Management of Frontal Sinus Fractures:

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.

Incidence of Frontal Sinus Fractures: A Single-Institution 12-year Experience

Frontal sinus fractures' reported incidence has varied widely in the United States. Although the past couple of decades have demonstrated an overall decrease among patients with facial fractures, the overall incidence of frontal sinus fractures remains unclear. We report our experience at a level 1 trauma center in the northeast region of the United States and analyze patients who have presented to our Emergency Department with facial fractures in a 12-year period, from 2011 to 2022. Our data show that 1.5% of all facial fracture patients had a frontal sinus fracture. Of those patients, 50% were victims of assault, 25% were involved in a motor vehicle accident, 12.5% were involved in a bicycle accident, and 12.5% were involved in a pedestrian struck by a vehicle. Overall, our data corroborate the decreasing national trend in frontal sinus fracture incidence and set the stage for further studies looking at the contributing factors for the observed decline.

Frontal Sinus Fractures: An Evaluation of Patient Demographics, Mechanisms of Injury, Classification, and Management Strategies in Patients Referred to a Trauma Center, From 2014 to 2019

This retrospective study aimed to present demographic data, mechanisms of injury, anatomical locations, and management strategies in patients with frontal sinus fractures. The study included 91 patients with frontal sinus fractures attending the Rajaee Hospital of Shiraz between 2014 and 2019. The data recorded for each patient included age, sex, injury mechanism, fracture classification, associated craniofacial fractures, nasofrontal duct injury, cerebrospinal fluid leak, and treatment approach. The mean age of patients was 31.0±14.0 years, with male predominance (95.6%). Car crashes represented the most frequent mechanism of frontal sinus fracture, involving 31 subjects (34%). Isolated anterior and posterior table fractures were seen in 32 (35.2%) and 5 (5.5%) patients. Fifty-four patients (59.3%) presented both tables' involvement. Frontal sinus injuries occurred frequently (74.7%) with other facial fractures. Nasofrontal duct injury was found in 7 patients (7.7%), and 13 (14.3%) exhibited cerebrospinal fluid leakage. Fifty patients (55%) were treated with observation alone; 16 (17.5%) underwent sinus preservation, 12 (13.2%) experienced sinus obliteration, and 13 (14.3%) endured cranialization. Fisher's exact test revealed no significant association between the classification of fracture and the mechanism of injury (P=0.591). However, a significant association was observed between the fracture classification and the treatment applied (P=0.023). Frontal sinus fractures were most often caused by car crashes in young adults. Combined anterior and posterior table fractures were more commonly found than isolated anterior or posterior table involvement. Most frontal sinus fractures were treated conservatively without DDS surgical operation.

Reduction of comminuted fractures of the anterior wall of the frontal sinus using threaded Kirschner wires and a small eyebrow incision

Background: Frontal sinus fractures are relatively rare. Their surgical management significantly differs depending on whether the posterior wall is invaded and the clinical features vary. A bicoronal incision or endoscopic approach can be used. However, the minimally invasive approach has been attracting attention, leading us to introduce a simple and effective surgical method using multiple-threaded Kirschner wires.Methods: All patients had isolated anterior wall fractures without nasofrontal duct impairment. The depth from the skin to the posterior wall was measured using computed tomography to prevent injury. The edge of the bone segment on the skin was marked, a threaded Kirschner wire was inserted into the center of the bone segment, and multiple Kirschner wires were gently reduced simultaneously.Results: Surgery was performed on 11 patients. Among them, seven patients required additional support for appropriate fracture reduction. Therefore, a periosteal elevator was used as an adjunct through a small sub-brow incision because the reduction was incomplete with the Kirschner wire alone. The reduction results were confirmed using facial bone computed tomography 1 to 3 days postoperatively. The follow-up period was 3 to 12 months.Conclusion: The patients had no complications and were satisfied with the surgical results. Here we demonstrated an easy and successful procedure to reduce a pure anterior wall frontal sinus fracture via non-invasive threaded Kirschner wire reduction.

Algorithms for the management of frontal sinus fractures: A retrospective study

The aim of this study was to evaluate the long-term results and to evaluate the validity of the treatment algorithm that can be safely applied in dfrontal sinus fractures. All patients were evaluated in terms of late-term contour deformity and further craniometric analysis for measurement of maximum amount of displacement, fracture surface area (mm2) and the maximum angulation of the fracture (degree) were done. 125 patients (101 male, 24 female) with frontal sinus fractures with an average age of 22.4 years (range,17-66 years) were reviewed. All patients with isolated anterior table fractures without displacement were followed up on conservative basis. 33 patients with anterior table fractures with displacement and 39 patients with anterior and posterior table fractures were also followed on conservative basis without surgical intervention. The cut-off value of the maximum amount of displacement was confirmed to be 4.5 mm in prediction of late-term contour deformities (p < 0.001). The maximum amount of displacement was decreased by an average of 1.8 mm at late-term. Apart from the standard protocols, within the limitations of the study it seems that isolated anterior table fractures with a maximum amount of displacement of less than 4.5 mm can be treated conservatively without leading to contour deformities. CSF leakage in the acute setting might not always require cranialization and this may spontaneously resolve within 10 days. Cranialization should be considered whenever CSF leakage lasts longer than 10 days.

Frontal Sinus Fractures: Evidence and Clinical Reflections

Background:

Despite significant advances in the management of frontal sinus fractures, there is still a paucity of large-cohort data, and a comprehensive synthesis of the current literature is warranted. The purpose of this study was to present an evidence-based overview of frontal sinus fracture management and outcomes.

Methods:

A comprehensive literature search of PubMed and MEDLINE was conducted for studies published between 1992 and 2020 investigating frontal sinus fractures. Data on fracture type, intervention, and outcome measurements were reported.

Results:

In total, 456 articles were identified, of which 53 met our criteria and were included in our analysis. No statistically significant difference in mechanism of injury, fracture pattern, form of management, or total complication rate was identified. We found a statistically significant increase in complication rates in patients with nasofrontal outflow tract injury compared with those without.

Conclusions:

Frontal sinus fracture management is a challenging clinical situation, with no widely accepted algorithm to guide appropriate management. Thorough clinical assessment of the fracture pattern and associated injuries can facilitate clinical decision-making.

Frontal Sinus Fractures: A Review on Etiology and Management Emphasizing Minimally Invasive and Endoscopic Techniques

ABSTRACT

In spite of a long and tortuous history of the acute management of frontal sinus fractures, current optimal management remains steeped in controversy. These fractures are frequently produced by excessive forces and are often accompanied with other injuries. However, disruption of the nasofrontal duct persists as essential to maintain proper sinus function and should guide current management. Although there has never been any distinct procedure defining optimal outcomes, proper treatment is contingent on precise diagnosis culled from a complete history, physical examination, and imaging studies. This is further augmented by the surgeon's intraoperative findings. Reconstruction will ultimately rest on the degree of disruption of the anterior and posterior sinus walls, as well as the status and function of the nasofrontal ducts. For these reasons, current management continues to be challenging and evolving. Thus, this review will discuss the etiology and clinical presentation of frontal sinus fractures, the current complications arising in the subject, and the evolution of treatment options towards a more conservative and endoscopic approach to care.

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.

Frontal Sinus Fractures: Management and Complications

Frontal sinus fractures are relatively rare maxillofacial injuries (only 5-15% of all facial fractures). The appropriate management of frontal sinus fracture and associated pathology is controversial. Diagnosis and treatment of frontal sinus fractures has improved with the advances of high-resolution computed tomography technology. Treatment of frontal sinus fractures depends on several factors, including contour deformity of anterior table; the presence of CSF leak or air-fluid level in the sinus, likelihood of nasofrontal duct obstruction, and degree of displacement of posterior table. Nasofrontal duct patency should be checked if fracture pattern is highly suspicious of ductal injury. Cranialization is performed in cases of severely comminuted posterior wall fracture. Long-term complication of frontal sinus fracture can occur up to 10 years after initial injury or intervention; so, judicious long-term follow-up is warranted. This article presents the management and complications of frontal sinus fractures.

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.

Feminizing the Face: Combination of Frontal Bone Reduction and Reduction Rhinoplasty

Gender affirmation surgeries in male-to-female patient transitioning include breast augmentation, genital construction, and facial feminization surgery (FFS). FFS improves mental health and quality of life in transgender patients. The nose and forehead are critical in facial attractiveness and gender identity; thus, frontal brow reduction and rhinoplasty are a mainstay of FFS. The open approach to reduction of the frontal brow is very successful in the feminization of the face; however, risks include alopecia and scarring. Endoscopic brow reduction, in properly selected patients, is minimally invasive with excellent outcomes avoiding these risks. Since both reduction rhinoplasty and frontal brow reduction are routinely performed in FFS, a combined approach provides superior control over the nasal radix and profile when performing surgery on the frontal bone region first followed by nose reduction. We present a case series of four transwomen undergoing frontal bone reduction in combination with a reduction rhinoplasty. All had excellent results with one DVT that resolved with treatment. Transgender patients frequently require multiple operations during their transition increasing their hospital stay and costs. This combined approach offers superior control over the nasofrontal angle and is not only safe but reduces hospitalizations and costs and is a novel indication to reduce gender dysphoria.

Temporary Frontal Paralysis Secondary to Blunt Trauma Frontal Sinus Fracture

Frontal sinus fractures (FSF) are relatively uncommon and can be challenging for trauma surgeons to manage. Patients with FSF typically present with facial swelling, pain, and nasofrontal ecchymosis. Here we present a rare case of a patient with FSF and anterior table fracture where the main presenting symptom was bilateral frontal paralysis. We outline our management strategy and review the current literature in regard to management of FSF.

Frontal Sinus Fractures

The frontal bone serves a protective role, representing the transition between the facial skeleton and the cranium. Within its enclosure, the frontal sinus lies adjacent to many important intracranial structures, and injury to this region has severe complications if not properly managed. Historically, the goals of frontal sinus fracture management have been to best prevent intracranial complications with invasive procedures, but a recent shift favoring conservative management now aims to preserve the form and function of the frontal sinus and its outflow tract. With the advancement of endoscopic techniques and the development of new technologies, many alternatives to aggressive surgical management are available.

Secondary Reconstruction of Frontal Sinus Fracture

Fractures of frontal sinus account for 5%-12% of all fractures of facial skeleton. Inadequately treated frontal sinus injuries may result in malposition of sinus structures, as well as subsequent distortion of the overlying soft tissue. Such inappropriate treatment can result in aesthetic complaints (contour deformity) as well as medical complications (recurrent sinusitis, mucocele or mucopyocele, osteomyelitis of the frontal bone, meningitis, encephalitis, brain abscess or thrombosis of the cavernous sinus) with potentially fatal outcomes. Frontal contour deformity warrants surgical intervention. Although deformities should be corrected by the deficiency in tissue type, skin and soft tissue correction is considered better choice than bone surgery because of minimal invasiveness. Development of infection in the postoperative period requires all secondary operations to be delayed, pending the resolution of infectious symptoms. The anterior cranial fossa must be isolated from the nasal cavity to prevent infectious complications. Because most of the complications are related to infection, frontal sinus fractures require extensive surgical debridement and adequate restructuring of the anatomy. The authors suggest surgeons to be familiar with various methods of treatment available in the prevention and management of complications following frontal sinus fractures, which is helpful in making the proper decision for secondary frontal sinus fracture surgery.

Pediatric frontal sinus fractures: outcomes and treatment algorithm

Pediatric frontal sinus fractures are a rare clinical entity. Owing to the large amount of force required to fracture the frontal sinus, it is often associated with severe intracranial and craniofacial injuries. The treatment of frontal sinus fractures is controversial, with many different established algorithms based mainly on the adult population. The authors present their experience with pediatric frontal sinus fractures; they also present a treatment algorithm. A retrospective review of the Cincinnati Children's Hospital Medical Center trauma database was performed. From 1998 to 2010, the authors identified patients between the ages of 0 and 18 with frontal sinus fractures and analyzed demographics, fracture pattern, associated injuries, methods of treatment, and complications. Descriptive statistics and univariate analyses were performed.A total of 39 patients were included in the study with a mean follow-up of 31.2 months. Fractures of the anterior and posterior table with displacement greater than one table width were significantly associated with higher hospital costs, higher velocity mechanism of injuries, lower Glasgow Coma Scale scores, nasofrontal outflow tract (NFOT) involvement, and cerebrospinal fluid leak. There were no differences in short- and long-term complications. Additionally, these patients were more likely to be treated surgically in the form of obliteration or cranialization.Patients without NFOT involvement can be managed with observation only. Patients with NFOT involvement or persistent cerebrospinal fluid leak should be treated with obliteration or cranialization, respectively, to reduce the risk of severe complications.

