Endoscopic Endonasal Removal of a Retained Bullet in the Clivus Following Submental Gunshot Wound

Background: The endoscopic endonasal approach (EEA) has undergone a dramatic transformation from a limited route for pituitary tumors to a versatile corridor for the ventral skull base. While most frequently employed for neoplastic and CSF leak pathologies, its use in penetrating ballistic trauma is rarely reported. Case Description: We report a case of a 43-year-old male patient who sustained a submental self-inflicted gunshot wound resulting in a retained bullet fragment lodged within the clivus. The patient was GCS 14 with intact cranial nerve function and no obvious CSF leak. Emergent airway stabilization was achieved. Imaging demonstrated a bullet fragment embedded within the clivus, just anterior to the basilar venous plexus, without evidence of vascular injury. The decision to remove the bullet fragment was in order to promote nasopharyngeal healing and prevent future complications (e.g. erosion, fistulas, CSF leaks), minimize the risk of lead leaching and poisoning, and to restore MRI compatibility given the patient’s young age. An endoscopic endonasal transsphenoidal approach was performed. A binarial wide sphenoidotomy corridor was established, the clivus was drilled under navigation, and the bullet was removed without vascular or cranial nerve injury. No CSF leak was noted. Reconstruction with a vascularized nasoseptal flap yielded a watertight closure. The patient recovered with no neurological deficits, cerebrospinal fluid leakage, or infectious complications. Conclusion: This case illustrates the feasibility and advantages of the EEA for management of ballistic injuries involving the clivus. The evolution of visualization, instrumentation, and reconstructive techniques has expanded the role of the EEA to include not only tumors and CSF leaks but also select traumatic scenarios. Multidisciplinary expertise, meticulous vascular evaluation, and robust reconstruction remain essential. Publication History Article published online: 27 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany