Frontal sinus injuries: associated injuries and surgical management of 93 patients

Frontal Sinus Fracture Management Meta-analysis: Endoscopic Versus Open Repair

INTRODUCTION

Frontal sinus fracture management continues to be a point of controversy. Many systematic reviews have been done, but meta-analyses comparing various approaches to frontal sinus fractures are scarce. Our study focuses on open surgical repair versus endoscopic repair of frontal sinus fractures.

MATERIALS AND METHODS

A MEDLINE search was performed to identify prospective RCTs, non-RCTs, guidelines, case-control, and observational studies published in English before April 2019. Search terms included (1) frontal sinus, (2) skull fractures, (3) frontal bone, alone or in combination. An in-depth review was conducted to identify publications relevant to this analysis. Studies that included pediatric patients, case reports, and review articles without original data were excluded. Postoperative outcomes included were cosmesis, sinus function, mucocele, sinusitis, cerebrospinal fluid leak, meningitis, and brain abscess. Meta-analysis of proportions, Fisher exact test, and relative risks were calculated.

RESULTS

Seven studies were ultimately included in the meta-analysis. The assessment of heterogeneity indicated that the studies are comparable. The weighted outcome proportions of patients with postoperative cosmetic deformity and mucocele are found to be significantly higher in patients who underwent open repair compared to patients who received endoscopic treatment. No significant difference between the 2 intervention groups in regards to the other outcomes.

CONCLUSION

Based on this meta-analysis, no definitive conclusions regarding superiority of one approach over the other can be made. There are currently no universally accepted algorithms that aid in the decision to proceed with either approach. It is likely that these 2 techniques will come to serve different roles in treatment, as they can each be utilized to achieve different goals. At this time, the only recommendation is to proceed with whichever technique can be safely performed based upon surgeon experience and fracture pattern.

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

A systematic review of the frontal sinus fracture management literature was undertaken to document measurable outcomes, with emphasis on complications associated with the various treatment strategies. A comprehensive electronic search was undertaken in October 2018. Randomized controlled trials (RCT), controlled clinical trials, retrospective and prospective studies describing the management of frontal sinus fractures and complications were included. Twenty-four publications were included: one reporting a prospective RCT and 23 reporting consecutive case series studies (four prospective, 19 retrospective). These included 2388 patients (84.1% male, average age 23-43 years); 50.7% of cases were due to motor vehicle accidents and 61.8% had a concomitant intracranial injury. There were six categories for anterior table reconstruction, three endoscopic surgery categories, 11 for obliteration, and six for cranialization. Forest plots demonstrating complications based on the Clavien-Dindo classification of 1 ('low') and >3 ('high') were determined for total, early, and late complications, with heterogeneous effect sizes. Fractures with a nasofrontal outflow tract (NFOT) injury without obstruction can be treated with reconstruction if displaced, or managed conservatively if undisplaced. Obliteration and cranialization should be considered when there is obstruction of the NFOT. A computed tomography scan should be performed at 6 months to evaluate re-ventilation of the sinus. Endoscopic sinus surgery is a reasonable salvage re-ventilation procedure.

Frontal sinus fractures and cerebrospinal fluid leaks: a change in surgical paradigm

PURPOSE OF REVIEW

Traditionally, frontal sinus trauma has been treated using open incisions to access the anterior and/or posterior table. Mounting evidence indicates frontal sinus trauma can be managed using an endoscopic endonasal approach (EEA) with less morbidity. Such an approach permits preservation of a functional sinus and less reliance on computed tomography for postoperative follow up. The goal of this article is to highlight a shift in paradigm away from open approaches using external incisions towards an EEA to repair cerebrospinal fluid (CSF) leaks and fractures of the frontal sinus.

RECENT FINDINGS

In a prospective case series of 46 patients undergoing EEA to frontal sinus fractures, 41 patients had active CSF leaks arising from the posterior table of the frontal sinus. A successful endoscopic repair was achieved in 97.6% with only one patient requiring revision Draf IIB surgery. Anterior table fractures were also successfully reduced with excellent cosmesis.

SUMMARY

Endoscopic repair of frontal sinus fractures and CSF leaks is effective and well tolerated. In select patients, it is the preferred treatment as it maintains normal sinus structure and function, minimizing both early and late complications.