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 aesthetic approach for correction of frontal sinus fracture

PURPOSE

Frontal sinus fracture management remains controversial and involves preserving function whenever possible or obliterating the sinus and duct as required by the fracture pattern. The purpose of this study was to introduce the simple and effective method in the surgical treatment of the anterior wall of frontal sinus fractures.

METHODS

All 11 patients who presented with anterior wall fractures of the frontal sinus between 2009 and 2013 were included in this study. Two 7-mm stab incisions were made on each side of the fracture, a titanium screw with an attached wire was fixed to the fractured fragment, and an elevator was used to apply force in the opposite vector. One titanium screw was also fixed to the firm normal frontal bone, and the reduction was conducted by observing the C-arm until the fractured fragment reached the height of the normal side.

RESULTS

No patients showed any recurrent displacement or infection during the follow-up period, nor did any patient complain of or demonstrate forehead paresthesia. The surgical scar was less than 3 cm in all 11 patients, and all of them reported satisfaction with the results.

CONCLUSION

We obtained the results of an open reduction while using a less invasive method in the surgical treatment of the anterior wall of frontal sinus fractures.

A novel approach to frontal sinus surgery: treatment algorithm revisited

BACKGROUND

Access to the frontal sinus remains a challenging problem for the craniofacial surgeon. A wide array of techniques including minimally invasive endoscopic approaches have been described. Here we present our technique using medical modeling to gain fast and safe access for multiple indications.

METHODS

Computer-aided surgery involves several distinct phases: planning, modeling, surgery, and evaluation. Computer-aided, precise cutting guides are designed preoperatively and allowed to perfectly outline and then cut the anterior table of the frontal sinus at its junction to the surrounding frontal bone. The outcomes are evaluated by postoperative three-dimensional computed tomography scan.

RESULTS

Eight patients sustaining frontal sinus fractures were treated with the aid of medical modeling. Three patients (37.5%) had isolated anterior table fractures, and 4 (50%) had combined anterior and posterior table fractures, whereas 1 patient (12.5%) sustained isolated posterior table fractures. Operative times were significantly shorter using the cutting guides, and fracture reduction was more precise. There was no statistically significant difference in complication rates or overall patient satisfaction.

CONCLUSIONS

The surgical approach to the frontal sinus can be made more efficient, safe, and precise when using computer-aided medical modeling to create customized cutting guides.

Surgical management of traumatic frontal sinus fractures: Case series from a single institution and literature review

BACKGROUND

Neurosurgeons are frequently involved in the management of patients with traumatic frontal sinus injury; however, management options and operative techniques can vary significantly. In this study, the authors review the current literature and retrospectively review the clinical series at a single tertiary referral center.

METHODS

After Institutional Review Board approval, the medical records and computed tomographic (CT) imaging of patients whose traumatic frontal sinus fractures were treated surgically at the University of Utah were retrospectively reviewed. Demographic information, mechanism of injury, associated injuries, operative technique, and pattern of injury on CT were analyzed.

RESULTS

Between 2000 and 2012, 33 patients underwent successful cranialization of the frontal sinus following traumatic injury. The material used to obliterate the sinus varied. No patients required immediate or delayed reoperation. Nasofrontal outflow tract obstruction, the importance of which has been emphasized in the plastic surgery literature, was apparent on either initial or retrospective review of the available CT imaging in 96%.

CONCLUSIONS

In this series, we successfully surgically treated 33 patients with frontal sinus fractures. The presence of cerebrospinal fluid leak, nasofrontal outflow tract injury, associated depressed skull fractures, and subsequent formation of communicating pathways and infection must be considered when constructing a treatment plan. The goals of treatment should be: (i) surgical repair of the defect and elimination of the conduit from the intracranial space to the outside and (ii) elimination of any cerebrospinal fluid pressure gradient that may develop across the surgical repair. We present a treatment algorithm focusing on the presence of nasofrontal outflow tract injury/obstruction, cosmetic deformity, and cerebrospinal fluid leak.

Paramedian forehead flap to treat chronically infected base of skull defect in a posttraumatic patient

Frontal sinus cranialization with obliteration of the frontal sinus outflow tracts is rarely needed but may be required with extensive comminution of the anterior and posterior walls of the frontal sinus. There is little in the literature about treatment of chronic larger defects of the anterior cranial fossa that communicate with the nose and drain externally after cranialization. We present a 49-year-old man who experienced extensive facial trauma requiring cranialization of the frontal sinus. Three years later, the patient presented with a chronic draining forehead wound that extended into the previously cranialized frontal sinus space with communication of the anterior cranial fossa and the internal nose. After thorough irrigation and debridement, the remaining dead space was found to be large and communicated with the nose, making autologous grafts a poor choice. A pericranial flap was not an option due to the previous soft tissue trauma. A paramedian forehead flap was deepithelialized and rotated into the space, obliterating the dead space and closing the communication between the nose and the anterior cranial fossa. Six months postoperatively, there are no signs of recurrence. The deepithelialized paramedian forehead flap should be considered for obliterating large dead spaces and closing off the communication between the cranial base and the nose.

The fusion of craniofacial reconstruction and microsurgery: a functional and aesthetic approach

BACKGROUND

Reconstruction of large, composite defects in the craniofacial region has evolved significantly over the past half century. During this time, there have been significant advances in craniofacial and microsurgical surgery. These contributions have often been in parallel; however, over the past 10 years, these two disciplines have begun to overlap more frequently, and the techniques of one have been used to advance the other. In the current review, the authors aim to describe the available options for free tissue reconstruction in craniofacial surgery.

METHODS

A review of microsurgical reconstructive options of aesthetic units within the craniofacial region was undertaken with attention directed toward surgeon flap preference.

RESULTS

Anatomical areas analyzed included scalp, calvaria, forehead, frontal sinus, nose, maxilla and midface, periorbita, mandible, lip, and tongue. Although certain flaps such as the ulnar forearm flap and lateral circumflex femoral artery-based flaps were used in multiple reconstructive sites, each anatomical location possesses a unique array of flaps to maximize outcomes.

CONCLUSIONS

Craniofacial surgery, like plastic surgery, has made tremendous advancements in the past 40 years. With innovations in technology, flap design, and training, microsurgery has become safer, faster, and more commonplace than at any time in history. Reconstructive microsurgery allows the surgeon to be creative in this approach, and free tissue transfer has become a mainstay of modern craniofacial reconstruction.

Breach of Posterior Wall of Frontal Sinus: Management with Preservation of the Sinus

OBJECTIVE

To analyze outcomes after the management of mild (<1 mm) and moderately severe (>1 mm and <5 mm) breaches of the posterior wall of the frontal sinus with a goal of maintaining or restoring the functional status of the sinus.

METHODS

A retrospective analysis of prospectively accrued data was performed on patients with mild and moderately severe breaches of the posterior wall of their frontal sinus who were managed with the intent to preserve the frontal sinus. Data on presenting features, pathology, details on breaches of the posterior wall, management, outcome, and complications were collected from medical records and neuroimages.

RESULTS

Forty-two cases met inclusion criteria. Diagnostic categories included trauma in 34 cases, infection in 3, and other categories in another 5 cases. Five presented with cerebrospinal fluid rhinorrhea, and 26 had radiographic evidence of obstruction of a nasofrontal duct at time of presentation. Fifteen patients were managed without surgical intervention, and 27 underwent surgery. No complications occurred in the patients managed without surgery and 4 postoperative cerebrospinal leaks that were managed successfully with a period of drainage occurred in the surgical group. No patient developed meningitis or mucocele.

CONCLUSIONS

Many patients with mild to moderately severe breaches of the posterior wall of the frontal sinus can be managed safely and effectively by techniques that preserve the anatomy and function of the frontal sinus.

Closed reduction of the isolated anterior frontal sinus fracture via percutaneous screw placement

Fractures of the frontal sinus are a common maxillofacial trauma and constitute 5-15% of all maxillofacial fractures. Conventional surgical approaches include the coronal flap, direct cutaneous incision, and endoscopic techniques. Minimally invasive techniques have recently been described for the reduction of the isolated anterior frontal sinus fracture via a closed approach. The medical records and radiological findings of all patients who underwent surgical treatment for anterior frontal sinus fractures from January 2009 to December 2013 at the study hospital in Florence, Italy, were reviewed. The final study sample consisted of 15 patients (13 males and two females) with isolated anterior frontal sinus fractures who were treated with closed reduction using percutaneous screws. The mean age was 32.1 years. The skin incisions healed without any visible scarring, and no depressions of the frontal sinuses were evident in the postoperative period. Computed tomography scans performed at 6 months postoperatively showed adequate reduction of the displaced fragments. This closed technique is a good option for displaced isolated fractures of the anterior frontal sinus. However, the technique is not adequate for complex fractures of the frontal sinus.

