Management of Frontal Sinus Fractures:

Complications of frontal sinus fractures

Frontal sinus fracture represents 5 to 12% of all maxillofacial fractures. Because of the anatomic position of the frontal sinus and the enormous amount of force required to create a fracture in this area, these injuries are often devastating and associated with other trauma. Associated injuries include skull base, intracranial, ophthalmologic, and maxillofacial. Complications should be categorized to address these four areas as well as the skin-soft tissue envelope, muscle, and bone. Other variables that should be examined are age of the patient, gender, mechanism of injury, fracture pattern, method of repair, and associated injuries. Management of frontal sinus fractures is so controversial that the indications, timing, method of repair, and surveillance remain disputable among several surgical specialties. The one universal truth that is agreed upon is that all patients undergoing reconstructive surgery of the frontal sinus have a lifelong risk for delayed complications. It is hoped that when patients do experience the first symptoms of a complication, they seek immediate medical attention and avoid potentially life-threatening situations and the need for crippling or disfiguring surgery. The best way to facilitate this is through long-term follow-up and routine surveillance.

Sinus preservation management for frontal sinus fractures in the endoscopic sinus surgery era: a systematic review

We systematically reviewed the existing literature supporting the efficacy and safety of sinus preservation management for frontal sinus fractures in the modern era of endoscopic frontal sinus surgery. A systematic review of the English literature for the targeted objective was conducted using the PubMed database between January 1995 and August 2008. The PubMed database was queried using two major search terms of frontal sinus fracture or frontal sinus injury along with manual review of citations within bibliographies. Citations acquired from the primary search were filtered and relevant abstracts were identified that merited full review. Articles were identified that included any cohort of patients with frontal sinus fractures involving the frontal sinus outflow tract or posterior wall with sinus preservation management. A total of 231 citations were generated, and 56 abstracts were identified as potentially relevant articles. Sixteen articles merited full review, with seven articles meeting inclusion criteria for sinus preservation. There were 515 total patients in the studies with 350 patients managed with frontal sinus preservation. Similar short-term complications and effectiveness were found between fractures managed with sinus preservation and those with traditional management. Sinus preservation appears to be a safe and effective management strategy for select frontal sinus fractures. More transparent reporting of management strategies for individual cases or cohorts is needed. A standardized algorithm and categorization framework for future studies are proposed. Longer-term follow-up and larger prospective studies are necessary to assess the safety and efficacy of sinus preservation protocols.

Role of the sagittal view of computed tomography in evaluation of the nasofrontal ducts in frontal sinus fractures

PURPOSE

Frontal sinus fractures are relatively uncommon due to the high-impact force required to produce these. However, their management is quite complex, with the treatment algorithm incorporating many factors in which the status of the nasofrontal ducts is critically important. Traditionally, this has been evaluated by both axial and coronal computed tomographic (CT) scan views. Anatomically, we propose that this is better evaluated by coronal and sagittal CT views. We evaluated the role of sagittal CT scan views in determining the status of the nasofrontal ducts in patients with frontal sinus fractures.

METHODS

A retrospective analysis examining 8 patients with frontal sinus fractures, from August 2004 to January 2008, was performed. Axial, coronal, and sagittal CT scan views were obtained routinely as part of the facial trauma workup. These views were assessed to determine the status of the nasofrontal ducts. The operative findings were also reviewed.

RESULTS

Five of the 8 patients had displaced anterior and posterior table frontal sinus fractures. Of these, 4 required surgical intervention that included addressing the nasofrontal ducts. Two of the 8 patients had displaced anterior table fractures that required no intervention of the nasofrontal ducts. One patient had nondisplaced anterior and posterior table fractures and did not require surgery. The sagittal CT view clearly demonstrated the anatomy of the nasofrontal ducts in all 8 patients, including patients in whom the axial and/or coronal views were questionable. Intraoperatively, where the patency of the nasofrontal ducts was directly evaluated, there was a direct correlation with the sagittal image findings.

CONCLUSIONS

The sagittal CT view provides invaluable information for evaluating the patency of the nasofrontal ducts in frontal sinus fractures. The ability to evaluate the frontal sinus in an anteroposterior dimension (the usual vector of the injury) and in a superoinferior dimension (the anatomic pathway of the ducts) is the reason for this imaging advantage.

