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Acute management of frontal sinus fractures
ACUTE MANAGEMENT OF FRONTAL SINUS FRACTURES LYLE S. LEIPZIGER, MD and SCOT BRADLEY GLASBERG, MD
The proper management of acute frontal sinus fracture relies on early accurate diagnosis and treatment. Missed diagnosis, delayed treatment, and incorrect surgical care may produce life-threatening complications. A surgical plan must be established after careful review of the physical examination and CT scan. An algorithmic approach is utilized to determine the operative treatment. Correct management of the acute frontal sinus fracture will produce an aesthetic and safe frontal sinus that avoids serious complications. Copyright 9 1998by W.B. Saunders Company KEY WORDS: frontal sinus fracture
Proper management of acute frontal sinus fractures is paramount to achieving successful results while avoiding potentially life-threatening complications. Frontal sinus fractures are usually the result of direct, high-impact trauma and may be associated with other open or closed head injury. Treatment is based on an algorithmic approach determined by the extent and displacement of the frontal sinus fracture components. Prompt diagnosis and correct immediate care will produce a safe and aesthetically correct frontal sinus that minimizes serious complications. It has been estimated that the frontal sinus is involved in 5% to 12% of all maxillofacial trauma. 1,2 Approximately one third of frontal sinus fractures have been shown to involve the anterior table alone, whereas two thirds involve the anteroposterior tables and/or nasofrontal ducts. The frontal sinus is in dose proximity to the cribriform plate (skull base), anterior dura mater, frontal lobes, and intracranial venous sinus system. Therefore, complex frontal sinus fractures may result in a significant risk of fatality in the acute setting. Forty percent of frontal sinus fractures have an accompanying dural laceration. 1 Similarly, delay in treatment or improper repair may lead to meningitis, mucocele, or brain abscess#
ANATOMY Understanding the anatomy of the frontal sinus is critical for the evaluation and treatment of frontal sinus injury. The frontal sinus occupies the central frontal bone (Fig 1). It has several septations and often varies greatly in size. The thick anterior wall provides structural support. The thin posterior wall separates the sinus from the frontal lobes of the brain. The delicate floor of the frontal sinus corresponds to the roof of the orbits. 4 The funnel-shaped From the Division of Plastic Surgery, Long Island Jewish Medical Center, New Hyde Park, and the Division of Plastic Surgery, SUNY Health Sciences Center, Brooklyn, NY. Address reprint requests to Lyle S. Leipziger, MD, Chief, Division of Plastic Surgery, Long Island Jewish Medical Center, 27005 76th Ave, New Hyde Park, NY 11040. Copyright 9 1998 by W.B. Saunders Company 1071-0949/98/0503-000858.00/0
nasofrontal ducts, the only drainage system for the sinus, pass through the anterior ethmoidal air cells to exit adjacent to the ethmoidal infundibulum. 4 Injury to the nasofrontal ducts prevents adequate drainage of normal mucosal secretions and predisposes to the development of obstructive pathological complications such as mucocele.
DIAGNOSIS Trauma to the frontal sinus may produce overt or subtle physical findings. Symptoms of frontal sinus injury may include overlying skin lacerations, bruises, hematoma, anesthesia of the supraorbital nerve, and cerebrospinal fluid rhinorrhea# Physical examination consists of thorough palpation of the forehead. Lacerations directly overlying the frontal bone should be carefully probed to assess anterior wall integrity (Fig 2). Significant frontal ecchymosis and hematoma should raise suspicions of deeper injury. If frontal sinus fracture is suspected, the nose must be carefully inspected for cerebrospinal fluid (CSF) rhinorrhea. Any clear fluid draining from the nose should be sent to the laboratory for verification of CSF. Bloody nasal fluid may be tested at the bedside for CSF by placing a drop on a white cloth or paper towel. Any CSF will diffuse faster than the blood and create a clean halo around a central, more darkly tinged area ("halo" test). Although clinical evaluation is important, it cannot adequately define the extent of the frontal injury. Radiological evaluation of the frontal sinus fracture is instrumental in determining the need for surgery. Plain skull radiographs of a frontal sinus fracture may reveal an air fluid level. However, computed tomography (CT) scan is the gold standard for analyzing acute frontal sinus trauma 6 (Fig 3). Scans should be performed with narrow cuts (1.5 to 3 mm) and include sagittal and coronal views. Complete visualization of the frontal sinus, superior orbits, and nasoethmoidal area should be obtained. The degree of bone displacement, amount of comminution, and presence of pneumocephalus will determine the severity of the fracture. Proper evaluation of the integrity of the anterior
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Fig 2. A deep forehead laceration with orbital ecchymosis indicates the superficial clinical symptoms that often present with frontal sinus fractures. CT scans should be obtained for anyone with significant blunt trauma to the forehead and supraorbital areas. The bilateral spectacle hematoma is diagnostic for an anterior fossa fracture.
Fig 1. The frontal sinus is quite variable in size and in symmetry, irregular septations divide it into right and left sides, often asymmetrically; partial or complete subseptations may be present. A comminuted frontal sinus fracture is illustrated above.
and posterior sinus walls, as well as of the nasofrontal ducts, is crucial for determining proper fracture management. Despite technological advances in CT imaging, the status of the nasofrontal ducts is still a difficult assessment for even the most experienced radiologistso7 Unless proven otherwise, fractures that extend into the nasofrontal ducts should be considered obstructive and require surgical intervention.
Fig 3. (A) An anterior wall fracture, largely unilateral and with depression is shown. Even a cutaneous laceration can be recognized in the CT scan. (B) A diffuse soft-tissue contusion is present with anterior and posterior wall fractures. Visible in the CT scan are an air-fluid level and sinus (nasofrontal duct) obstruction. The posterior wall fracture is slightly displaced, and a small amount of pneumocephalus is present. The probability of a CSF leak is significant. (C) Comminuted anterior and posterior wall fractures from a gunshot wound. This injury requires exploration and repair of the dura and debridement of any devitalized cerebral tissue.