Modified cranialization and secondary cranioplasty for frontal sinus infection after craniotomy: technical note

Frontal sinus infection after incorrect treatment of an opened frontal sinus may require extended approaches. This article aims to introduce modified cranialization technique and secondary cranioplasty for frontal sinus infection involving the frontal sinus outflow tract after craniotomy. Eight patients with delayed onset frontal sinus infection involving frontal outflow tract after craniotomy were treated from 2008 to 2012. Debridement and cranialization involving the elimination of the frontal outflow tract was performed. Unilateral sinus cranialization combined with reduction of the non-affected contralateral sinus was carried out for the patients with unilateral sinusitis. A pericranial-frontalis muscle flap was used to separate the intracranial and extracranial spaces. Secondary cranioplasty with hydroxyapatite was performed approximately 3 months after the cranialization. The patients' original conditions included brain tumors (n = 3), frontal sinus fractures (n = 2), and subarachnoid hemorrhage (n = 3). The mean interval between the initial treatment and the onset of sinus infection was 23 years. The frontal sinus infection was bilateral in six cases and unilateral in two cases. Frontal sinus outflow tract was involved in sinus infection in every case. None of the patients suffered recurrent rhinogenic infections within the follow-up period (mean = 35 months) after the secondary cranioplasty. Aesthetic results were satisfactory in every case. Modified cranialization involving elimination of the frontal outflow tract is an alternative method for the patients with pathology in the frontal outflow tract after frontal craniotomy. Secondary cranioplasty provides an esthetically pleasing appearance in such cases.

Management of fractures of the nasofrontal complex

Repair of fractures involving the nasofrontal region remains a mainstay of contemporary oral and maxillofacial surgery. This article discusses the epidemiology of these injuries, anatomy of the area, and management of these fractures with insight into potential complications. These include fractures of the frontal sinus, naso-orbital-ethmoidal region, root of the nose, and associated adjacent structures.

Unfavourable outcomes in maxillofacial injuries: How to avoid and manage

Faciomaxillary injuries remain one of the common injuries managed by plastic surgeons. The goal of treatment in these injuries is the three-dimensional restoration of the disturbed anatomy so as to achieve pre-injury form and function. In this article, the authors review the anatomic, diagnostic and management considerations to optimise results and minimise the late post-traumatic deformities. Most of the adverse outcomes are usually a result of poorly addressed underlying structural injury during the primary management. An accurate physical examination combined with detailed computed tomographic scanning of the craniofacial skeleton is required to generate an appropriate treatment plan. This organised approach has proven effective in restoring the injured structures to pre-injury status. Multiple clinical cases are used to illustrate the different fracture patterns along with various surgical techniques to achieve an acceptable outcome. Early diagnosis and timely management of complications in these complex injuries is also discussed.

Frontal sinus obliteration with iliac crest bone grafts. Review of 8 cases

This study evaluated postoperative results of 8 cases of frontal sinus fractures treated by frontal sinus obliteration with autogenous bone from the anterior iliac crest.

PATIENTS AND METHODS

The medical charts of patients sequentially treated for frontal sinus fractures by obliteration with autogenous cancellous iliac crest bone in the Oral and Maxillofacial Surgery Division of this institution were reviewed. From those, eight had complete records and adequately described long-term follow-up. All were operated by the same surgical team. Those patients were recalled and independently evaluated by 2 examiners. Radiographs and/or CT scans were available for this evaluation. Associated fractures and complications were noted. The average postoperative follow-up was 7 years, ranging from 3 to 16 years. The main complication was infection. Four patients (50%) had uneventful long-term follow-ups and four (50%) experienced complications requiring reoperation. Based on the studied sample studied the authors conclude that the obliteration with autogenous bone presented a high percentage of complications in this series.

A nasal mucocele originating from complex facial fractures

Mucoceles are benign, epithelial-lined mucous cysts. Commonly mucoceles form secondary to obstruction of a sinus outflow tract or from mucosal gland entrapment from chronic infection, inflammation, iatrogenic trauma, external trauma, or neoplasm. We present a rare case of a nasal mucocele in a 37-year old male arising from a remote history of maxillofacial trauma. To our knowledge, mucoceles associated with nasal bone fractures have not been reported in the literature.

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.

