Frontal Sinus Fractures

Abstract

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

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

“…All sinus mucosa should be removed using either a burr or a CO 2 laser in addition to scraping the mucosa out. 5 After burring of sinus walls to eliminate mucosal invaginations, 11 the sinus cavity can be plugged with allogeneic materials such as hydroxyapatite, bioactive glass, methyl methacrylate, calcium phosphate bone cement, and oxidized regenerated cellulose, or autogenous materials such as abdominal fat, muscles, or bone. 7 Then, the anterior table is plated back to its original position.…”

“…3. 9 Late complications can occur during the timeframe of 6 months after injury up to 35 years in one publication, 11 illustrating the importance of close follow-up. The overall incidence of long-term complications as described by Johnson et al's meta-analysis was 11.9% in 804 patients.…”

“…12 By providing the defect an opportunity to heal while CSF flow is diverted away from the injury site, the need for operative intervention for traumatic CSF rhinorrhea is uncommon. Treatment algorithms typically hinge on the results of these conservative therapies, with failure resulting in a decision to pursue operative interventions 7 such as obliteration, cranialization with a pericranial flap, 11 or an endoscopic endonasal approach with or without a nasoseptal flap. 8 Given the intracranial complexity, collaboration with a neurosurgical team is often advocated.…”

“…When infected, these typically require operative intervention with drainage, source control endoscopically, and possible reconstruction of the cranial vault, orbit, and nasal cavity. 5,11 Some authors have advocated for an algorithm in which surveillance imaging is performed either once at 2 to 6 months or at 3 to 6 month intervals to surveille for NFOT obstruction. 8,9 Orbit Epidemiology and Anatomy Isolated orbital fractures comprise 4 to 16% of facial fractures, and with the majority caused by assault or MVC.…”