Management of Rare Shot Wounds of the Skull Base

Shot wounds of the face and the skull base are rare in German clinics. Thus the clinical experiences with these special injury samples are very small. It is possible to make a distinction between injuries from single projectiles and from multiple projectiles of a shooting with pellets. While projectile injuries were particularly discussed in the military medical literature, there are almost no empiric reports about the treatment of injuries caused by shooting with pellets.

We had two patients with pellets injuries of the face in the last 15 years; we also treated a patient with a shot fracture of the laterobasis. In the radiographs of the first, a female patient with shotgun pellets in the face, we counted 220 projectiles, all in the soft parts of the face and neck, the orbita, and the nose lumen. Because an extirpation of many of the projectiles in the soft tissue was not possible without large aesthetic deficits, we removed only projectiles in the orbita and the paranasal sinuses. The aesthetic result was excellent under serological control of the lead value over 2 years.

A second patient was fired at by a shotgun with pellets. The x-rays showed a projectile in the cranium, in the occipital part of the brain, with a few projectile fragments in the firing channel and also several projectiles and projectile fragments in the facial soft tissue. The neurosurgeons removed the projectile in the brain. The ENT surgeon closed the defect in the skull base.

The last patient had suffered a destruction of the left mastoides by a shot which had torn the nervus facialis. In the further process of the firing channel it passed the A. carotid interna and spinal column and stopped in the oropharynx. Within 24 hours the projectile was removed transorally. Over a mastoidectomy a primary nerve reconstruction with a nervus auricularis magnus transplant was performed.

Shot wounds of the face and the skull base represent a very rare event. While injuries by individual projectiles can be substantial, destroying internal tissues and making an immediate revision and reconstruction necessary, damage by and removal of all projectiles is to be carefully considered in cases of multiple projectile injuries from shootings with pellets. In addition, serological control of the lead value is to be always included.