Cranialization in a cohort of 154 consecutive patients with frontal sinus fractures (1987-2007): review and update of a compelling procedure in the selected patient

Retrospective review of charts of 180 consecutive patients with frontal sinus fractures managed by plastic surgeons at the University of Kentucky between 1987 and 2007 was performed with institutional review board approval. Twenty-six charts did not meet the criteria. The remaining 154 records provided 1-to-20-year follow-up. The study included 34 patients who underwent cranialization and 120 patients who did not. A low-complication rate of 6% after cranialization is ascribed by the authors to meticulous sinus mucosal debridement; thorough obliteration of the frontal sinus outflow tract (with sterile gelatin sponge pledgets and bone chips from the outer cortex of the temporoparietal skull); and avoidance of avascular barriers, such as abdominal fat. As high-resolution computerized tomography with parasaggital views was introduced, an increasing ability to preoperatively define the extent of injury of the medial and lateral sinus floor was observed. The authors conclude selective use of cranialization is indicated.

Vascular pericranial graft: a viable resource for frontal sinus obliteration

Inappropriate treatments of frontal sinus fractures may lead to serious complications, such as mucopyocele, meningitis, and brain abscess. Assessment of nasofrontal duct injury is crucial, and nasofrontal duct injury requires sinus obliteration, which is often accomplished by autologous grafts such as fat, muscle, or bone. These avascular grafts have an increased risk of resorption and infection, as well as donor site morbidity. For these reasons, pericranial flap, which is vascular, should be used for frontal sinus obliteration. The pericranial flap presented with less morbidity procedure and has decreased infection rates, which justifies its use in frontal sinus obliteration. This paper aims to report a case of a comminuted frontal sinus fracture in a 29-year-old man who was successfully treated by frontal sinus obliteration, using pericranial local flap. The patient was followed up postoperatively for 16 months without infection.

Open surgical management of an asymptomatic giant frontal sinus osteoma

Osteomas are benign, slow-growing tumors that arise most frequently in the craniomaxillofacial region, and in particular in correspondence of the nose and paranasal sinuses. Osteomas may be asymptomatic for a long time until they cause deformation of the bone or compress adjacent structures. The treatment of osteomas of the frontal sinus may involve endoscopic approach or open approach. Although endoscopic treatment is the most common approach for frontal sinus osteomas, a coronal approach combined with the use of titanium mesh may still constitute a valuable option for the reconstruction of the anterior wall of the frontal sinus. This intervention is extremely important and delicate because the restoration of the integrity of the frontal sinus is crucial for its function. The purpose of this article is to present a case of frontal sinus osteoma that was treated by a coronal approach and a titanium mesh to restore frontal sinus contour.

Nasofrontal outflow tract visibility in computed tomography imaging of frontal sinus fractures

The choice of frontal sinus fracture treatment is based on multiple factors, one of which is injury to the nasofrontal outflow tract (NFOT). Computed tomography (CT) imaging of the NFOT can play an important role in the decision process. We sought to assess the visibility of the NFOT on CT scans in frontal sinus fractures. Patients with frontal sinus fractures (including the posterior table) receiving a CT scan from April 1st 2001 to December 31st 2009 were included. Scans were retrospectively assessed for available views (axial, coronal, and sagittal), slice thickness, inclusion of the anatomical NFOT region in the scanned area, and visibility of the NFOT. A total of 170 patients were included. In majority (71%) of patients NFOT was visible on one or more views, whereas in 33% (N = 56) of patients had three complete views (complete anatomical NFOT region scanned in three views). In this subgroup, the ability to assess the NFOT increased to 89%. When selecting patients with three complete views of ≤ 2 mm slice thickness (N = 47), the ability to assess the NFOT increased to 96%. In conclusion, when assessing the NFOT using CT imaging, having three complete views (axial, coronal, and sagittal) and a ≤ 2 mm slice thickness greatly increases the NFOT visibility.

Frontal sinus fractures: a conservative shift

This article reflects on the changing management of frontal sinus fractures. Severity of these injuries has decreased tremendously since the universal adoption of seat belts and air bags. Recently, there has been a shift from aggressive surgical management to more conservative management strategies, some forgoing surgery all together. New technologies, such as bioabsorbable plates and endoscopic sinus surgery, are leading the way in improved surgical management strategies and offer promising alternatives to the more traditional approaches.