Aplasia and agenesis of the frontal sinus in Turkish individuals: a retrospective study using dental volumetric tomography

Agenesis of the paranasal sinuses is an uncommon clinical condition that appears mainly in the frontal (12%) and maxillary (5-6%) sinuses; in some populations, it appears at a higher proportion. This study investigated the prevalence of agenesis of the frontal sinuses using dental volumetric tomography (DVT) in Turkish individuals. The frontal sinuses of 410 patients were examined by DVT scans in the coronal planes for evidence of the absence of the frontal sinuses. A bilateral and unilateral absence of the frontal sinuses was seen in 0.73% and 1.22% of cases, respectively. In one case, both agenesis and aplasia of the frontal sinus was seen (0.24%). The low percentage of frontal sinus agenesis must be considered during pre-surgical planning related to the sinuses. DVT may be used as a diagnostic tool for the examination of frontal sinus aplasia.

Modified technique for frontal sinus obliteration using calvarial bone and Tisseel glue

BACKGROUND

Frontal sinus obliteration is indicated in trauma and frontal sinus disease. We present our experience with a modified technique of frontal sinus obliteration.

METHODS

We reviewed the records of 17 patients who underwent frontal sinus obliteration with a combination of Tisseel fibrin glue (Baxter Healthcare Corporation, Deerfield, IL) and calvarial bone and describe our technique.

RESULTS

One female and 16 male patients (mean age, 36.6) underwent frontal sinus obliteration from 2001 to 2005. Traumatic fracture was the most common indication. The patients were followed up for a median of 15 months. There were no major complications. Postoperatively, one patient developed a localized frontal wound infection at 3 weeks; this resolved with debridement. At latest follow-up, all were free from local sinus complications, disease recurrence, headaches, or intracranial events.

CONCLUSIONS

The combined use of autogenous calvarial bone and Tisseel is suitable for frontal sinus obliteration. Our technique is associated with low donor site morbidity, avoids a separate donor surgical site, and has a low complication rate.

Techniques in frontal sinus fracture repair

Constituting only 5 percent of facial fractures, frontal sinus fractures are relatively uncommon. However, given the great amount of force required to produce them, substantial morbidity is often seen. A thorough understanding of corrective techniques is essential when approaching these challenging injuries. In cases requiring sinus obliteration, it is critical that all mucosa be fully destroyed, the nasofrontal meatus completely sealed, and any posterior wall disruptions appropriately addressed. In this article, as a supplement to their video presentation, the authors discuss the surgical approach to frontal sinus fracture.

Definitive treatment of persistent frontal sinus infections: elimination of dead space and sinonasal communication

BACKGROUND

Frontal sinus injury involving nasofrontal outflow tract obstruction is routinely managed by obliteration or cranialization; however, a small percentage of patients develop persistent indolent infections despite routine measures. The authors discuss the course of persistent infection following frontal sinus fractures and propose a novel treatment that definitively obliterates and separates the nasofrontal outflow tract from the cranium in these patients.

METHODS

Seven consecutive patients with persistent indolent infections associated with frontal sinus fractures were identified and treated at the R Adams Cowley Shock Trauma Center and The Johns Hopkins Hospital from 2005 to 2008.

RESULTS

There were three women and four men, with an average age of 41 years. Injury resulted from motor vehicle crashes (n = 4), motorcycle crash (n = 1), fall (n = 1), and other accident (n = 1). All patients were previously treated with conventional techniques (average, 3.6 procedures and 11 years from initial injury) and prolonged antibiotic therapy without resolution of symptoms. Definitive treatment included radical débridement and obliteration with a free fibula flap in a single stage. All flaps survived and resulted in complete sinonasal separation and eradication of infection. There were no donor-site or frontal sinus complications.

CONCLUSIONS

Radical débridement, meticulous removal of the tenacious sinus mucosa, and reconstruction with a free fibular flap in a single stage is a superb choice for eliminating persistent infectious complications associated with frontal sinus fractures in patients who have failed conventional management. The fibular flap provides a secure horizontal buttress, seals the nasofrontal outflow tract with vascularized muscle, and obliterates dead space.

