# Lead Airgun Projectiles Inside the Maximly
## 4 Discussion
### Treatment  
There are known cases of many years of foreign bodies remaining within the maxillary sinuses [16; 25; 26]. The apparently asymptomatic presence of foreign bodies in the maxillary sinus, however, results in a local inflammatory reaction and the risk of poisoning in the case of toxic materials [16; 26; 27; 28]. The lead penetration into the blood may depend on the type and location of the pellet and in the case of the maxillary sinus, we may consider the location to be favorable, allowing the separation of the foreign body with the inflamed mucosa [16; 27; 28]. According to [PERSON] et al., lead poisoning symptoms are nonspecific, such as anorexia, vomiting, weight loss and renal toxicity [29]. The same authors indicate that chronic body exposure to low doses of lead can cause behavioral changes, low height and weight gain in childhood [29]. However, [PERSON] et al. also believe that retained pellets are a rare cause of lead poisoning [29]. Among a group of 23 children who were wounded by a gunshot and afterwards examined by these researchers there was no evidence of lead poisoning [29]. As stated in a case report by [PERSON] et al., a blood test showed the lead level of 80 mg/L in a patient who was shot 50 years earlier, whereas the reference value is up to 90 mg/L [16]. [PERSON] et al. explained the lack of symptoms of lead poisoning in a blood test by the lack of contact of the bullet with the tissue fluid [16]. Thus, it can be assumed that the location of the projectile inside the maxillary sinus is advantageous in terms of avoiding intoxication.  
[PERSON] et al. are of the opinion that lead poisoning from a bullet left in the body is a rare but occurring complication [30]. Other authors believe that metallic foreign bodies such as airgun pellets gradually become surrounded by fibrous tissue and inert to the body [28]. Nevertheless, a pellet left in the body can cause foreign body reaction [27]. On the one hand, there have been reported many serious effects of pellets in the paranasal sinus such as chronic sinusitis, formation of rhinolith and persistent pain [14; 15; 31]. On the other hand, there are also reports of foreign bodies being present without sequelae [16; 24; 32; 33].  
The decision to remove a foreign body can therefore be a topic of discussion. According to the assessment of [PERSON] et al., based on the analysis of gunshots of the paranasal sinuses and the base of the skull, metal foreign bodies should be removed when surgical treatment is safe and the presence of a foreign body creates a risk of infection [31]. These authors consider the proximity of mucosa to a foreign body to be a risk factor for infection, as is the case in the cases analyzed in this systematic review [31]. The guidelines of [PERSON] et al. in each case of a penetrating midface injury suggest a procedure to allow for the surgical removal of the foreign body [4]. In the case of small foreign bodies within the maxillary sinuses, access through the wound or intentional artotomy carried out in an endoscopic or conventional manner should always be considered [16; 31; 34].  
With such assumptions, it should be considered that metallic foreign bodies from the area of the maxillary sinuses should be removed when the general health of the patients allows it [4; 31; 34].  
In case of a foreign body within the maxillary sinus, a simple method may be the Caldwell-Luc approach, causing minimal complications and a short hospital stay [13]. Nevertheless, according to some authors, most foreign bodies located in the maxillary sinus can be removed by endoscopic antrostomy [14; 34; 35]. [PERSON] et al. believe that the antrostomy method is the preferred method of removing only foreign bodies embedded anteriorly or of large dimensions from maxillary sinuses [14]. According to the case reports analyzed in this systematic review, the results of endoscopic and non-endoscopic treatments are equally effective in terms of the absence of intra- and postoperative complications [12; 13; 14; 15; 16].