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LEIPZIGER AND GLASBERG
AnteriorTable Fracture
ing the frontal sinus pathologic condition. 11 Variations of this technique provide the current basis for surgical management of frontal sinus fractures. 12
CURRENT SURGICAL CARE
Displaced
No
Yes
No
Nasofrontal Duct involved
Operative Intervention
The treatment of frontal sinus fractures is determined exclusively by the extent of damage to the specific frontal sinus anatomical components. An algorithmic treatment approach may be used that is based on which anatomic components of the frontal sinus are involved in the fracture. Specifically, fracture management is determined by the amount of damage to the anterior frontal sinus wall, posterior frontal sinus w a l l nasofrontal duct, or the combined anterior/posterior wall (Figs 4 and 5). 13 Combined Anterior/PosterlorTable Fracture
No
Yes
Displaced PosteriorWall Reduction/Stabilization with Sinus Preservation
Reduction/Stabilization and then Sinus Obliteration with Spontaneous Osteogenesis with or without Bone Graft
No (<1 table width)
Yes (>1 table width)
CSF Leak
CSF Leak
Fig 4. An algorithm from Rohrich et al that describes a pathway for the management of anterior wall fractures. Displaced fractures, or those with nasofrontal duct obstruction, should be managed with obliteration and bone grafting. (Reprinted with permission. 5)
HISTORY OF SURGICAL TREATMENT Frontal sinus injuries were first treated by Reidel in 1898 by removing the entire anterior table of bone and allowing the anterior soft tissues to fall into the empty sinus space. 7 This resulted in significant contour deformities, as well as complications from nasofrontal duct obstruction. Other surgeons attempted to refine this technique to improve on the cosmetic and functional results. In 1921, Lynch devised the external frontoethmoidectomy with resection of only the frontal sinus floor, ethmoid bone, and middle turbinates. 7 This allowed for improved drainage and decreased the contour deformity. However, this procedure could only be used when the anterior table of bone was uninvolved. A variation of this technique using nasoendoscopy is practiced today to treat some of the complications of frontal sinus fracture. 8An endoscope may be passed from the nose to enter the sinus and relieve obstruction. Others have used endoscopic approaches for anterior sinus wall repair. Bergara and Bergara in 19519 and later Goodale and Montgomery 1~ devised the osteoplastic flap procedure for sinus obliteration. This was the first attempt to address frontal sinus fractures in an aesthetic and functional manner. The frontal sinus was approached either through a fracture present in the anterior wall or through a window created in the bone. The anterior wall would be removed, the frontal sinus explored, the mucosa stripped, the sinus defect obliterated, and the anterior wall replaced. This procedure avoided frontal contour deformity while addressMANAGEMENT OF FRONTAL SINUS FRACTURES
No
I
No
Yes
No Operative Intervention
Allow 4-7 days for resolution. If persistent, cr a C O ;
Yes
Nasofrontal 1. Duct Involved i S ~ ~ ~
No
1. Reduction/Stabilization of Anterior Wall 2. Sinus Preservation
Reduction/ Stabilization of Anterior Wall l ization
Yes
1. Reduction/Stabilization of Anterior Wall 2. Sinus Obliteration with Spontaneous Osteogenesis with or without bone graft
Fig 5. Algorithm for management of combined anteroposterior wall fractures. Fractures that have displaced anterior and posterior walls require obliteration or cranialization depending on whether or not neurosurgical exposure (a frontal bone flap) has been achieved. In cranialization, the sinus is converted to a portion of the intracranial cavity by its elimination. This procedure requires neurosurgical exposure. In obliterative techniques, the sinus and duct are obliterated with bone graft material. The sinus is thereby defunctionalized after removal of its mucosa. (Reprinted with permission, s) 259
O
Fig 6. (A) CT scan of depressed anterior wall. (B) Anterior wall fracture in a patient with large sinus. The anterior wall depressed fracture is visualized. (C) The fragments of the depressed anterior wall are removed and placed on a back table. (D) The large sinus is shown. It is treated with reconstruction where the remaining mucosa is preserved, (E) The use of a small fragment plate and screw system enables repositioning and stabilization of the anterior wall.
Isolated, nondisplaced fractures of the anterior wall of the frontal sinus may be managed without surgery in the absence of duct obstruction. If anterior wall displacement is present, open reduction and rigid fixation best treats the fracture. This avoids a frontal-bone aesthetic deformity. 14 The sinus may be approached through an appropriate skin laceration (if present) or with a coronal incision. The best exposure is obtained through the use of the coronal incision. At the time of sinus exploration, any devitalized mucosa is removed. This should include the traumatized mucosa on the underside of the broken anterior-wall bone fragments. The sinus should be copiously irrigated with normal saline. Normal mucosa within the frontal sinus is left intact. The nasofrontal ducts will remain functional as long as they have not been injured by the fracture or by surgical dissection. The anterior sinus wall is anatomically reduced or reconstructed, and rigid fixation is accomplished through the use of a microplating system. All the anterior frontal-bone fragments should be used in the repair. If significant anterior-wall bone loss is present, or if 260
the segments are judged too small to be useful, split calvarial bone grafts can be collected for reconstruction. This procedure (repairing the frontal sinus while maintaining nasofrontal duct patency) is known as functional treatment. This can only be accomplished in the absence of nasofrontal duct injury (Fig 6). Because of anatomic proximity, any fracture of the anterior frontal sinus wall can be associated with nasofrontal duct injury and functional or anatomic obstruction. Preoperative CT scans that show displaced anterior wall fractures extending to the base of the sinus or into the anterior ethmoidal area are highly suspicious for duct injury. Intraoperative evaluation of the nasofrontal duct should then be performed at the time of sinus exploration. Any fracture that extends into the nasofrontal duct may produce obstruction and therefore requires nasofrontal duct obliteration. Duct obstruction may also be analyzed intraoperatively by first using cocaine vasoconstriction on the mucosa and then attempting to pass liquid or fluorescein through the ducts. 3,7 If the dye does not pass to the LEIPZIGER AND GLASBERG
Fig 7. Management of an anterior-posterior wall fracture with obliterative techniques. (A) A combined anterior and posterior wall fracture is shown that has resulted in partial obstruction of the nasofrontal duct in CT scan. (B) Surgical exposure showing the fractures of the sinus. (C) A portion of the sinus wall is removed to accomplish safe sinus management (elimination). (D) The mucosa is removed, and the walls of the sinus are lightly burred with an abrasive bit to eliminate invaginations of the mucosa into the bone. This prevents mucosal regeneration. (E) Particulate bone graft is obtained from the external table of the parietal calvarium. (F) This material is used to pack the sinus after obliteration of the duct with a cortical cancellous bone graft wedged into the duct.
nose, then the ducts are obstructed. Any evidence of nasofrontal duct obstruction makes obliteration of both the sinus and ducts mandatory. This is performed by first carefully removing all the mucosa from the sinus and both MANAGEMENT OF FRONTAL SINUS FRACTURES
ducts (mucosal exenteration). A high-speed burr is then used to lightly remove the inner cortex of bone from the sinus. Calvarial bone grafts are then contoured as formfitting plugs to completely obliterate the nasofrontal ducts.
