Transfacial Trans-sphenoidal Gunshot Wound: Endonasal-Endoscopic Management and Duraplasty

Purpose: Gunshot wounds of the skull base and neural tissues have high mortality and morbidity due to the presence of vital structures in this area. Surgical removal of bullet particles and treatment of associated damage can sometimes be quite challenging due to the complexity of reaching the lesion and the close anatomic proximity of foreign bodies to vital structures. The paranasal sinuses provide a natural pathway to the skull base. Today, experience gained in endoscopic sinus surgery and advanced instrumentation enables rhinosurgeons to perform endonasal-endoscopic dura repairs safely with high success rates (95%). This case presents a unique transfacial trans-sphenoidal gunshot wound to the skull base causing traumatic cerebrospinal fluid (CSF) fistula from the sphenoid sinus posterior wall, which was repaired through an endonasal-endoscopic approach.

Method: A 25-year-old man presented with a right-sided massive CSF rhinorrhea after a left transfacial gunshot wound with the bullet inlet inferior to the left epicanthus. Computed tomography (CT) revealed the trace of the bullet starting from the maxilla anterior wall, moving posteroinferomedially to the ethmoids, then to the middle concha and posterior nasal septum with destruction. It then proceeded to the right sphenoid sinus and penetrated through the posterior wall between the right optic nerve, internal carotid artery, and pituitary gland; tearing the dura, it stopped in close anterolateral proximity to the brainstem, which caused left hemiplegia, damage to the fifth and sixth cranial nerves, and CSF rhinorrhea. As neurosurgical removal of a retained bullet from the brainstem posed a high risk of death, it was decided only to close the dural defect and remove bullet particles from the nasal cavity and sinuses.

Results: A minimally invasive endonasal-endoscopic approach was successfully implemented for duraplasty with no associated morbidity or complications. Additionally, sanitation of the damaged sinuses and nasal cavity was accomplished. A watertight dural closure was controlled with beta-2-transferrin test at postoperative 1-month and 1-year follow-ups.

Conclusion: As demonstrated with this unique case, an endonasal-endoscopic approach achieves successful dura repairs along the skull base and also at locations where other approaches would have higher morbidity. With adequate experience and instrumentation this approach provides an easily applicable, yet highly effective standard for CSF rhinorrhea management with practically no complications.