Endoscopic repair of isolated anterior table frontal sinus fractures without fixation

A new aesthetic pretrichial approach for upper third-facial fractures and pathologies: The "Crown incision"

BACKGROUND

The coronal incision represents the cornerstone for the treatment of upper-third maxillofacial pathologies. However, this approach leaves long scars that in numerous patients, it can cause extensive surrounding alopecia and sensory skin deficits. This clinical evidence prompted the authors to propose a full pretrichial incision, the crown incision, in order to overcome these drawbacks.

METHODS

A retrospective study was performed to investigate and report the aesthetic and functional outcomes of 15 patients treated with this new approach.

RESULTS

In the postoperative period, no major or minor complications were detected. The aesthetic evaluation of the scar by the operator and the patient showed overlapping results. The overall rating was 2.93 for the patient and 2.87 for the surgeon, on a scale from 0 (as normal skin) to 10 (very different from normal skin). The recovery of sensitivity in the innervation territories of the supratrochlear and supraorbital nerves was found to be complete in 14 patients. In one case, the sharp/blunt discriminative sensitivity was absent in all three points assessed.

CONCLUSIONS

This study showed the crown incision to be a safe approach with an optimal recovery of scalp sensitivity and excellent aesthetic results even in bald patients. Therefore, it can be considered a valid aesthetic and effective alternative to the classic coronal approach and should form part of the craniomaxillofacial surgical armamentarium.

Minimally Invasive Treatment With a Patient Specific Implant in Reconstruction of Isolated Anterior Wall Fracture of the Frontal Sinus

ABSTRACT

Isolated fractures of the anterior wall of the frontal sinus are most often treated through a coronal approach. Although the coronal approach is a relatively easy procedure, the size of the incision is causing more problems related to patient morbidity and recovery time than smaller approaches. A novel, minimal invasive procedure for reconstruction of the anterior wall fracture of the frontal sinus is presented in this article. An endoscopic assisted approach to camouflage the defect of the anterior wall and restore the contour of the frontal bone with a titanium patient specific implant is described in 2 patients. The aim of this procedure is to evaluate the effect on the operating time, recovery time, length of hospital stay and facial scarring compared to the conventional coronal approach. Postoperative evaluation was performed by superimposing pre and postoperative 3D stereophotographs and computed tomography scans. A distance map demonstrated an accurate reconstruction of the preoperatively planned contour. Postoperative recovery of both patients was quick and uneventful with no complications. The use of endoscopically inserted patient specific implant for contour reconstruction in anterior wall fractures of the frontal sinus seems to offer a predictable and minimal invasive alternative to the conventional approach.

What Is the Role of the Endoscope in the Sinus Preservation Management of Frontal Sinus Fractures?

PURPOSE

The management of frontal sinus fractures has remained controversial. The present study investigated the role of minimally invasive endoscopic surgery in a sinus preservation treatment protocol and described the ideal approach for each frontal sinus fracture type.

PATIENTS AND METHODS

We performed a prospective cohort study of patients with multiple frontal sinus fracture types. Patient demographic data, including age, gender, and cause of the fracture, were recorded. Four main management methods were proposed. Group A underwent observation only, group B underwent reduction and fixation of the anterior table, group C underwent endoscopic management of the frontal sinus outflow tract (FSOT), and group D underwent cranialization with an assessment of FSOT. The outcome measurements were the correction of the clinical deformity, which was determined by comparison of the preoperative and postoperative images, and the patent frontal sinus drainage, which was measured on the postoperative radiologic sagittal and coronal views of the frontal recess. The long-term outcomes were confirmed by the absence of long-term complications on postoperative follow-up examinations. Statistical analysis and comparisons were performed using SPSS software (IBM Corp, Armonk, NY).

RESULTS

A total of 60 patients (52 men, 8 women; mean age, 29.5 ± 8 years) were included in the present study. Of the 60 patients, 20 were in group A, 20 in group B, 16 in group C, and 4 in group D. All 60 patients had undergone correction of the deformity and had a patent FSOT postoperatively. No long-term complications were encountered in the follow-up period (median, 24 months; range, 12 to 36 months).

CONCLUSIONS

Endoscopic evaluation of the FSOT is of great importance in the surgical management of frontal fractures, because it allows for sinus preservation. The outcomes achieved in the present study were the result of selecting the right management plan for each fracture type.

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.

Frontal Sinus Fractures: Evolving Clinical Considerations and Surgical Approaches

Frontal sinus fractures are an uncommon injury of the maxillofacial skeleton, and account for 5-15% of all maxillofacial fractures. As the force of impact increases, fractures may extend beyond the anterior table to involve adjacent skull, posterior table and frontal sinus outflow tract (FSOT). Fractures at these subsites should be evaluated independently to assess the need for and type of operative intervention. Historically, these fractures were managed aggressively with open techniques resulting in obliteration or cranialization. With significant injuries, these approaches are still indispensable. However, the treatment of frontal sinus fractures has changed dramatically over the past half-century, and recent case series have demonstrated favorable outcomes with conservative management. Concurrently, there has been an increasing role of minimally invasive endoscopic techniques, both for primary and expectant management, with a focus on sinus preservation. Here, we review the diagnosis and management of frontal sinus fractures, with an emphasis on subsite evaluation. Following a detailed assessment, an appropriate treatment strategy is selected from a variety of open and minimally invasive approaches available in the surgeon's armamentarium.

Upper Eyelid Approach for the Reconstruction of Isolated Fractures of the Anterior Wall of the Frontal Sinus

The management of frontal sinus fractures can vary widely depending on involvement of the anterior wall, the posterior wall, and the frontonasal duct. The main morbidity associated with isolated anterior wall fractures is an aesthetic deformity. Treatment includes coronal, endoscopic, and transcutaneous approaches. However, each has reported limitations and associated risks of iatrogenic injuries. In this paper, the authors discuss a novel approach through the upper eyelid crease and examine 4 cases where it is utilized for anterior frontal sinus wall, superior orbital rim, and orbital roof fracture repair.

Percutaneous Screws and External Fixation in Frontal Sinus Anterior Wall Fractures

Fractures of the frontal sinus are frequently encountered injuries of maxillofacial fractures. The most common causes are traffic accidents, followed by sports-related injuries. There is still no consensus regarding the optimal management of frontal sinus fractures. The authors report a patient with depressed anterior wall fracture of the frontal sinus and superior orbital rim fracture. Reduction was performed by traction from 2 screws applied percutaneously to the depressed fragments and external fixation with an aluminum nasal splint. This technique is both minimally invasive and permits easy fixation in suitable patients.

Survey of Current Practice Patterns in the Management of Frontal Sinus Fractures

The management of frontal sinus fractures has evolved in the endoscopic era. The development of functional endoscopic sinus surgery (FESS) has been incorporated into management algorithms proposed by otolaryngologists, but the extent of its influence on plastic surgeons and oral and maxillofacial surgeons is heretofore unknown. A cross-sectional survey was performed to assess the practice pattern variations in frontal sinus fracture management across multiple surgical disciplines. A total of 298 surveys were reviewed. 33.5% were facial plastic surgeons with otolaryngology training, 25.8% general otolaryngologists, 25.5% plastic surgeons, and 15.1% oral and maxillofacial surgeons. 74.8% of respondents practiced in an academic setting. 61.7% felt endoscopic sinus surgery changed their management of frontal sinus fractures. 91.8% of respondents favored observation for uncomplicated, nondisplaced frontal sinus outflow tract fractures. 36.4% favored observation and 35.9% favored endoscopic sinus surgery for uncomplicated, displaced frontal sinus outflow tract fractures. For complicated, displaced frontal sinus outflow tract fractures, obliteration was more frequently favored by plastic surgeons and oral and maxillofacial surgeons than those with otolaryngology training. The utility of FESS in managing frontal sinus fractures appears to be recognized across multiple surgical disciplines.