261
Fig 7. (Cont'd). (G) The anterior sinus wall is replaced over the particulate graft material. (H) A small-fragment plate and screw system replaces the fragments of the anterior frontal sinus wall,
Some investigators advocate nasofrontal duct occlusion with free temporalis fascia and a pedicled flap of muscular fascial tissue or corrugator and procerus muscle. 2,3,14Obliteration of the frontal sinus is then performed. The best material for frontal sinus obliteration remains controversial. Spontaneous osteoneogeriesis or the implantation of temporalis muscle, autologous fat, or bone grafts have been recommended. Spontaneous osteoneogenesis of the frontal sinus occurs by the slow ingrowth of bone from the burred-down inner cortex. Care must be taken to completely remove all sinus mucosa and pack the nasofrontal ducts adequately. Improper sinus treatment or unrecognized duct injury may predispose to the potentially devastating complications of mucocele and mucopyocele. Treatment of displaced anterior wall fractures with nasofrontal duct obstruction requires complete mucosal exenteration of the frontal sinus, followed by light burring of the bony walls. Form-fitting calvarial bone graft occlusion of the nasofrontal ducts is then performed. If the frontal sinus is small packed calvarial bone chips may be used to obliterate the sinus (Fig 7). If the frontal sinus is large, we prefer spontaneous osteoneogenesis to occur. If only one of the nasofrontal ducts is injured, we still prefer bilateral duct and sinus obliteration because patency of the uninvolved duct cannot be assured. Fractures of the posterior wall of the frontal sinus are often associated with intracranial injury. CSF leak, pneumocephalus, and frontal lobe contusion may be present. Evaluation and treatment may involve the combined efforts of the plastic surgeon and neurosurgeon. Appropriate management is based on the degree of posterior wall displacement or comminution, involvement of the nasofrontal ducts, and presence of a CSF leak. 7 No operative intervention is required for posterior wall fractures that are nondisplaced and exhibit no evidence of CSF leak. All fractures of the posterior sinus wall that are significantly displaced require operative intervention. If there is no CSF leak and the nasofrontal ducts are not involved, the sinus can be preserved (functional treatment) with rigid fixation of both the anterior and posterior sinus walls. If there is no CSF leak but the nasofrontal ducts are involved, complete rnucosal exenteration with sinus and duct obliteration is performed. Severely displaced and comminuted fractures 262
of the posterior wall associated with CSF leaks require a cranialization procedure (Fig 8). Cranialization is the removal of the posterior wall of the frontal sinus, which allows the brain to occupy the space. Once the posterior wall has been removed, the dural injury may be repaired. Complete sinus mucosal exenteration is followed by obliteration of the nasofrontal ducts with bone grafts as described above. A pedicled galeal-frontalis flap may be obtained and advanced over the occluded nasofrontal ducts. This provides a vascularized barrier between the dural repair and nasofrontal ducts. The anterior sinus wall is then restored. Multiple studies have shown this to be an effective method of treating these types of fractures while maintaining a good aesthetic contour and preventing further rhinorrhea. 7,15A6 Cases of CSF leaks that present with nondisplaced or minimally displaced fractures of the posterior wall of the frontal sinus are less common. These situations are usually allowed 5 to 7 days to resolve spontaneously with observation. If the CSF leak continues, cranialization of the frontal sinus and repair of the dural laceration are performed. Anterior-posterior-wall frontal sinus fractures may be managed by the same principles as previously described. Severity of the fracture will guide treatment. Nondisplaced fractures are managed with observation. Frontal sinus fractures that avoid the nasofrontal ducts will undergo "functional treatment." These fractures will be anatomically reduced and bone fragments rigidly fixed. If the nasofrontal ducts are intact, frontal sinus function will be preserved. Nasofrontal duct injury in association with anterior and posterior wall displacement requires mucosal stripping, followed by sinus and duct obliteration. Severe posterior-wall injury will require cranialization. Open fractures of the frontal sinus require immediate attention. Wounds should be d6brided and lavaged. Repair of the sinus fracture should follow the previously described basic management principles. Closed fractures of the frontal sinus should be repaired in a timely fashion. Definitive fracture treatment should occur within 24 to 72 hours of injury unless other significant injuries contraindicate surgical care. Intravenous antibiotics are administered preoperatively and for at least 48 hours postoperatively in LEIPZIGER AND GLASBERG
Fig8. An anteroposterior wall fracture managed by cranialization. (A) CT scan of combined fracture of the anteroposterior wall. (B) Appearance of injury, (C and D) Neurosurgical exposure facilitates elimination of the sinus "cranialization," (E) Reconstruction of calvarium. The nasofrontal duct and floor of the frontal sinus and ethmoid area have been bone grafted to isolate the nasal cavity from the intracranial cavity, (F) Reconstructed calvarium.
all patients with frontal sinus fractures that require surgical repair.
COMPLICATIONS Missed diagnosis and incorrect surgical management of frontal sinus fractures may result in potentially lifethreatening complications. Unrecognized or prolonged CSF leak may predispose to meningitis. CSF leaks repreMANAGEMENT OF FRONTAL SINUS FRACTURES
sent an open communication between the CSF rhinorrhea and bacteria of the upper respiratory tract. Early repair of the dural defect is the best method of avoiding this serious complication. Improper management of the frontal sinus mucosa and nasofrontal ducts will lead to obstructive pathological complications. The frontal sinus mucosa invaginates within small channels of the anterior and posterior walls. Therefore, when mucosal stripping is required, a high-speed burr and loupe magnification are used to 263
Fig 8. (Cont'd). (G) Patient appearance after surgery.
ensure complete mucosal removal. Incomplete mucosal exenteration will allow new mucosa to grow within an obstructed frontal sinus. This will produce mucoceles and mucous cysts. Similar problems occur from incomplete nasofrontal duct obliteration. If untreated, mucoceles may become infected (mucopyocele), leading to brain abscess and meningitis. Over time, sterile mucoceles may produce symptoms of chronic sinusitis and eventually cause bony erosion of the walls and floor of the frontal sinus (Fig 9). Frontal sinus complications are best classified into those occurring early, within the first 6 months after surgery, or late, occurring more than 6 months after initial treatment.7 A thorough understanding of frontal sinus pathology is crucial for recognizing and treating complications as early as possible. The most common early complication is frontal sinusitis33 Symptoms include fever, forehead pain, forehead erythema, diffuse headache, ocular pain, nasal pain, and swelling of one or all of these structures. 17CT scan is the most effective means of confirming the diagnosis. A C T scan of frontal sinusitis usually shows edema of the mucosa and may show fluid within the sinus. 8,9Significant sinus opacification is an indication of advanced disease and requires early surgical exenteration and obliteration of the frontal sinus. 17 Frontal sinusitis is always first treated with medical therapy. Management begins with a course of deconges264
tants and antibiotics. Antibiotic therapy should start as broad s p e c t r u m until specific organisms are isolated. If pain and s y m p t o m s persist or conditions deteriorate, operative i n t e r v e n t i o n is required. Patients should be followed closely a n d intervention considered as soon as possible to a v o i d m o r e advanced complications. Chronic s i n u s obstruction that is unresponsive to medical therapy m a y b e treated by a transnasal endoscopic approach. This m e t h o d allows wide resection of the intranasal median frontal sinus floor to allow adequate frontal sinus drainage. TM The endoscopic approach is actually a modification o f a procedure first described by Lothrop in 1899 l~ and later b y Close. s If successful, this approach provides a m i n i m a l l y invasive alternative to frontal sinus obliteration. Long-term outcome studies with this technique have s h o w n excellent functional results with good residual patency of the frontal sinus. 19 Other possible early complications of frontal sinus injury include meningitis and brain or epidural abscess. These are the most serious Complications of frontal sinus injury and involve up to approximately 6% of patients, a~Diagnosis is always confirmed by CT scan, and therapy is always surgical. Operative intervention generally involves an intracranial approach.21 The surgery is usually performed in conjunction with a neurosurgical team. The main goals of the operation include drainage of any abscess present, repair of the dural tear, and, finally, cranialization of the frontal sinus. Mucocele is a rare but possible late complication of frontal sinus injury.3,22 Symptoms of mucocele and its variants usually present in a very slow, progressive, and subtle fashion (Fig 10). Increased pressure from mucous accumulation within the sinus may produce headache, as well as frontal, orbital, and nasal pain. 21 Any of these symptoms presenting in a patient who has a history of treated or untreated frontal sinus fracture is highly suspicious for mucocele. CT scan will confirm the diagnosis and delineate the extent of disease. Early treatment by transnasal endoscopic rnarsupialization and stenting may be successful in removing the mucocele and establishing frontal sinus drainage.23 Late in their course, mucoceles may produce bone erosion of the boundaries of the frontal sinus. Treatment involves mucosal exenteration and oblit-
Fig 9. A patient With a mucocele presents with inflammation and drainage simultaneously from the upper-forehead area and from the upper eyelid. LEIPZlGER AND GLASBERG
Fig 10. (A) A CT scan of a patient with a remote, untreated frontal sinus fracture presenting as a mucocele. (B) Intraoperative view with anterior frontal sinus wall removed. Mucus is seen in the right aspect of the frontal sinus. The mucus must be removed, and the sinus eliminated by mucosal removal and bone grafting.
e r a t i o n of the s i n u s a n d n a s o f r o n t a l d u c t s . F r o n t a l b o n e anterior-contour irregularities m a y be reconstructed with c a l v a r i a l b o n e grafts or alloplastic m a t e r i a l s .
9.
SUMMARY
10.
T h e p r o p e r m a n a g e m e n t of a c u t e f r o n t a l s i n u s f r a c t u r e relies o n e a r l y a c c u r a t e d i a g n o s i s a n d t r e a t m e n t . M i s s e d d i a g n o s i s , d e l a y e d t r e a t m e n t , a n d i n c o r r e c t s u r g i c a l care m a y produce life-threatening complications. A surgical p l a n m u s t b e e s t a b l i s h e d after careful r e v i e w of the p h y s i c a l e x a m i n a t i o n a n d CT scan. The e x t e n t of the f r o n t a l sinus fracture determines the operative treatment, Correct m a n a g e m e n t of the a n t e r i o r a n d p o s t e r i o r walls, as w e l l as of the n a s o f r o n t a l d u c t , is m a n d a t o r y . A p p l i c a t i o n of these p r i n c i p l e s w i l l p r o d u c e a n aesthetic a n d safe f r o n t a l s i n u s that a v o i d s s e r i o u s c o m p l i c a t i o n s .
11.
REFERENCES 1. Luce EH: Frontal sinus fractures: Guidelines to management. Plast Reconstr Surg 80:500-510, 1987 2. Stanley RB Jr: Fractures of the frontal sinus. Clin Plast Surg 16:115-123, 1989 3. Lee D, Brody R, Har-E1 G: Frontal sinus outflow anatomy. Am J Rhinol 11:283-285, 1997 4. Heller EM, Jacobs JB, Holliday RA: Evaluation of the frontonasal duct in frontal sinus fractures. Head Neck 11:46-50, 1989 5. Rohrich RJ, Hollier LH: Management of frontal sinus fractures, changing concepts. Clin Plast Surg 19:219-232, 1992 '6. Olson EM, Wright DL, Hoffman HT, et al: Frontal sinus fractures: Evaluation of CT scans in 132 patients. Am J Neuroradiology 13:897-902, 1992 7. Harris L, Marano GD, McCorkle D: Nasofrontal duct: CT in frontal sinus trauma. Radiology 165:195-198, 1987 8. Close LG, Lee NK, Leach JL, et al: Endoscopic resection of the
MANAGEMENT OF FRONTAL SINUS FRACTURES
12. 13.
14.
15. 16.
17.
18.
19.
20. 21.
22. 23.
intranasal frontal sinus floor. Ann Otol Rhinol Laryngol 103:952-958, 1994 Bergara AR, Bergara C: Chronic frontoethmoidal sinusitis: Osteoplastic method according to author's technique. Ann Otorhinolaryngol 5:192, 1955 Goodale RL, Montgomery WW: Experiences with osteoplastic anterior wall approach to the frontal sinus. Arch Otolaryngol 68:271, 1958 Hardy SM, Montgomery WW: Osteoplastic frontal sinusotomy: An analysis of 250 operations. Ann Otol Rhinol Laryngo185:523,1976 Thaller SR, Donald P: The use of pericranial flaps in frontal sinus fractures. Ann Plast Surg 32:284-287, 1994 Helmy ES, Koh ML, Bays RA: Management of frontal sinus fractures. Review of the literature and clinical update. Oral Surg Oral Med Oral Path 69:137-148, 1990 Vasconez HC: Frontal sinus fractures: Controversies in management, in Worthington, P. and Evans, J (ed): Controversies in Aural and Maxillofacial Surgery, Philadelphia, PA, Saunder 1994, pp 267-274 Donald PJ: Frontal sinus ablation by cranialization: A report of 21 cases. Arch Otolaryngo1108:590, 1982 Onismi K, Nakajima T, Yoshimura Y: Treatment and therapeutic devices in the management of frontal sinus fractures. J Craniomaxillofac Surg 17:58, 1989 Ruoppi P, Seppa J, Nuutinen J: Acute frontal sinusitis--Etiological factors and treatment outcome. Acta Otolaryngol (Stockh) 113:201205, 1993 Gross WE, Gross CW, Becker D, et al: Modified transnasal endoscopic Lothrop procedure as an alternative to frontal sinus obliteration. Otolaryngol Head Neck Surg 113:427-434, 1995 Draf W, Weber R, Keerl R, et al: Current aspects of frontal sinus surgery. I: Endonasal frontal sinus drainage in inflammatory diseases of the paranasal sinuses. HNO 43:352-357, 1995 Wallis A, Donald PJ: Frontal sinus fractures--a review of 72 cases. Laryngoscope 98:593, 1988 Dolan RW, Chowdhury K: Diagnosis and treatment of intracranial complications of paranasal sinus infections. J Oral Maxillofac Surg 53:1080-1087, 1995 Kay PP: Frontal sinus fractures--to obliterate or not to obliterate. Outlook Plast Surg 9, 1989 Har-El: Telescopic extracranial approach to frontal mucoceles with intracranial extension. J Otolaryngo124:98-101,1995
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The proper management of acute frontal sinus fracture relies on early accurate diagnosis and treatment. Missed diagnosis, delayed treatment, and incorrect surgical care may produce life-threatening complications. A surgical plan must be established after careful review of the physical examination and CT scan. An algorithmic approach is utilized to determine the operative treatment. Correct management of the acute frontal sinus fracture will produce an aesthetic and safe frontal sinus that avoids serious complications. Copyright 9 1998by W.B. Saunders Company KEY WORDS: frontal sinus fracture
