Complications of frontal sinus fractures

Abstract

Frontal sinus fracture represents 5 to 12% of all maxillofacial fractures. Because of the anatomic position of the frontal sinus and the enormous amount of force required to create a fracture in this area, these injuries are often devastating and associated with other trauma. Associated injuries include skull base, intracranial, ophthalmologic, and maxillofacial. Complications should be categorized to address these four areas as well as the skin-soft tissue envelope, muscle, and bone. Other variables that should be examined are age of the patient, gender, mechanism of injury, fracture pattern, method of repair, and associated injuries. Management of frontal sinus fractures is so controversial that the indications, timing, method of repair, and surveillance remain disputable among several surgical specialties. The one universal truth that is agreed upon is that all patients undergoing reconstructive surgery of the frontal sinus have a lifelong risk for delayed complications. It is hoped that when patients do experience the first symptoms of a complication, they seek immediate medical attention and avoid potentially life-threatening situations and the need for crippling or disfiguring surgery. The best way to facilitate this is through long-term follow-up and routine surveillance.

Keywords: Complication; acute; chronic; fracture; frontal; sinus.

Figure 1

Photograph of patient involved in a motor vehicle accident with open, linear, minimally displaced anterior table frontal sinus fracture. This is the usual presentation for an open frontal sinus fracture with the usual orbital, maxillofacial, neurologic, and ophthalmologic sequelae.

Figure 2

Intraoperative photograph of anterior and posterior wall frontal sinus fractures with no CSF leak and destruction of the nasofrontal ostia (drainage system).

Figure 3

Placement of a well-vascularized pericranial flap for separation of the anterior skull base from the nasal cavity. The ducts are plugged with temporalis muscle after thorough mucosal removal, and the pericranial flap is tucked in and secured with fibrin glue.

Figure 4

Mucocele eroding through anterior table of old frontal sinus fracture patient. This particular case is 8 years after original treatment (reconstruction of anterior wall). This again demonstrates the need for constant follow-up and periodic imaging studies.

Figure 5

The frontal sinus mucosa is tenacious. The mucosa looks black in this frontal sinus fracture with extension into the orbit. It is ciliated pseudostratified columnar epithelium with unidirectional sweeping motion toward the nasofrontal ostia. The mucosa is densely adherent to the diplopic veins via the foramina of Breschet.

Figure 6

Anterior and posterior table fracture with comminution and displacement of posterior table with CSF leak. (A) Elevation of pericranial flap, (B) comminution of posterior table with CSF leak, (C) posterior table fracture with dural tear, (D) cranialization with repair of dura, (E) placement of pericranial flap to separate anterior skull base from nasal cavity, (F) reconstruction of anterior table.

Figure 7

Computed tomography scan of isolated posterior table fracture with pneumocephalus.

Figure 8

(A) Full-thickness injury through anterior and posterior tables of frontal sinus with loss of skin–soft tissue envelope and devitalized dura in the middle of the wound. (B) Outline for thoracodorsal artery perforator flap (T-DAP) for wound coverage. (C) Excellent pedicle length of T-DAP to reach neck if temporal vessels are not adequate. (D) Inset of T-DAP with closure of defect (vascularized fat used to obliterate remaining sinus). (E) Final result at 1-year postoperative visit.

Figure 9

Frontal bone chronic contour irregularity after frontal impact trauma.

Figure 10

(A) Obliteration of frontal sinus with pericranial flap and cancellous bone. (B) Reconstruction of anterior table with split-calvarial bone graft.