Asymptomatic pellet in the maxillary sinus: Medico-legal perspective

Background

Air guns used for plinking are weapons with a short range. They fire pellets at low velocity which, for this reason, will usually enter the body without causing any immediate life-threatening complications. There have been reports in the scientific literature of air gun pellets becoming lodged in the maxillary sinus as a result of accidental firing.^1–4 Air gun pellets are low-velocity diabolo-shaped projectiles usually made of 95% lead, 2.5% tin, and 2.5% antimony. ⁵ Lead toxicity is a potential side effect of a bullet/pellet lodged in the body.^6,7 As a result, pellet removal is common practice. When lead bullets/pellets are located inside the body in a wet environment, lead intoxication is more common.^6–8 We present a case of an asymptomatic maxillary sinus foreign body (an air gun pellet forgotten by the patient) and discuss the various medico-legal aspects of it in the Nepalese context.

Case report

A 40-year-old man arrived at the emergency department with flu-like symptoms and a severe headache. An anteroposterior and lateral X-ray of the skull (Figure 1) revealed a metallic foreign body that appeared to be an air gun pellet with a flat head (wadcutter type) at the left maxillary sinus immediately beneath the orbit. When questioned, the patient recalled receiving a gunshot wound to his left cheek while cleaning an air gun at his home ten years ago. In this case, the gun was a single-shot air gun with a shooting range of about 25 metres. The patient was then rushed to a nearby medical facility. Because the vision was intact, the bleeding was minimal, and there were no obvious clinical signs and symptoms other than pain, it was assumed that the pellet did not enter the body but had ricocheted and exited. Due to limited resources at the health post, an X-ray examination was not performed. There was no active intervention, and the patient was discharged with a dressing on the injury (the entry wound) and a shot of anti-tetanus immunization. Because the wound healed, the pain subsided, and the patient was symptom-free, he did not seek further medical attention. Every winter, he suffered from flu-like symptoms such as a cold and a runny nose, which he treated himself with over-the-counter antihistamines and anti-cold tablets. He applied for a government health insurance scheme last year, which would cover his medical expenses up to a hundred thousand rupees. As a result, he visited the hospital this year for a thorough medical examination.

OPEN IN VIEWER

Figure 1.

The pellet is seen lodged in the left maxillary sinus (indicated by an arrow).

Discussion

People who have a retained metallic foreign body are at risk of chronic metal toxicity. Kühnel et al., on the other hand, reported a case in which the blood lead level was below the reference value even after five decades of an air gun pellet remaining in the maxillary sinus. ³ In addition to describing their findings, they conducted a brief literature review and cited 14 studies that reported low-velocity gun injuries in the paranasal sinuses. ³ The victims' ages ranged from 1 year to 63 years, and the time the foreign body was present in the body ranged between 1 hour and 34 weeks. ³ There was disagreement on whether the foreign body should be surgically removed or not. ³ There have been accounts of patients with asymptomatic air gun pellets from decades ago, who had normal blood lead concentration, where the pellets were successfully removed.^2,9 Some of the factors considered when removing a foreign body from a paranasal air sinus are the type of foreign body, location of the foreign body, intactness of surrounding structures, degree of damage caused, complications that would arise if not removed, and accessibility of the foreign body for uncomplicated removal. ¹⁰ Sinusitis is a common sequel to an impacted foreign body in the maxillary sinus. ¹¹ Asymptomatic foreign bodies do not need to be removed if they are inert, get walled off by fibrous tissue, and do not pose any threat to human life. ¹² Furthermore, any deliberate attempt to remove it not only carries the risk of complications, but also places a financial burden on the patient. On the other hand, although uncommon, the possibility of chronic lead toxicity, chronic sinusitis, rhinolith and lead-induced cancer are some of the feared side effects of long-term air gun pellets in the maxillary sinus.^3,5,11

In the present case, the pellet was positioned directly below the orbit in the left maxillary sinus. The patient was willing to have the foreign body removed because his insurance plan covered his medical bills. The pellet's placement directly below the delicate orbital floor raised the possibility of a visual deficit following the surgical removal of the foreign body. Adverse medical outcomes are the root factor for mob frenzy environment and vandalism. ¹³ A popular maxim in the ethical practice of medicine is primum non nocere (first do no harm). ¹⁴ The principle of non-maleficence was adopted in the present case. The pellet was not removed.

Possession of a gun without a valid licence is an offence in Nepal. The Nepalese law has not specified the type of gun (which uses fire, compressed air, or spring) and the purpose (for killing, for sound, for a sign, or for plinking), therefore possession of any type of gun is an offence. ¹⁵ Despite this there are still guns kept in illegal possession, especially for trophy hunting. ¹⁶ The gun in the present case was a single-shot air gun with a shooting range of about 25 metres. It was used for plinking (balloon popping) by the patient, which was his source of income. As the gun operates based on a spring action without the need for gunpowder, has a short shooting range, and the pellets are discharged at a low velocity, these guns are overlooked as they do not pose a potential threat to the life of a person.

The present case also highlights the dire state of healthcare facilities in rural Nepal. The patients are treated for symptoms rather than to achieve a cure and it is evident that there is a lack of essential investigation equipment for the diagnosis of a disease or condition and also a lack of proper counselling for the patient to seek medical care at a higher centre. The current case study also illustrates how low-income people are unwilling to pay for medical treatment but may volunteer for investigations when given the opportunity.