Proper management of acute frontal sinus fractures is paramount to achieving successful results while avoiding potentially life-threatening complications. Frontal sinus fractures are usually the result of direct, high-impact trauma and may be associated with other open or closed head injury. Treatment is based on an algorithmic approach determined by the extent and displacement of the frontal sinus fracture components. Prompt diagnosis and correct immediate care will produce a safe and aesthetically correct frontal sinus that minimizes serious complications. It has been estimated that the frontal sinus is involved in 5% to 12% of all maxillofacial trauma. 1,2 Approximately one third of frontal sinus fractures have been shown to involve the anterior table alone, whereas two thirds involve the anteroposterior tables and/or nasofrontal ducts. The frontal sinus is in dose proximity to the cribriform plate (skull base), anterior dura mater, frontal lobes, and intracranial venous sinus system. Therefore, complex frontal sinus fractures may result in a significant risk of fatality in the acute setting. Forty percent of frontal sinus fractures have an accompanying dural laceration. 1 Similarly, delay in treatment or improper repair may lead to meningitis, mucocele, or brain abscess#
ANATOMY Understanding the anatomy of the frontal sinus is critical for the evaluation and treatment of frontal sinus injury. The frontal sinus occupies the central frontal bone (Fig 1). It has several septations and often varies greatly in size. The thick anterior wall provides structural support. The thin posterior wall separates the sinus from the frontal lobes of the brain. The delicate floor of the frontal sinus corresponds to the roof of the orbits. 4 The funnel-shaped From the Division of Plastic Surgery, Long Island Jewish Medical Center, New Hyde Park, and the Division of Plastic Surgery, SUNY Health Sciences Center, Brooklyn, NY. Address reprint requests to Lyle S. Leipziger, MD, Chief, Division of Plastic Surgery, Long Island Jewish Medical Center, 27005 76th Ave, New Hyde Park, NY 11040. Copyright 9 1998 by W.B. Saunders Company 1071-0949/98/0503-000858.00/0
nasofrontal ducts, the only drainage system for the sinus, pass through the anterior ethmoidal air cells to exit adjacent to the ethmoidal infundibulum. 4 Injury to the nasofrontal ducts prevents adequate drainage of normal mucosal secretions and predisposes to the development of obstructive pathological complications such as mucocele.
DIAGNOSIS Trauma to the frontal sinus may produce overt or subtle physical findings. Symptoms of frontal sinus injury may include overlying skin lacerations, bruises, hematoma, anesthesia of the supraorbital nerve, and cerebrospinal fluid rhinorrhea# Physical examination consists of thorough palpation of the forehead. Lacerations directly overlying the frontal bone should be carefully probed to assess anterior wall integrity (Fig 2). Significant frontal ecchymosis and hematoma should raise suspicions of deeper injury. If frontal sinus fracture is suspected, the nose must be carefully inspected for cerebrospinal fluid (CSF) rhinorrhea. Any clear fluid draining from the nose should be sent to the laboratory for verification of CSF. Bloody nasal fluid may be tested at the bedside for CSF by placing a drop on a white cloth or paper towel. Any CSF will diffuse faster than the blood and create a clean halo around a central, more darkly tinged area ("halo" test). Although clinical evaluation is important, it cannot adequately define the extent of the frontal injury. Radiological evaluation of the frontal sinus fracture is instrumental in determining the need for surgery. Plain skull radiographs of a frontal sinus fracture may reveal an air fluid level. However, computed tomography (CT) scan is the gold standard for analyzing acute frontal sinus trauma 6 (Fig 3). Scans should be performed with narrow cuts (1.5 to 3 mm) and include sagittal and coronal views. Complete visualization of the frontal sinus, superior orbits, and nasoethmoidal area should be obtained. The degree of bone displacement, amount of comminution, and presence of pneumocephalus will determine the severity of the fracture. Proper evaluation of the integrity of the anterior
Operative Techniques in Plastic and Reconstructive Surge~ Vol 5, No 3 (August), 1998: pp 257-265
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Fig 2. A deep forehead laceration with orbital ecchymosis indicates the superficial clinical symptoms that often present with frontal sinus fractures. CT scans should be obtained for anyone with significant blunt trauma to the forehead and supraorbital areas. The bilateral spectacle hematoma is diagnostic for an anterior fossa fracture.
Fig 1. The frontal sinus is quite variable in size and in symmetry, irregular septations divide it into right and left sides, often asymmetrically; partial or complete subseptations may be present. A comminuted frontal sinus fracture is illustrated above.
and posterior sinus walls, as well as of the nasofrontal ducts, is crucial for determining proper fracture management. Despite technological advances in CT imaging, the status of the nasofrontal ducts is still a difficult assessment for even the most experienced radiologistso7 Unless proven otherwise, fractures that extend into the nasofrontal ducts should be considered obstructive and require surgical intervention.
Fig 3. (A) An anterior wall fracture, largely unilateral and with depression is shown. Even a cutaneous laceration can be recognized in the CT scan. (B) A diffuse soft-tissue contusion is present with anterior and posterior wall fractures. Visible in the CT scan are an air-fluid level and sinus (nasofrontal duct) obstruction. The posterior wall fracture is slightly displaced, and a small amount of pneumocephalus is present. The probability of a CSF leak is significant. (C) Comminuted anterior and posterior wall fractures from a gunshot wound. This injury requires exploration and repair of the dura and debridement of any devitalized cerebral tissue.
