Frontal sinus fracture management: a systematic review and meta-analysis

Patient satisfaction after conservative treatment of anterior wall frontal sinus fractures

This study aims to determine patient forehead aesthetics satisfaction after conservative treatment of non-dislocated and dislocated anterior wall frontal sinus fractures. Prospectively, patients older than 15 years of age with a frontal sinus fracture, treated conservatively between the period of 2010-2020, were analysed. The Face-Q questionnaire was used to assess patient satisfaction, and the fracture dimensional properties were measured using computed tomography. The results were compared with a matched non-fractured control group. The mean total Face-Q questionnaire score was 114.77 (SD = 17.38) versus 114.23 (SD = 15.23) (research-versus control group, respectively), with a mean difference of 0.55 (SD = 4.85), which was not significant (p = 0.91). The size of impression area did not appear to have a linear relationship with patient satisfaction within the entire population (p = 0.87; r = 0.00). Presence of a scar in the fracture site was a significant predictor of patient satisfaction, contributing to 31% of the entire population's overall score (p = 0.01) and 57% in the dislocated fracture population (p = 0.003). The conservatively treated patients' satisfaction score was comparable to the control group. A higher satisfaction score after a conservative treatment is associated with the absence of a scar on the fracture site, even with dislocations up to 6 mm at the deepest impression point.

Surgical management of naso-orbito-ethmoidal fractures: a systematic review

OBJECTIVE

Naso-orbito-ethmoidal fractures (NOE) fractures are uncommon but critical injuries. This review aims to investigate the patient factors, procedural factors, and postoperative outcomes associated with the surgical management of NOE fractures.

STUDY DESIGN

PubMed and Scopus databases were systematically searched between 1993 and 2023 using the search strategy "(naso-orbito-ethmoidal OR nasoethmoid OR nasoorbitoethmoidal) AND fracture." Articles reporting clinical studies investigating the surgical management of NOE fractures were included. Articles that were duplicates, non-English, or non-full text; reported an unclear age range; reported insufficient data; and/or reported on a sample size less than 10 were excluded. Data on patient factors, procedural factors, and postoperative outcomes were extracted.

RESULTS

Of the 412 articles identified, 6 eligible articles (retrospective case series) representing 95 adult cases and 84 pediatric cases were included. The mean ages were 29.0 and 10.2 years, respectively. Most cases were male (65.3%; 73.9%). Motor vehicle accidents were the most common mechanism of injury (79.2% and 50.0%, respectively). Coronal incision was the most common approach. Epiphora (n = 33) and scar problems (n = 21) were the most common complications in adult and pediatric cases, respectively.

CONCLUSIONS

Further robust longitudinal studies with a clear description of fracture classification and surgical timing would be helpful. Gaps in knowledge include concomitant injuries, digitally-assisted applications, and risk factors for adverse outcomes.

Surgical management of frontal bone and naso-orbito-ethmoidal fractures: a 7-year multi-center retrospective review

OBJECTIVE

Frontal and naso-orbito-ethmoidal (NOE) fractures are rare but important injuries due to their anatomical complexity and proximity to vital structures. This study aims to describe the patient factors, procedural factors, and postoperative outcomes in the surgical management of these fractures.

STUDY DESIGN

Retrospective review of patients aged 18 years or older who were surgically treated for these fractures at two Australian tertiary hospitals (2014-2020). Patient factors (demographics, mechanism of injury, fracture pattern, concomitant injuries); procedural factors (operation timing, surgical approach); and postoperative outcomes (complications, revision surgeries) were recorded.

RESULTS

60 cases were included (41 frontal; 29 NOE; 10 combined). Mean age was 37 (frontal) and 39 years (NOE). Most cases were male (87.8%; 75.9%). The most common mechanism was traffic accidents (29.3%; 34.5%). The most common associated facial fractures were Le Fort fractures (46.3%; 89.7%). The most common associated systemic injuries were brain injuries (36.6%; 34.5%). Mean operation timing was 13 days (frontal) and 11 days (NOE). Coronal flap was most commonly used (68.3%; 82.8%). Postoperative complication rates were 39.0% (frontal) and 37.9% (NOE). Three cases required revision surgeries.

CONCLUSION

Further larger longitudinal studies are required to build knowledge and improve patient outcomes.

Epidemiological Study of Frontal Sinus Fractures: Evaluation of 16 Years of Care at the Faculty of Dentistry of Ribeirão Preto/Brazil

Purpose

Aiming to evaluate and study the epidemiological profile of frontal sinus fractures treated in the region of Ribeirão Preto-Brazil.

Methods

Sixteen years of activity in the Oral and Maxillofacial service of the Faculty of Dentistry of Ribeirão Preto/SP (FORP/USP), totaling 9,736 consultations, 4,524 with facial fractures, those diagnosed with frontal sinus fracture (113) were evaluated and selected for the study.

Results

Frontal sinus fractures accounted for 2.5% of facial fractures, the majority occurring in men (89.4%), concentrated in the age group 21-30 years old, with 52.2% of cases being caused by road traffic accidents (RTA). Associations with other facial fractures are common and appeared in 75.2% of cases. Treatment was followed either surgically, by open reduction internal fixation (52.2%) or conservatively (35.4%). Analyzing only the 28 isolated frontal sinus fractures, the most common treatment was conservative (46.4%). surgical treatment dropped to 25%. The most common postoperative complications were temporal branch paralysis and supraorbital nerve paresthesia, both occurring in 30.5% of surgical cases.

Conclusion

The frequency of frontal sinus fractures may be decreasing, but the pattern of occurrence in young men due to road traffic accidents does not seem to change, fortunately the appearance of serious complications is not common and it is usually associated with more severe trauma.

Management of Frontal Sinus Fractures at a Level 1 Trauma Center: Retrospective Study and Review of the Literature

Study Design

Case series.

Objective

This retrospective review of frontal sinus fractures aims to describe our current experience managing these fractures at an urban level I trauma center.

Methods

An institutional database of 2081 patients who presented with maxillofacial fractures on computed tomography face/sinus in 2019 was queried for all patients with traumatic frontal sinus fractures. Demographics, trauma-related history, management approach, and follow-up data were collected and analyzed.

Results

Sixty-three (7.3%) patients had at least one fracture involving the frontal sinus. The most common etiologies were assaults, falls, and motor vehicle accidents. Surgical repair was performed in 26.8% of patients with frontal sinus fractures, and the other 73.2% were observed. Fractures that were displaced, comminuted, obstructive of the frontal sinus outflow tract, or associated with a dural tear or cerebrospinal fluid leak were more likely to be operative.

Conclusions

The majority of frontal sinus fractures in this study were treated with observation. Despite advances in transnasal endoscopic approaches, many surgeons still rely on open approaches to repair frontal sinus fractures.

Frontal trans-sinusal approach: how I do it

BACKGROUND

Anterior skull base lesions could be reached by different approaches (subfrontal, pterional, interhemispheric, etc.). In selected cases, the frontal trans-sinusal approach is an effective alternative to conventional techniques.

METHODS

We present our technique to perform a frontal trans-sinusal approach in a patient affected by a large olfactory groove meningioma.

DISCUSSION-CONCLUSION

The frontal trans-sinusal approach allows to approach safely lesions of the median anterior cranial fossa. This approach provides lower brain retraction, easier access to olfactory grooves, and earlier tumor devascularization. However, it remains limited to patients with large-sized frontal sinuses and entails some postoperative risks such as mucocele or CSF leak.

Evidence-Based Medicine for Midface/Orbit/Upper Facial Fracture Repair

The face is one of the most common areas of traumatic injury, making up approximately 25% of all injuries in 2016. Assault, motor vehicle collision (MVC), fall, sports, occupational, and gunshot wounds (GSW) are all common causes of facial fractures, with MVC and GSW leading to significantly higher severity of injuries. Most facial fractures occur in the upper two-thirds of the face. Most facial fractures require timely assessment, diagnosis, and treatment for optimal restoration of facial structures and functions. Without proper initial management, significant complications including immediate complications such as airway compromise, massive bleeding, infection, intracranial hemorrhages, or even death, and long-term complications such as poor functional outcomes and aesthetic setbacks can occur. The goal of this review is to summarize the management of fractures of the upper face, orbit, and midface and provide an update about complications and their management.

