Frontal Sinus Fractures: Management Guidelines

Abstract

Management of frontal sinus fractures (FSF) has been the subject of great debate for more than six decades. Multiple treatment options and algorithms have been proposed by multiple specialties throughout the years; however, the optimal method of frontal sinus repair has yet to be elucidated. Because of the location of the frontal sinus and its proximity to numerous intracranial structures, inadequate treatment may lead to life-threatening intracranial infectious complications. Meningitis, encephalitis, and brain abscess are the most common intracranial complications. Other complications include persistent cerebrospinal leakage, mucopyoceles, frontal osteomyelitis, meningoencephalocele, and nonunion of the frontal bone. Orbital involvement may result in ophthalmoplegia, orbital abscess, diplopia, enophthalmos, proptosis, preseptal cellulitis, and partial or complete loss of vision. Morbidity and mortality are often dependent on the anatomic characteristics of the fracture, concomitant injuries, treatments rendered, age, gender, and mechanism of injury. Management of frontal sinus fractures is so controversial that the indications, timing, method of repair, and surveillance remain disputable among several surgical specialties. The most important tenet of frontal sinus fracture management remains the same: create a safe sinus. This is accomplished by following four basic principles: reestablish the frontal bony contour to its premorbid state, restore normal sinus mucosa with a patent drainage system if possible, eradicate the sinus cavity if the normal mucosa or drainage system cannot be reestablished, and create a permanent barrier between the intracranial and extracranial systems to prevent overwhelming infectious complications. By following these four basic principles, frontal sinus fracture management will be safe and effective as long as extended surveillance is part of the protocol.

Endoscopically assisted reduction of anterior table frontal sinus fractures

“…In cases of extensive trauma with involvement of the anterior wall, frontal recess and posterior wall fractures, a conventional approach is needed according to several authors, because of possible complications, including meningitis, encephalitis, brain abcesses, mucocèles and sinusitis (Wallis and Donald, 1988;Wilson et al, 1988;Chen et al, 2003;Cunningham and Haug, 2004;Metzinger et al, 2005;Yavuzer et al, 2005).…”

“…Single outer table fractures include 18e43% of frontal sinus fractures (Wallis and Donald, 1988;Wilson et al, 1988;Lappert and Jesse, 1998;Strong et al, 2003;Gabrielli et al, 2004;Metzinger et al, 2005). The other patients represent more extensive trauma, with involvement of anterior wall, frontal recess and posterior wall, making, according to the literature, a conventional bicoronal approach necessary (Wallis and Donald, 1988;Wilson et al, 1988;Chen et al, 2003;Cunningham and Haug, 2004;Metzinger et al, 2005;Yavuzer et al, 2005).…”

“…Treatment of the single outer table fractures has a mainly aesthetic goal and carries a low risk of long term morbidity (Wallis and Donald, 1988;Lappert and Jesse, 1998;Gonty et al, 1999;Chen et al, 2003;Schon et al, 2003;Strong et al, 2003;Metzinger et al, 2005;Pham and Strong, 2006;Shumrick, 2006;Steiger et al, 2006;Strong and Kellman, 2006). However this procedure is also traditionally approached with a bicoronal incision.…”

“…However this procedure is also traditionally approached with a bicoronal incision. This procedure carries a relatively high morbidity with possible scarring, alopecia, numbness of the forehead and possible facial nerve damage (Lappert and Jesse, 1998;Gonty et al, 1999;Chen et al, 2003;Strong et al, 2003;Metzinger et al, 2005;Pham and Strong, 2006;Steiger et al, 2006).…”

Treatment of Frontal Sinus and Nasoethmoid Orbital Fractures

“…At times, the NFDs are less well defined, however, communication from the sinuses to the nose then continues through the frontal recess, which is bounded by lamina papyracea laterally, middle turbinate medially, ethmoid bulla posteriorly, and agger nasi cells anteriorly [16]. The NFDs, which provide for drainage and aeration of the frontal sinuses, are located in the inferiormedial aspect of the frontal sinuses and communicate with their ipsilateral middle meati.…”