258
LEIPZIGER AND GLASBERG
AnteriorTable Fracture
ing the frontal sinus pathologic condition. 11 Variations of this technique provide the current basis for surgical management of frontal sinus fractures. 12
CURRENT SURGICAL CARE
Displaced
No
Yes
No
Nasofrontal Duct involved
Operative Intervention
The treatment of frontal sinus fractures is determined exclusively by the extent of damage to the specific frontal sinus anatomical components. An algorithmic treatment approach may be used that is based on which anatomic components of the frontal sinus are involved in the fracture. Specifically, fracture management is determined by the amount of damage to the anterior frontal sinus wall, posterior frontal sinus w a l l nasofrontal duct, or the combined anterior/posterior wall (Figs 4 and 5). 13 Combined Anterior/PosterlorTable Fracture
No
Yes
Displaced PosteriorWall Reduction/Stabilization with Sinus Preservation
Reduction/Stabilization and then Sinus Obliteration with Spontaneous Osteogenesis with or without Bone Graft
No (<1 table width)
Yes (>1 table width)
CSF Leak
CSF Leak
Fig 4. An algorithm from Rohrich et al that describes a pathway for the management of anterior wall fractures. Displaced fractures, or those with nasofrontal duct obstruction, should be managed with obliteration and bone grafting. (Reprinted with permission. 5)
HISTORY OF SURGICAL TREATMENT Frontal sinus injuries were first treated by Reidel in 1898 by removing the entire anterior table of bone and allowing the anterior soft tissues to fall into the empty sinus space. 7 This resulted in significant contour deformities, as well as complications from nasofrontal duct obstruction. Other surgeons attempted to refine this technique to improve on the cosmetic and functional results. In 1921, Lynch devised the external frontoethmoidectomy with resection of only the frontal sinus floor, ethmoid bone, and middle turbinates. 7 This allowed for improved drainage and decreased the contour deformity. However, this procedure could only be used when the anterior table of bone was uninvolved. A variation of this technique using nasoendoscopy is practiced today to treat some of the complications of frontal sinus fracture. 8An endoscope may be passed from the nose to enter the sinus and relieve obstruction. Others have used endoscopic approaches for anterior sinus wall repair. Bergara and Bergara in 19519 and later Goodale and Montgomery 1~ devised the osteoplastic flap procedure for sinus obliteration. This was the first attempt to address frontal sinus fractures in an aesthetic and functional manner. The frontal sinus was approached either through a fracture present in the anterior wall or through a window created in the bone. The anterior wall would be removed, the frontal sinus explored, the mucosa stripped, the sinus defect obliterated, and the anterior wall replaced. This procedure avoided frontal contour deformity while addressMANAGEMENT OF FRONTAL SINUS FRACTURES
No
I
No
Yes
No Operative Intervention
Allow 4-7 days for resolution. If persistent, cr a C O ;
Yes
Nasofrontal 1. Duct Involved i S ~ ~ ~
No
1. Reduction/Stabilization of Anterior Wall 2. Sinus Preservation
Reduction/ Stabilization of Anterior Wall l ization
Yes
1. Reduction/Stabilization of Anterior Wall 2. Sinus Obliteration with Spontaneous Osteogenesis with or without bone graft
Fig 5. Algorithm for management of combined anteroposterior wall fractures. Fractures that have displaced anterior and posterior walls require obliteration or cranialization depending on whether or not neurosurgical exposure (a frontal bone flap) has been achieved. In cranialization, the sinus is converted to a portion of the intracranial cavity by its elimination. This procedure requires neurosurgical exposure. In obliterative techniques, the sinus and duct are obliterated with bone graft material. The sinus is thereby defunctionalized after removal of its mucosa. (Reprinted with permission, s) 259
O
Fig 6. (A) CT scan of depressed anterior wall. (B) Anterior wall fracture in a patient with large sinus. The anterior wall depressed fracture is visualized. (C) The fragments of the depressed anterior wall are removed and placed on a back table. (D) The large sinus is shown. It is treated with reconstruction where the remaining mucosa is preserved, (E) The use of a small fragment plate and screw system enables repositioning and stabilization of the anterior wall.
Isolated, nondisplaced fractures of the anterior wall of the frontal sinus may be managed without surgery in the absence of duct obstruction. If anterior wall displacement is present, open reduction and rigid fixation best treats the fracture. This avoids a frontal-bone aesthetic deformity. 14 The sinus may be approached through an appropriate skin laceration (if present) or with a coronal incision. The best exposure is obtained through the use of the coronal incision. At the time of sinus exploration, any devitalized mucosa is removed. This should include the traumatized mucosa on the underside of the broken anterior-wall bone fragments. The sinus should be copiously irrigated with normal saline. Normal mucosa within the frontal sinus is left intact. The nasofrontal ducts will remain functional as long as they have not been injured by the fracture or by surgical dissection. The anterior sinus wall is anatomically reduced or reconstructed, and rigid fixation is accomplished through the use of a microplating system. All the anterior frontal-bone fragments should be used in the repair. If significant anterior-wall bone loss is present, or if 260
the segments are judged too small to be useful, split calvarial bone grafts can be collected for reconstruction. This procedure (repairing the frontal sinus while maintaining nasofrontal duct patency) is known as functional treatment. This can only be accomplished in the absence of nasofrontal duct injury (Fig 6). Because of anatomic proximity, any fracture of the anterior frontal sinus wall can be associated with nasofrontal duct injury and functional or anatomic obstruction. Preoperative CT scans that show displaced anterior wall fractures extending to the base of the sinus or into the anterior ethmoidal area are highly suspicious for duct injury. Intraoperative evaluation of the nasofrontal duct should then be performed at the time of sinus exploration. Any fracture that extends into the nasofrontal duct may produce obstruction and therefore requires nasofrontal duct obliteration. Duct obstruction may also be analyzed intraoperatively by first using cocaine vasoconstriction on the mucosa and then attempting to pass liquid or fluorescein through the ducts. 3,7 If the dye does not pass to the LEIPZIGER AND GLASBERG
Fig 7. Management of an anterior-posterior wall fracture with obliterative techniques. (A) A combined anterior and posterior wall fracture is shown that has resulted in partial obstruction of the nasofrontal duct in CT scan. (B) Surgical exposure showing the fractures of the sinus. (C) A portion of the sinus wall is removed to accomplish safe sinus management (elimination). (D) The mucosa is removed, and the walls of the sinus are lightly burred with an abrasive bit to eliminate invaginations of the mucosa into the bone. This prevents mucosal regeneration. (E) Particulate bone graft is obtained from the external table of the parietal calvarium. (F) This material is used to pack the sinus after obliteration of the duct with a cortical cancellous bone graft wedged into the duct.
nose, then the ducts are obstructed. Any evidence of nasofrontal duct obstruction makes obliteration of both the sinus and ducts mandatory. This is performed by first carefully removing all the mucosa from the sinus and both MANAGEMENT OF FRONTAL SINUS FRACTURES
ducts (mucosal exenteration). A high-speed burr is then used to lightly remove the inner cortex of bone from the sinus. Calvarial bone grafts are then contoured as formfitting plugs to completely obliterate the nasofrontal ducts.