Supramuscular upper blepharoplasty approach to orbital roof and/or lower anterior table frontal sinus fractures: A meta-narrative review

BACKGROUND

An approach to orbital roof fractures (ORFs) and/or lower anterior table frontal sinus fractures (LATFSFs) is a challenging task. The conventional coronal approach (CCA) appears to suit multiple/complex fractures of the upper face, while periorbital transcutaneous incisions (PTIs), e.g. gull wing, open sky, butterfly, and Lynch incisions, often impair aesthetic outcomes. The aims of this paper were to provide an overview of the supramuscular upper blepharoplasty approach (SUBA) to ORFs/LATFSFs.

METHODS

Using a meta-narrative review study design, the investigators enrolled published data extracted from PubMed/Medline, Embase, Cochrane Library, and Google Scholar concerning SUBA to ORFs/LATFSFs. Only publications with the highest and most recent level of evidence (LoE) in English, French or German available until 6 May 2022 were included. The LoE were evaluated using the 2011 Oxford Centre for Evidence-Based Medicine (OCEBM)'s classification.

RESULTS

In total, 70 articles were included; however, most contained low LoE. Under general and local anaesthesia, SUBA to ORFs/LATFSFs can be performed safely and appeared to be superior to its submuscular counterpart in terms of fewer risks of adjacent tissue injuries, and speedy operative time (maximal 5 min. in experienced hands).

CONCLUSIONS

In contrast to CCA and PTIs, the SUBA is a minimally invasive approach to the ORF/LATFSF with favourable aesthetic outcomes, direct visualisation of the fracture, quick operative time, rare complications, and easy learning.

Frontal Sinus Fractures

Management of frontal sinus fractures is controversial with no universally accepted treatment protocol. Goals of management are to correct aesthetic deformity, preserve sinus function when it is deemed salvageable, prevent sequela related to the injury, and minimize complications associated with intervention. Studies suggest that frontal sinus injuries, including disruption of the nasofrontal outflow tract (NFOT), can be managed nonoperatively in many cases. Advances in the utilization of endoscopic techniques have led to an evolution in management that reduces the need for open procedures, which have increased morbidity compared with endoscopic approaches. We employ a minimally disruptive protocol that treats the majority of fractures nonoperatively with serial clinical and radiographic examinations to assess for sinus aeration. Surgical intervention is reserved for the most severely displaced and comminuted posterior table fractures and unsalvageable NFOTs utilizing endoscopic approaches whenever possible.

Treatment of Frontal Sinus Fractures: A Systematic Review and Meta-analysis

PURPOSE

There is still no consensus about the best treatment for frontal sinus fractures (FSFs). Thus, the aims of this study were to answer the following questions: 1) what treatment of FSFs has the lowest rate of postoperative complications? 2) does sinus preservation using observation produce a lower complication rate? 3) are FSFs with nasofrontal outflow tract (NFOT) injury associated with greater complication rates following different treatment options when compared to those patients without NFOT involvement?

METHODS

A systematic review and meta-analysis were performed based on PRISMA that included several databases with specific keywords, a reference search, and a manual search for suitable articles. Randomized clinical trials, controlled clinical studies, retrospective studies and case series that estimated complications rate after different treatments options for FSFs were included. The predictor variable was treatment groups, including observation, ORIF, cranialization and obliteration. The outcome variable was complication rate and correlation between complication rate and presence/absence of NFOT. A weighted complication rate/proportion using a random effect model, or risk ratio (RR) with a 95% confidence interval (CI), was performed to construct forest plots. Data analysis was done using a comprehensive meta-analysis.

RESULTS

A total of 2,911 patients with FSFs enrolled in 23 studies were included in this study. The weighted complication rate for different treatment was as follows: observation (7%), ORIF (9.4%), obliteration (10.6%), and cranialization (11%). Nonsurgical treatment decreased the complication rate by 2.1 times (low quality evidence, RR = 2.1, CI: 1.13 to 3.9, P = .000) when compared to surgical treatments for FSFs. CR for fractures with NFOT was 8 % (55/619) compared to a complication rate of 5% (18/353) for fractures without NFOT with insignificant difference (very low quality evidence, RR = 1.7, CI: 0.75 to 4.1, P = .158).

CONCLUSIONS

FSFs vary in their severity and treatments. The more severe fractures, the higher the complication rate, no matter how they were treated.