Treatment strategies for frontal sinus anterior table fractures and contour deformities

Anterior table frontal sinus fractures can result in aesthetically displeasing contour deformities. Acute anterior table frontal sinus fractures that are depressed may be reduced with an open, closed, or endoscope-assisted approach. Delayed contour deformity camouflage can be achieved using bone grafts, titanium meshes, methyl methacrylate, hydroxyapatite cement, and polyether ether ketone implants. The selection of surgical approach to repair a frontal sinus contour deformity depends on the fracture severity, chronicity, complexity, patient comorbidities, and surgeon preference and experience. Advancement in endoscopic technology and expertise has created a paradigm shift toward a less invasive approach to the frontal region, with considerably less morbidity than conventional open techniques.

Trauma of the midface

Fractures of the midface pose a serious medical problem as for their complexity, frequency and their socio-economic impact. Interdisciplinary approaches and up-to-date diagnostic and surgical techniques provide favorable results in the majority of cases though. Traffic accidents are the leading cause and male adults in their thirties are affected most often. Treatment algorithms for nasal bone fractures, maxillary and zygomatic fractures are widely agreed upon whereas trauma to the frontal sinus and the orbital apex are matter of current debate. Advances in endoscopic surgery and limitations of evidence based gain of knowledge are matters that are focused on in the corresponding chapter. As for the fractures of the frontal sinus a strong tendency towards minimized approaches can be seen. Obliteration and cranialization seem to decrease in numbers. Some critical remarks in terms of high dose methylprednisolone therapy for traumatic optic nerve injury seem to be appropriate. Intraoperative cone beam radiographs and preshaped titanium mesh implants for orbital reconstruction are new techniques and essential aspects in midface traumatology. Fractures of the anterior skull base with cerebrospinal fluid leaks show very promising results in endonasal endoscopic repair.

Update on approaches to the craniomaxillofacial skeleton

PURPOSE OF REVIEW

A myriad of surgical approaches to the craniomaxillofacial skeleton exist. Depending on the purpose of the procedure and the anatomic area to be addressed, classically used approaches include coronal approach, midfacial degloving, eyelid incisions, and other cutaneous incisions. Over the last decade, endoscopic approaches have become more popular. Whether external, transoral, or endoscopic, a detailed knowledge of the indications, anatomy, limitations, and potential complications is critical to the successful employment of these approaches. This article reviews the recent literature on classic as well as novel advancements to the craniofacial skeleton.

RECENT FINDINGS

Multiple studies in the last 5 years have investigated the approaches to the craniofacial skeleton. Most of these focus on trauma. Recent advances have concentrated on external versus endoscopic approaches to the mandibular condyle, an endoscopic approach to the midface and orbit, three-dimensional imaging of the facial skeleton, and improving upon the existing classic approaches and techniques.

SUMMARY

Approaches to the craniomaxillofacial skeleton continue to evolve with the refinement of classic approaches and advent of new technologies and approaches. This study reviews the recent literature and provides a comprehensive review of options for craniofacial exposure and the most up-to-date surgical options.

Frontal sinus and naso-orbital-ethmoid fractures

IMPORTANCE

Frontal sinus and naso-orbital-ethmoid (NOE) fractures are among the most challenging injuries in the treatment of maxillofacial trauma.

OBJECTIVE

To summarize the current knowledge regarding frontal sinus and NOE fractures and to present some of the more recent, evidence-based literature to support current treatment recommendations.

EVIDENCE REVIEW

A PubMed search of articles from 1990 through 2013 was performed. Search terms included frontal sinus fracture, NOE fracture, naso-orbito-ethmoid fracture, naso-ethmoid-orbital fracture, and nasoethmoid fracture.

FINDINGS

Advances in sophisticated imaging and evolution in minimally invasive surgical techniques are introducing more conservative options that may provide better patient outcomes while minimizing the risks and morbidity associated with more traditional treatment approaches.

CONCLUSIONS AND RELEVANCE

The treatment of frontal sinus and NOE fractures is challenging, given the complex anatomy and associated pattern of injuries. Traditional treatment paradigms are evolving and support the role of more conservative treatment algorithms in selected patients.