261
Fig 7. (Cont'd). (G) The anterior sinus wall is replaced over the particulate graft material. (H) A small-fragment plate and screw system replaces the fragments of the anterior frontal sinus wall,
Some investigators advocate nasofrontal duct occlusion with free temporalis fascia and a pedicled flap of muscular fascial tissue or corrugator and procerus muscle. 2,3,14Obliteration of the frontal sinus is then performed. The best material for frontal sinus obliteration remains controversial. Spontaneous osteoneogeriesis or the implantation of temporalis muscle, autologous fat, or bone grafts have been recommended. Spontaneous osteoneogenesis of the frontal sinus occurs by the slow ingrowth of bone from the burred-down inner cortex. Care must be taken to completely remove all sinus mucosa and pack the nasofrontal ducts adequately. Improper sinus treatment or unrecognized duct injury may predispose to the potentially devastating complications of mucocele and mucopyocele. Treatment of displaced anterior wall fractures with nasofrontal duct obstruction requires complete mucosal exenteration of the frontal sinus, followed by light burring of the bony walls. Form-fitting calvarial bone graft occlusion of the nasofrontal ducts is then performed. If the frontal sinus is small packed calvarial bone chips may be used to obliterate the sinus (Fig 7). If the frontal sinus is large, we prefer spontaneous osteoneogenesis to occur. If only one of the nasofrontal ducts is injured, we still prefer bilateral duct and sinus obliteration because patency of the uninvolved duct cannot be assured. Fractures of the posterior wall of the frontal sinus are often associated with intracranial injury. CSF leak, pneumocephalus, and frontal lobe contusion may be present. Evaluation and treatment may involve the combined efforts of the plastic surgeon and neurosurgeon. Appropriate management is based on the degree of posterior wall displacement or comminution, involvement of the nasofrontal ducts, and presence of a CSF leak. 7 No operative intervention is required for posterior wall fractures that are nondisplaced and exhibit no evidence of CSF leak. All fractures of the posterior sinus wall that are significantly displaced require operative intervention. If there is no CSF leak and the nasofrontal ducts are not involved, the sinus can be preserved (functional treatment) with rigid fixation of both the anterior and posterior sinus walls. If there is no CSF leak but the nasofrontal ducts are involved, complete rnucosal exenteration with sinus and duct obliteration is performed. Severely displaced and comminuted fractures 262
of the posterior wall associated with CSF leaks require a cranialization procedure (Fig 8). Cranialization is the removal of the posterior wall of the frontal sinus, which allows the brain to occupy the space. Once the posterior wall has been removed, the dural injury may be repaired. Complete sinus mucosal exenteration is followed by obliteration of the nasofrontal ducts with bone grafts as described above. A pedicled galeal-frontalis flap may be obtained and advanced over the occluded nasofrontal ducts. This provides a vascularized barrier between the dural repair and nasofrontal ducts. The anterior sinus wall is then restored. Multiple studies have shown this to be an effective method of treating these types of fractures while maintaining a good aesthetic contour and preventing further rhinorrhea. 7,15A6 Cases of CSF leaks that present with nondisplaced or minimally displaced fractures of the posterior wall of the frontal sinus are less common. These situations are usually allowed 5 to 7 days to resolve spontaneously with observation. If the CSF leak continues, cranialization of the frontal sinus and repair of the dural laceration are performed. Anterior-posterior-wall frontal sinus fractures may be managed by the same principles as previously described. Severity of the fracture will guide treatment. Nondisplaced fractures are managed with observation. Frontal sinus fractures that avoid the nasofrontal ducts will undergo "functional treatment." These fractures will be anatomically reduced and bone fragments rigidly fixed. If the nasofrontal ducts are intact, frontal sinus function will be preserved. Nasofrontal duct injury in association with anterior and posterior wall displacement requires mucosal stripping, followed by sinus and duct obliteration. Severe posterior-wall injury will require cranialization. Open fractures of the frontal sinus require immediate attention. Wounds should be d6brided and lavaged. Repair of the sinus fracture should follow the previously described basic management principles. Closed fractures of the frontal sinus should be repaired in a timely fashion. Definitive fracture treatment should occur within 24 to 72 hours of injury unless other significant injuries contraindicate surgical care. Intravenous antibiotics are administered preoperatively and for at least 48 hours postoperatively in LEIPZIGER AND GLASBERG
Fig8. An anteroposterior wall fracture managed by cranialization. (A) CT scan of combined fracture of the anteroposterior wall. (B) Appearance of injury, (C and D) Neurosurgical exposure facilitates elimination of the sinus "cranialization," (E) Reconstruction of calvarium. The nasofrontal duct and floor of the frontal sinus and ethmoid area have been bone grafted to isolate the nasal cavity from the intracranial cavity, (F) Reconstructed calvarium.
all patients with frontal sinus fractures that require surgical repair.
COMPLICATIONS Missed diagnosis and incorrect surgical management of frontal sinus fractures may result in potentially lifethreatening complications. Unrecognized or prolonged CSF leak may predispose to meningitis. CSF leaks repreMANAGEMENT OF FRONTAL SINUS FRACTURES
sent an open communication between the CSF rhinorrhea and bacteria of the upper respiratory tract. Early repair of the dural defect is the best method of avoiding this serious complication. Improper management of the frontal sinus mucosa and nasofrontal ducts will lead to obstructive pathological complications. The frontal sinus mucosa invaginates within small channels of the anterior and posterior walls. Therefore, when mucosal stripping is required, a high-speed burr and loupe magnification are used to 263
Fig 8. (Cont'd). (G) Patient appearance after surgery.
ensure complete mucosal removal. Incomplete mucosal exenteration will allow new mucosa to grow within an obstructed frontal sinus. This will produce mucoceles and mucous cysts. Similar problems occur from incomplete nasofrontal duct obliteration. If untreated, mucoceles may become infected (mucopyocele), leading to brain abscess and meningitis. Over time, sterile mucoceles may produce symptoms of chronic sinusitis and eventually cause bony erosion of the walls and floor of the frontal sinus (Fig 9). Frontal sinus complications are best classified into those occurring early, within the first 6 months after surgery, or late, occurring more than 6 months after initial treatment.7 A thorough understanding of frontal sinus pathology is crucial for recognizing and treating complications as early as possible. The most common early complication is frontal sinusitis33 Symptoms include fever, forehead pain, forehead erythema, diffuse headache, ocular pain, nasal pain, and swelling of one or all of these structures. 17CT scan is the most effective means of confirming the diagnosis. A C T scan of frontal sinusitis usually shows edema of the mucosa and may show fluid within the sinus. 8,9Significant sinus opacification is an indication of advanced disease and requires early surgical exenteration and obliteration of the frontal sinus. 17 Frontal sinusitis is always first treated with medical therapy. Management begins with a course of deconges264
tants and antibiotics. Antibiotic therapy should start as broad s p e c t r u m until specific organisms are isolated. If pain and s y m p t o m s persist or conditions deteriorate, operative i n t e r v e n t i o n is required. Patients should be followed closely a n d intervention considered as soon as possible to a v o i d m o r e advanced complications. Chronic s i n u s obstruction that is unresponsive to medical therapy m a y b e treated by a transnasal endoscopic approach. This m e t h o d allows wide resection of the intranasal median frontal sinus floor to allow adequate frontal sinus drainage. TM The endoscopic approach is actually a modification o f a procedure first described by Lothrop in 1899 l~ and later b y Close. s If successful, this approach provides a m i n i m a l l y invasive alternative to frontal sinus obliteration. Long-term outcome studies with this technique have s h o w n excellent functional results with good residual patency of the frontal sinus. 19 Other possible early complications of frontal sinus injury include meningitis and brain or epidural abscess. These are the most serious Complications of frontal sinus injury and involve up to approximately 6% of patients, a~Diagnosis is always confirmed by CT scan, and therapy is always surgical. Operative intervention generally involves an intracranial approach.21 The surgery is usually performed in conjunction with a neurosurgical team. The main goals of the operation include drainage of any abscess present, repair of the dural tear, and, finally, cranialization of the frontal sinus. Mucocele is a rare but possible late complication of frontal sinus injury.3,22 Symptoms of mucocele and its variants usually present in a very slow, progressive, and subtle fashion (Fig 10). Increased pressure from mucous accumulation within the sinus may produce headache, as well as frontal, orbital, and nasal pain. 21 Any of these symptoms presenting in a patient who has a history of treated or untreated frontal sinus fracture is highly suspicious for mucocele. CT scan will confirm the diagnosis and delineate the extent of disease. Early treatment by transnasal endoscopic rnarsupialization and stenting may be successful in removing the mucocele and establishing frontal sinus drainage.23 Late in their course, mucoceles may produce bone erosion of the boundaries of the frontal sinus. Treatment involves mucosal exenteration and oblit-
Fig 9. A patient With a mucocele presents with inflammation and drainage simultaneously from the upper-forehead area and from the upper eyelid. LEIPZlGER AND GLASBERG
Fig 10. (A) A CT scan of a patient with a remote, untreated frontal sinus fracture presenting as a mucocele. (B) Intraoperative view with anterior frontal sinus wall removed. Mucus is seen in the right aspect of the frontal sinus. The mucus must be removed, and the sinus eliminated by mucosal removal and bone grafting.