Management of facial fractures

This article presents up-to-date information for the emergency medicine community on several patterns of facial fractures and their associated injuries. The article contains information about the anatomic structure and pathologic injuries that occur in the setting of facial trauma and guides the emergency medicine community in the thorough physical and diagnostic evaluation, emergent treatment, and proper surgical or outpatient treatment.

Multidetector computed tomography of maxillofacial fractures: the key to high-impact radiological reporting

Maxillofacial fractures are very common. Recognizing patterns of facial fractures is helpful in assessing maxillofacial injury and accurately characterizing all fractures that may be present. Facial fractures are grouped into the following categories: nasal bone, naso-orbito-ethmoid, orbital, zygomatic, maxillary (including Le Fort-type fractures), mandibular, and frontal sinus fractures. Within each subgroup of facial fractures, there are key findings, whether of the fracture itself or of potential associated injuries, that are important factors in determining whether the patient is managed conservatively or with surgery. This article highlights the features of facial fractures that are the most important to the surgeons and provides a framework for effective radiological reporting.

Fracture depth and delayed contour deformity in frontal sinus anterior wall fracture

OBJECTIVES

The choice to manage isolated frontal sinus anterior wall fractures without the involvement of nasofrontal outflow tract is mainly based on aesthetic concern and depends largely on surgeons' preferences. Minimally depressed anterior wall fractures can be monitored by observation only with little risk of long-term morbidity and contour deformity. The purposes of this study were to evaluate the course of a nonoperated depressed frontal sinus anterior wall fracture and to identify the cutoff value of anterior wall displacement requiring surgical correction.

MATERIALS AND METHODS

A retrospective chart review of 51 nonoperated isolated frontal sinus anterior wall fractures was performed. The depth and area of each fracture were measured by computed tomographic scans. Medical records were carefully reviewed to identify the delayed complications or contour changes.

RESULTS

The mean fracture depth and size were 3.9 mm and 352 mm(2), respectively. Patients who had a fracture depth of 4 mm or less did not develop late depressive contour changes of the skin. However, 7 patients who each had a fracture depth of more than 4 mm developed mild contour changes during the months of follow-up. The delayed contour change was associated with fracture depth (P < 0.01), but the fracture area was not considered as an independent factor for delayed contour deformity (P > 0.05).

CONCLUSIONS

The presence of depressive contour changes on the skin is an indication for surgical correction of the frontal sinus fracture. Mildly displaced isolated frontal sinus anterior wall fractures can be observed if the fracture depression is less than 4 mm.

Treatment of frontal sinus fracture using bioabsorbable mesh plates

Accurate reduction and stable fixation are important in the treatment of frontal sinus fracture. Usually, metal plates and screws were used because of easy handling and delicate fixation. However, palpability and possibility for secondary operation for plate removal were shortcomings. For improving these problems, we used absorbable mesh plate for fixation of reduced frontal bones.In this study, 14 patients with frontal sinus fracture were treated by open reduction and rigid fixation using absorbable mesh plates. Mean follow-up period was 17.6 months. Considering anterior and posterior table involvement, nasofrontal duct injury, and concomitant neurosurgical problems, additional surgical procedures including degloving sinus mucosa, cranialization, and obliteration of nasofrontal duct were also conducted.There was no remarkable early and late postoperative complication. Aesthetic results were also satisfactory. Absorbable mesh plates were easy to mold and convenient for screw fixation. Moreover, there was no necessity of secondary operation for removal of plates.We believe that absorbable mesh plates might be a useful material for fixation instead of metal plates and screws especially in mild to moderate degree of frontal bone fractures.

Versatility of the pedicled nasoseptal flap in the complicated basal skull fractures

With the advancement of transnasal endoscopic technique, endoscopic repair of basal skull fractures has considerably substituted former external approaches. The endoscopically feasible pedicled flap, named nasoseptal flap has been extending its range of application, since it was introduced for the reconstruction of the defect after resection of skull base tumors. We introduce two patients with complicated basal skull fractures at different sites who were successfully treated by the transnasal endoscopic approach using nasoseptal flap.

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.

Bilateral aplasia of paranasal sinuses

Paranasal sinus anatomical anomalies with unknown etiology are common. Maxillary and/or frontal sinus aplasia or hypoplasia are more common than the other types. Although there are some reports about paranasal sinus anomalies in the literature, there is no case similar to ours, with total paranasal sinus aplasia. Here, we present a unique case of total paranasal sinus aplasia with a symptom of fullness on the face.