Pediatric Diffuse Large B-Cell Lymphoma of the Frontal Sinus: A Case Report

An 11-year-old male presented with right proptosis, bulbar conjunctivitis, and diplopia. Computerized tomography (CT) and magnetic resonance imaging revealed an enhancing mass involving the superio-medial orbit, ethmoids, frontal sinus, and anterior cranial fossa with skull base destruction. Diffuse large B-cell lymphoma was diagnosed via CT-guided biopsy. As a component of multidisciplinary care, the patient underwent frontal sinus cranialization, with orbital and skull base reconstruction. Trauma reconstructive principles guided recreation of orbital, frontal sinus, and anterior skull base anatomy. This rare primary location is undescribed in the pediatric literature.

Risk of frontal sinus anterior table fractures after craniofacial trauma and the role of anatomic variations in frontal sinus size: A retrospective case-control study

INTRODUCTION

Purpose of this study was to evaluate a probable risk of frontal sinus size for traumatic depressed anterior table fractures in patients with similar forehead trauma.

METHODS

We conducted a retrospective case-control study with a case group of consecutive treated patients with displaced frontal sinus anterior table fractures. The control group was randomly sampled from patients who presented with a blunt forehead trauma in our institution's emergency unit. In computed tomography data sets, all patients' frontal sinus size was categorized by Guerram's classification that is defined as aplasia, hypoplasia, medium-size and hyperplasia. Odds for prevalence of the sinus types as well as sinus total width and height were compared between both groups.

RESULTS

In total, 47 cases and 93 controls were identified. Hyperplasia in the case group had an odds ratio of 46:1 (p < 0.001) compared to the controls. Mean sinus width (73 mm vs. 46 mm; p < 0.001) and sinus height (30 mm vs. 15 mm; p < 0.001) were larger in the case group.

CONCLUSION

Depressed traumatic fractures of the anterior table are an injury with a high risk specific for enlarged frontal sinus sizes. Anatomy is the predictive factor for this mode of craniofacial trauma.

Frontal Bone Fractures and Frontal Sinus Injuries: Treatment Paradigms

Background:

Timely, expeditious and appropriate management of Frontal bone fractures and associated Frontal Sinus (FS) injuries are both crucial as well as challenging. Treatment options vary considerably, depending upon the nature, extent and severity of these injuries as well as operator skill, expertise and experience. In cases of posterior table fractures of the Frontal Sinus, literature reports have in general, propounded direct visualization and exploration of the sinus via a bifrontal craniotomy, followed by sinus cranialization.

Aims and Objectives:

To review the standard protocols of management of Frontal bone fractures and Frontal Sinus injuries. To assess the efficacy of a more conservative approach in the management of outer and inner table fractures of the FS.

Materials and Methods:

Contemporary and evolving management protocols and changing treatment paradigms of different types and severities of frontal bone fractures and frontal sinus injuries, have been presented in this case series. A useful Treatment Algorithm has been proposed to efficiently and effectively manage these injuries.

Results:

In the present case series, effective and satisfactory results could be achieved in cases of significantly displaced inner and outer table fractures of the Frontal sinus by a more conservative protocol comprising of open reduction and internal fixation carried out via the existing scar of injury, without having to resort to the more radical intracranial approach and sinus cranialization. Nevertheless, presence of complicating factors such as cerebrospinal fluid rhinorrhea, evidence of meningitis or the development of encephalomeningocoeles necessitated the standard protocol of sinus exploration and its cranialization or obliteration.

Conclusion:

Management protocols of Frontal Sinus injuries vary, based on aspects such as the timing of presentation and intervention, degree of injury sustained, concomitant associated Craniomaxillofacial injuries present, presence of complicating factors or Secondary/Residual deformities & Functional debility, and need to be decided upon on a case to case basis.

Surgical Treatment of Anterior Sinus Wall Fracture Due to Sports Accident

Frontal bone fractures represent a low percentage of craniofacial fractures. However, a systematic approach and a correct diagnosis are essential for successful treatment and maintenance of physiology of the frontal sinus and late complications. The purpose of this study was to report a clinical patient with anterior wall fracture of the frontal due to sports accident sinus that was surgically treated.

Frontal Sinus Morphology: A Reliable Factor for Classification of Frontal Bone Fractures?

PURPOSE

The frontal sinus shows a wide range of morphologic variations. The aim of this study was to evaluate the influence of frontal sinus size on fracture characteristics in frontal bone trauma.

MATERIALS AND METHODS

In this cross-sectional study, data from patients with traumatic fractures of the frontal bone were retrospectively collected from the institution's database. Radiometric analysis of computed tomography and cone-beam computed tomography datasets was performed. Frontal sinus size was measured as variables of height, width, and depth. The secondary predictor was morphologic sinus type according to Guerram's classification: hyperplasia, medium size, hypoplasia, or aplasia of the frontal sinus. To determine outcomes, we classified fractures into the following categories: fracture isolated to the anterior table, combined fractures of the anterior and posterior tables, fracture isolated to the posterior table, and frontal bone fracture without sinus involvement. Further study variables were patients' demographic characteristics, combined midfacial fractures, orbital rim involvement, fracture displacement, and surgical approach. For statistical analysis, fracture types were assessed for frontal sinus metric size and morphologic type using bivariate tests with P < .05 defined as significant.