e r a t i o n of the s i n u s a n d n a s o f r o n t a l d u c t s . F r o n t a l b o n e anterior-contour irregularities m a y be reconstructed with c a l v a r i a l b o n e grafts or alloplastic m a t e r i a l s .
9.
SUMMARY
10.
T h e p r o p e r m a n a g e m e n t of a c u t e f r o n t a l s i n u s f r a c t u r e relies o n e a r l y a c c u r a t e d i a g n o s i s a n d t r e a t m e n t . M i s s e d d i a g n o s i s , d e l a y e d t r e a t m e n t , a n d i n c o r r e c t s u r g i c a l care m a y produce life-threatening complications. A surgical p l a n m u s t b e e s t a b l i s h e d after careful r e v i e w of the p h y s i c a l e x a m i n a t i o n a n d CT scan. The e x t e n t of the f r o n t a l sinus fracture determines the operative treatment, Correct m a n a g e m e n t of the a n t e r i o r a n d p o s t e r i o r walls, as w e l l as of the n a s o f r o n t a l d u c t , is m a n d a t o r y . A p p l i c a t i o n of these p r i n c i p l e s w i l l p r o d u c e a n aesthetic a n d safe f r o n t a l s i n u s that a v o i d s s e r i o u s c o m p l i c a t i o n s .
11.
REFERENCES 1. Luce EH: Frontal sinus fractures: Guidelines to management. Plast Reconstr Surg 80:500-510, 1987 2. Stanley RB Jr: Fractures of the frontal sinus. Clin Plast Surg 16:115-123, 1989 3. Lee D, Brody R, Har-E1 G: Frontal sinus outflow anatomy. Am J Rhinol 11:283-285, 1997 4. Heller EM, Jacobs JB, Holliday RA: Evaluation of the frontonasal duct in frontal sinus fractures. Head Neck 11:46-50, 1989 5. Rohrich RJ, Hollier LH: Management of frontal sinus fractures, changing concepts. Clin Plast Surg 19:219-232, 1992 '6. Olson EM, Wright DL, Hoffman HT, et al: Frontal sinus fractures: Evaluation of CT scans in 132 patients. Am J Neuroradiology 13:897-902, 1992 7. Harris L, Marano GD, McCorkle D: Nasofrontal duct: CT in frontal sinus trauma. Radiology 165:195-198, 1987 8. Close LG, Lee NK, Leach JL, et al: Endoscopic resection of the
MANAGEMENT OF FRONTAL SINUS FRACTURES
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19.
20. 21.
22. 23.
intranasal frontal sinus floor. Ann Otol Rhinol Laryngol 103:952-958, 1994 Bergara AR, Bergara C: Chronic frontoethmoidal sinusitis: Osteoplastic method according to author's technique. Ann Otorhinolaryngol 5:192, 1955 Goodale RL, Montgomery WW: Experiences with osteoplastic anterior wall approach to the frontal sinus. Arch Otolaryngol 68:271, 1958 Hardy SM, Montgomery WW: Osteoplastic frontal sinusotomy: An analysis of 250 operations. Ann Otol Rhinol Laryngo185:523,1976 Thaller SR, Donald P: The use of pericranial flaps in frontal sinus fractures. Ann Plast Surg 32:284-287, 1994 Helmy ES, Koh ML, Bays RA: Management of frontal sinus fractures. Review of the literature and clinical update. Oral Surg Oral Med Oral Path 69:137-148, 1990 Vasconez HC: Frontal sinus fractures: Controversies in management, in Worthington, P. and Evans, J (ed): Controversies in Aural and Maxillofacial Surgery, Philadelphia, PA, Saunder 1994, pp 267-274 Donald PJ: Frontal sinus ablation by cranialization: A report of 21 cases. Arch Otolaryngo1108:590, 1982 Onismi K, Nakajima T, Yoshimura Y: Treatment and therapeutic devices in the management of frontal sinus fractures. J Craniomaxillofac Surg 17:58, 1989 Ruoppi P, Seppa J, Nuutinen J: Acute frontal sinusitis--Etiological factors and treatment outcome. Acta Otolaryngol (Stockh) 113:201205, 1993 Gross WE, Gross CW, Becker D, et al: Modified transnasal endoscopic Lothrop procedure as an alternative to frontal sinus obliteration. Otolaryngol Head Neck Surg 113:427-434, 1995 Draf W, Weber R, Keerl R, et al: Current aspects of frontal sinus surgery. I: Endonasal frontal sinus drainage in inflammatory diseases of the paranasal sinuses. HNO 43:352-357, 1995 Wallis A, Donald PJ: Frontal sinus fractures--a review of 72 cases. Laryngoscope 98:593, 1988 Dolan RW, Chowdhury K: Diagnosis and treatment of intracranial complications of paranasal sinus infections. J Oral Maxillofac Surg 53:1080-1087, 1995 Kay PP: Frontal sinus fractures--to obliterate or not to obliterate. Outlook Plast Surg 9, 1989 Har-El: Telescopic extracranial approach to frontal mucoceles with intracranial extension. J Otolaryngo124:98-101,1995
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