing lumens and sites with minimally invasive surgical exposure. The advantage of endoscopy is obvious as it does not damage the surrounding tissues thus decreasing surgical complications.[8] Endoscopic techniques have gained acceptance for foreign body removal because of lesser morbidity and increased magnification allowing for removal of smaller impacted foreign bodies that would have otherwise remained in situ.

The ITF can be a difficult area to access as it is situated deep in the face. Traditional surgical approaches to ITF include lateral transtemporal and preauricular approaches and anterior transfacial approaches, all associated with morbidity and complications such as facial edema.

The lateral approach involves dissection of the parotid gland and involves the risk of injury to the facial nerve. The anterior approach involves facial incision and lip split for the elevation of facial flap and removal of anterior, posterior, and medial maxillary sinus walls to reach ITF.[9]

In the above case, given the location of the bullet in the ITF, a minimally invasive endoscopic approach was considered. This avoided the external incision and morbidity associated with an open approach. In a similar case report, a bullet in the maxillary antrum and ITF was removed safely by a combination of sublabial antrotomy with an endoscopic approach.[10]

  Conclusion Top

The ITF is an anatomically complex retromaxillary space containing major structures such as the internal carotid and maxillary artery, pterygoid plexus, and trigeminal nerve branches. Endoscopy is an option to be considered in selected cases of foreign bodies and benign tumors located in areas like the ITF. Transmaxillary endoscopic approach is a minimally invasive technique with low morbidity and better acceptability and quicker postoperative recovery than traditional approaches. The limitations of the endoscopic approach are that it has a higher learning curve and the endoscopic equipment is not always available.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Can M, Yildirim N, Ataç GK. Dissecting firearm injury to the head and neck with non-linear bullet trajectory: a case report. Forensic Sci Int 2010;197:13-7.  Back to cited text no. 1
Vatsyayan A, Adhyapok AK, Debnath SC, Malik K. Reconstruction and rehabilitation of short-range gunshot injury to lower part of face: a systematic approach of three cases. Chin J Traumatol 2016;19:239-43.  Back to cited text no. 2
Reddy KS Narayan, Murty OP. The Essentials of Forensic Medicine and Toxicology. 33rd ed. New Delhi, India: Jaypee Brothers Medical Publishers 2014. p. 215-6.  Back to cited text no. 3
Vorrasi J, Calvi R, Lv M, Hammond R. What factors necessitate removal of retained ballistic fragments in the head and neck?. J Oral Maxillofac Surg 2018;76:819-25.  Back to cited text no. 4
Biler ED, Onay MP, Ceylan N, Ceper BY. Unusual route of a bullet: from scapula to eye. Indian J Ophthalmol 2017;65:52.  Back to cited text no. 5
[PUBMED]  [Full text]  
Bayram A, Kaya A, Kalkan M, Özcan I, Mutlu C. An unusual bullet trajectory: entered through the face and ended up in the neck. J Craniofac Surg 2017;28:e636-7.  Back to cited text no. 6
Protas M, Yilmaz E, Patel AP, Iwanaga J, Oskouian RJ, Tubbs RS. Review of treatment of gunshot wounds to head in late 19th century. World Neurosurg 2018;116:396-401.  Back to cited text no. 7
Li Q, Jiang Z, Zhuo X, Zhang X. Endoscopic removal of bullets from the cranial ridge junction region via transoral and transnasal approaches: two case reports and review of literature. Medicine 2016;95(24).  Back to cited text no. 8
Neff LL, Liess BD, Chang CD. Transoral endoscopic removal of a bullet from the infratemporal fossa. Otolaryngol Head Neck Surg 2008;138:113-4.  Back to cited text no. 9
Goswami S. A bullet in the maxillary antrum and infratemporal fossa. Indian J Dental Res 2013;24(1):149.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]


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