A simple aesthetic approach for correction of frontal sinus fracture

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.

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.

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

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.