RESULTS

We enrolled 53 consecutive patients with a mean age of 35 years; male patients comprised 91%. Fracture types differed significantly in sinus width and height (both P < .001), as well as depth (P = .002). Frontal sinus morphology was hyperplastic in 66%, medium in 30.2%, and hypoplastic in 3.8%. Patients with a hyperplastic frontal sinus had an increased likelihood of isolated anterior table fractures (odds ratio, 6.0; P = .007) compared with medium-sized types. Fractures without sinus involvement were more likely in hypoplastic and medium types (P < .001).

CONCLUSIONS

The morphology of the frontal sinus determines the probability of fracture types from craniofacial trauma. Thus the frontal sinus size appears to be a major factor for frontal bone resistance to traumatic force impingement.

Treatment of frontal bone fracture sequelae through inversion of the bone fragment

Treatment of frontal sinus fractures depends on the structures involved: the anterior wall, the posterior wall and the nasofrontal duct. It may vary from the correction of the defect in the anterior wall to the cranialization with obliteration of the nasofrontal duct. The inversion of the frontal sinus's anterior wall to correct the defect in the fractured region is a good treatment option for sequelae, since this technique eliminates or reduces the use of biomaterial in the area, and allows direct assessment of the permeability of the nasofrontal duct. This work describes the technique of fractured segment inversion for the treatment of frontal sinus fracture sequelae in a motorcycle accident victim.

Postoperative CT of the Midfacial Skeleton After Trauma: Review of Normal Appearances and Common Complications

OBJECTIVE

The objective of this article is to describe the CT appearance of the midfacial skeleton after surgical repair of posttraumatic Le Fort, nasoorbitoethmoidal (NOE), and frontal sinus fractures. Several of the more commonly encountered complications will also be described.

CONCLUSION

Surgery after midfacial trauma is aimed at restoring both form and function. Knowledge of the principal tenets of Le Fort, NOE, and frontal sinus fracture repair is vital for radiologists to accurately assess the adequacy of treatment on postoperative CT and provide meaningful reports for the surgeon.

Changing the surgical dogma in frontal sinus trauma: transnasal endoscopic repair

BACKGROUND

Management of frontal sinus trauma includes coronal or direct open approaches through skin incisions to either ablate or obliterate the frontal sinus for posterior table fractures and openly reduce/internally fixate fractured anterior tables. The objective of this prospective case-series study was to evaluate outcomes of frontal sinus anterior and posterior table trauma using endoscopic techniques.

METHODS

Prospective evaluation of patients undergoing surgery for frontal sinus fractures was performed. Data were collected regarding demographics, etiology, technique, operative site, length involving the posterior table, size of skull base defects, complications, and clinical follow-up.

RESULTS

Forty-six patients (average age, 42 years) with frontal sinus fractures were treated using endoscopic techniques from 2008 to 2016. Mean follow-up was 26 (range, 0.5 to 79) months. Patients were treated primarily with a Draf IIb frontal sinusotomies. Draf III was used in 8 patients. Average fracture defect (length vs width) was 17.1 × 9.1 mm, and the average length involving the posterior table was 13.1 mm. Skull base defects were covered with either nasoseptal flaps or free tissue grafts. One individual required Draf IIb revision, but all sinuses were patent on final examination and all closed reductions of anterior table defects resulted in cosmetically acceptable outcomes.

CONCLUSION

Frontal sinus trauma has traditionally been treated using open approaches. Our findings show that endoscopic management should become part of the management algorithm for frontal sinus trauma, which challenges current surgical dogma regarding mandatory open approaches.

Frontal bone fractures

The aim of this retrospective study was to evaluate the epidemiology, treatment, and complications of frontal bone fractures associated, or not, with other facial fractures. This evaluation also sought to minimize the influence of the surgeon's skills and the preference for any rigid internal fixation system. The files from 3758 patients who attended the Oral and Maxillofacial Surgery Department of the School of Dentistry of Ribeirao Preto, University of Sao Paulo, from March 2004 to November 2011 and presented with facial trauma were scanned, and 52 files were chosen for the review. Eleven (21.15%) of these patients had pure fractures of the frontal bone, and trauma incidence was more prevalent in men (92.3%), whites (61.53%), and adults (50%). Despite the use of helmets at the moment of the trauma, motorcycle crashes were the most common etiological factor (32.69%). Fracture of the anterior wall of the frontal sinus with displacement was the main injury observed (54.9%), and the most common treatment was internal fixation with a plate and screws (45.09%). Postoperative complications were observed in 35.29% of the cases. The therapy applied was effective in handling this type of fracture, and the success rate was comparable to that reported in other published studies.

