Chronic sinonasal symptoms due to retained bullet fragments in the skull base

Intranasal foreign bodies (FB) are a rare cause of chronic rhinosinusitis in adults. This report describes a unique case of bullet fragments embedded in the sphenoid bone and clivus for 34 years after a gunshot wound (GSW) to the face, leading to chronic rhinosinusitis. Recurrent acute infections were managed with antibiotics; however long-term cure required surgical intervention and removal of the largest bullet fragment. Surgery had been avoided on the patient for decades because of the proximity to critical neurovascular structures in the paracentral skull base, more specifically the sphenoid bone and clivus. Conservative endoscopic sinus surgery with left partial posterior ethmoidectomy and left maxillary antrostomy, followed by drilling of the sphenoid bone and clivus was performed to remove the FB. Bacterial cultures of surgical specimens revealed the presence of Proteus Mirabilis. The patient reported complete resolution of symptoms following surgery, which was maintained at six months follow-up. This case presents a patient with a metallic foreign body in the skull base for greater than 30 years. Removal of the retained metallic fragment addressed the patient's symptoms effectively. Despite the risks of the procedure related to the location of the foreign body, this case highlights the importance of addressing foreign bodies as underlying cause of chronic rhinosinusitis-like symptoms. Endonasal sinus surgery primarily for removal of a foreign body, also allows opening sinus outflow tracts and removing chronically infected bone and soft tissue.