Transcutaneous transfrontal approach through a small peri-eyebrow incision for the reduction of closed anterior table frontal sinus fractures

Transcutaneous or endoscopic approaches are commonly used to reduce closed anterior table frontal sinus fractures. However, transcutaneous approaches cause serious skin sequelae, and endoscopic approaches have a steep learning curve. To resolve these problems, between 2001 and 2008, a transcutaneous transfrontal approach through a small peri-eyebrow skin incision was used in 17 male patients. Postoperative computed tomography scans showed adequate reduction of displaced bone fragments in all cases. No complications related to this procedure, such as uncontrollable sinus bleeding, infection and posterior table and brain injuries, were observed. Follow-ups ranged from 4 to 27 months, with an average of 14 months. Contour deformities were effectively restored and cosmetic results at incision sites were acceptable in all patients. The transcutaneous transfrontal approach through a small peri-eyebrow incision is a safe procedure that can be performed with minimal morbidity and offers good access and excellent aesthetic results. Based on the results obtained, the authors suggest that this method be considered the treatment of choice for the reduction of closed anterior table frontal sinus fractures.

Twenty-six-year experience treating frontal sinus fractures: a novel algorithm based on anatomical fracture pattern and failure of conventional techniques

BACKGROUND

Frontal sinus fracture treatment strategies lack statistical power. The authors propose statistically valid treatment protocols for frontal sinus fracture based on injury pattern, nasofrontal outflow tract injury, and complication(s).

METHODS

An institutional review board-approved retrospective review was conducted on frontal sinus fracture patients from 1979 to 2005. Fractures were categorized by location, displacement, comminution, and nasofrontal outflow tract injury. Demographic data, treatment, and complications were compiled.

RESULTS

One thousand ninety-seven frontal sinus fracture patients were identified; 87 died and 153 were excluded because of insufficient data, leaving a cohort of 857 patients. The most common injury was simultaneous displaced anteroposterior walls (38.4 percent). Nasofrontal outflow tract injury constituted the majority (70.7 percent), with 67 percent having a diagnosis of obstruction. Of the 857 patients, 504 (58.8 percent) underwent surgery, with a 10.4 percent complication rate; and 353 were observed, with a 3.1 percent complication rate. All complications except one involved nasofrontal outflow tract injury (98.5 percent). Nasofrontal outflow tract injuries with obstruction were best managed by obliteration or cranialization (complication rates: 9 and 10 percent, respectively). Fat obliteration and osteoneogenesis had the highest complication rates (22 and 42.9 percent, respectively). The authors' treatment algorithm provides a receiver operating characteristic area under the curve of 0.8621.

CONCLUSIONS

A frontal sinus fracture treatment algorithm is proposed and statistically validated. Nasofrontal outflow tract involvement with obstruction is best managed by obliteration or cranialization. Osteoneogenesis and fat obliteration are associated with unacceptable complication rates. Observation is safe when the nasofrontal outflow tract is intact.

State of the art in craniomaxillofacial trauma: frontal sinus

PURPOSE OF REVIEW

Many of the successes and controversies in endoscopic management of craniofacial trauma are exemplified in the management of frontal sinus trauma.

RECENT FINDINGS

The effort to reduce surgical morbidity and to optimize reconstruction of craniomaxillofacial injuries has resulted in the development of less invasive surgical approaches and in the use of computer image guidance in surgical planning and execution. Minimally invasive management of frontal sinus inflammatory disease has gained wide acceptance. The technology and techniques applied to surgery of the floor of the frontal sinus is now being applied to the management of frontal sinus trauma. A paradigm shift in the treatment of frontal sinus trauma may be underway.

SUMMARY

An increasing scope of less severe injuries is being managed expectantly with endoscopic frontal sinus surgery available for salvage. There may be an overall decrease in the most severe frontal sinus injuries owing to enforcement of seatbelt and airbag usage. And the most severe injuries are often best managed through cranialization with anterior skull base reconstruction. Thus, the role for frontal sinus obliteration purely to obviate fractures of the frontal sinus outflow tract may be vanishing.