A simple method for the repair of frontal sinus fracture: the bone mesh pull-up technique

Accurate reduction and stable fixation are important in the treatment of frontal sinus fracture. In this article, we introduce a rapid and simple method for the treatment of frontal fractures and restoration of normal forehead contour, named the "bone mesh pull-up technique" (BMPUT). We describe our experience with this technique in frontal trauma cases, with emphasis on the technical aspects and clinical results of this simple method. Postoperative computed tomography scans showed adequate reduction of displaced bone fragments in all cases. Esthetic results were satisfactory and no complications related to this procedure, such as uncontrollable sinus bleeding, infection, and posterior table and brain injuries, were observed. Follow-ups ranged from 1 to 24 months, with an average of 12 months. Contour deformities were effectively restored and cosmetic results were very good. The BMPUT is a safe procedure that can be performed with minimal morbidity and offers, good access, and excellent esthetic results.

The spectrum of facial fractures in motor vehicle accidents: an MDCT study of 374 patients

Road traffic accidents are a major health problem worldwide resulting frequently in maxillofacial injuries. The purpose of the study was to assess the incidence and spectrum of facial fractures in patients involved in a motor vehicle accident (MVA). Using picture archiving and communication system, all requests for suspected facial trauma were retrieved during a 62-month period; 374 met the inclusion criteria. Two researchers interpreted the multidetector computed tomography images by consensus. The motor vehicles involved were divided into two groups: those involving a passenger car or a larger vehicle and those involving a motorized two-wheeler. Furthermore, the motor vehicle accidents were divided into collisions and run-off-road accidents. Of the 374 patients (aged 15-80, mean 34), 271 (72 %) were male and 103 (28 %) female. Of all patients, 262 (70 %) had a facial or skull base fracture; of these, multiple separate fractures were present in 56 %. Nasal fractures were the most common fractures followed by orbital, skull base, and maxillary fractures. Frontal bone, LeFort, and zygomatic arch fractures were always accompanied by other fractures. Fractures were more frequent in the group of collisions compared with run-off-road accidents. In the two-wheeled group, only 15 % did not have facial or skull base fractures. Fractures often occur in multitudes as 39 % of all patients have multiple facial or skull bone fractures, and thus, emergency radiologists should be familiar with the complexity of the injuries. Negative clear sinus sign and low-energy sentinel injuries should be trusted as indications of undetected injuries in MVA victims.

Surgical treatment of frontal sinus fractures: the simple percutaneous reduction revised

Frontal sinus fractures are common fractures in high-energetic trauma. Different treatments options are available for different types of frontal sinus fractures. A fracture that consists only of the anterior wall is most commonly reduced with the coronal approach. This approach is invasive and produces a large scar on the scalp, which can result in an unfavourable situation in patients with alopecia and in balding men. To avoid this, a percutaneous reduction method can be used to treat patients with simple anterior wall fractures. This approach is less invasive and does not result in a conspicuous scar. The disadvantages of this procedure are the absence of direct vision and less control of the fracture, which can reduce the chances of complete reduction. This paper provides an overview of anterior wall fractures of the frontal sinus and elaborates on the simple percutaneous reduction technique.

Management of frontal sinus fractures

The traditional treatment of frontal sinus fractures is undergoing a review by many clinicians. This review will undoubtedly contribute to the existing controversy surrounding the management of patients with this condition. This article seeks to further the review and suggest the authors' perspective on a more appropriate approach to the care of patients with frontal sinus injuries.

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.

Violence-related facial trauma: analysis of multidetector computed tomography findings of 727 patients

OBJECTIVES

The multidetector CT (MDCT) findings of facial trauma in victims of interpersonal violence were assessed.

METHODS

All MDCT requests for suspected facial injury during a 62 month period were retrieved; 727 cases met the inclusion criteria. Images were interpreted by two researchers by consensus.

RESULTS

Of the 727 patients (aged 15-86 years old, mean 37), 583 (80.2%) were male and 144 (19.8%) female. Of all the patients, 74% had a fracture, and of these 44% had multiple non-contiguous fractures.

