Sinus preservation management for frontal sinus fractures in the endoscopic sinus surgery era: a systematic review

Abstract

We systematically reviewed the existing literature supporting the efficacy and safety of sinus preservation management for frontal sinus fractures in the modern era of endoscopic frontal sinus surgery. A systematic review of the English literature for the targeted objective was conducted using the PubMed database between January 1995 and August 2008. The PubMed database was queried using two major search terms of frontal sinus fracture or frontal sinus injury along with manual review of citations within bibliographies. Citations acquired from the primary search were filtered and relevant abstracts were identified that merited full review. Articles were identified that included any cohort of patients with frontal sinus fractures involving the frontal sinus outflow tract or posterior wall with sinus preservation management. A total of 231 citations were generated, and 56 abstracts were identified as potentially relevant articles. Sixteen articles merited full review, with seven articles meeting inclusion criteria for sinus preservation. There were 515 total patients in the studies with 350 patients managed with frontal sinus preservation. Similar short-term complications and effectiveness were found between fractures managed with sinus preservation and those with traditional management. Sinus preservation appears to be a safe and effective management strategy for select frontal sinus fractures. More transparent reporting of management strategies for individual cases or cohorts is needed. A standardized algorithm and categorization framework for future studies are proposed. Longer-term follow-up and larger prospective studies are necessary to assess the safety and efficacy of sinus preservation protocols.

Keywords: Frontal sinus trauma; endoscopic sinus surgery; frontal sinus outflow tract; osteoplastic obliteration; sinus cranialization; sinus preservation.

Figure 1

Proposed algorithm for reporting management of frontal sinus fractures. FSOT, frontal sinus outflow tract.

Figure 2

Selection of articles for inclusion in review.

Figure 3

(A–F) Fracture classification and management strategy using proposed algorithm for included studies. CSF, cerebrospinal fluid; FSOT, sinus outflow tract.

Figure 4

(A) Preoperative axial computed tomography (CT) demonstrating a displaced fracture of the anterior table of the frontal sinus. (B) Preoperative coronal CT demonstrating extensive fractures in the region of the frontal sinus outflow tract (FSOT). (C) Preoperative axial CT demonstrating associated naso-orbital ethmoid fracture and likely FSOT.

Figure 5

Patient at 3 months postoperatively with persistent frontal sinus outflow tract obstruction even with maximal medical therapy. (A) Coronal computed tomography demonstrating residual right frontal sinus opacification after open reduction and internal fixation of anterior frontal sinus table and naso-orbital ethmoid fracture repair with sinus preservation. (B) Intraoperative nasal view of purulent discharge being suctioned from the nonventilated frontal sinus during the endoscopic frontal sinus surgery.

Figure 6

(A) Postoperative coronal computed tomography scan after unilateral extended frontal sinusotomy (Draf type III) demonstrating frontal sinus ventilation. (B) Endoscopic examination in the office at 6 months demonstrating patency of the open reduction and internal fixation. The screws used for fixation of the anterior table fracture are seen penetrating the wall of the frontal sinus.