CONCLUSIONS

Violence is a very common cause of facial injury. Nasal and orbital fractures predominate. Males are more often involved; they are younger, sustain fractures more often and significantly more often present with high-energy fracture patterns. LeFort fractures are often unilateral or asymmetrical, and are frequently accompanied by other, clinically significant fractures. Up to 25% of patients with fractures do not have paranasal sinus effusions.

Management of frontal sinus fractures

The goals in the treatment of frontal sinus injuries are to provide an esthetic outcome, restore function, and prevent complications. However, there is no consensus as to how to best achieve these goals. Unfortunately, the questions that Stanley proposed in 1989 still lack definitive answers more than 19 years later: (1) Which fractures, if left untreated, will lead to an immediate or delayed complication? and (2) What is the appropriate surgical procedure if treatment of the fracture is deemed necessary? This article discusses the controversies in the surgical treatment of such fractures and provides a scientific rationale for proper management.

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.

Acute facial trauma in falling accidents: MDCT analysis of 500 patients

The aim of this study is to assess multidetector computed tomography (MDCT) findings of facial trauma due to a falling accident. Using picture-archiving and communications system, we retrieved all MDCT requests for suspected facial injury during a 62-month period. Images were interpreted by two researchers. Five hundred patients met the inclusion criteria and 329 (66%) had a total of 515 fractures. Falls on stairs were seen in 109 (22%) patients and slips or trips in 391 (78%). The corresponding number of fractures was 169 (33%) and 346 (67%). Males (N = 241) had more fractures than females (N = 259), 327 vs. 188, respectively. The zygomatic complex was the most common fracture, seen in 40% of patients suffering a fracture. Twenty patients (4%) had fractures involving the sinus walls without paranasal sinus effusions. Facial fractures due to falls are common. The zygomatic complex is the most common fracture. A clear sinus sign may be less reliable than previously thought.

A Protocol for the Management of Frontal Sinus Fractures Emphasizing Sinus Preservation

PURPOSE

The purpose of this retrospective study is to review the incidence and etiology of frontal sinus fractures at an urban trauma center and validate a treatment protocol by assessing the outcome of a consecutive series of patients treated over a 10-year period.

PATIENTS AND METHODS

All patients with frontal sinus fractures admitted to our trauma service from 1995 to 2005 were managed by the same surgeons using similar treatment philosophies based on the amount of displacement or comminution of the anterior and/or posterior table, the integrity of the nasofrontal duct, and the neurologic status of the patient as determined by clinical and radiographic examination. Using information obtained from the Trauma Registry and from individual physician chart notes, a database was created for the purpose of assessing outcome, defined as complications, length of hospital stay, and death. Demographics, injury severity score, fracture pattern, mechanism of injury, length of hospital stay, the number of operations, concomitant maxillofacial injuries, treatment, follow-up, and complications were statistically described. Outcome measures were evaluated by Student's t test using continuous variables.

RESULTS

One thousand two hundred seventy-five patients with facial fractures were identified during the study period, of which 144 patients (11.3%) carried the diagnosis of frontal sinus fracture; 28 patients had inadequate records, leaving a study group of 116 patients. The majority of patients were male, had a mean age of 33.7 years, and presented with significant injuries demonstrated by a mean injury severity score of 23.7 and mean length of hospital stay of 8.9 days. The most common mechanisms of injury were blunt trauma resulting from a motor vehicle collision, fall, assault, or other accidents. Sixty-six patients presented with nondisplaced frontal sinus fractures that were managed nonoperatively; 50 patients had frontal sinus injuries that required surgical repair consisting of: 1) open reduction and internal fixation of the anterior table alone, with preservation of the sinus membrane (n = 29); 2) removal of all sinus mucosa, obliteration of the frontal sinus with autogenous abdominal fat, and reconstruction of the anterior table (n = 5); and 3) removal of all sinus mucosa, cranialization of the frontal sinus, and lining of the nasofrontal recess with a pericranial flap (n = 16). Six patients died of concomitant injuries. With follow-up ranging between 0 and 90 weeks, there were no known complications in the patients treated nonoperatively; 82% of the patients maintained normal sinus function and anatomy and the overall complication rate was 6.9%. Complications occurred in 16% of those patients treated surgically: including brain abscess, contour deformity, osteomyelitis, hematoma, meningitis, and mucocele. There was no statistically significant association between complications and other patient variables (P > .05), other than the test for injury severity score, which was different between survivors and nonsurvivors (P < .01).

CONCLUSION

Application of the management protocol described in this report results in functional sinus preservation for the majority of patients, with relatively few significant perioperative complications.