Evaluation of a Minimally Disruptive Treatment Protocol for Frontal Sinus Fractures

Abstract

Importance: Despite common goals of frontal sinus fracture treatment (restoring forehead contour and creating a safe sinus), there remains significant variability in evaluation and treatment.

Objective: To describe our experience with a minimally disruptive treatment protocol for the treatment of frontal sinus fractures.

Design, setting, and participants: Analysis of prospectively collected data from 2010 through 2015 at a level 1 trauma center. All patients with frontal sinus fractures treated with our protocol from January 2010 to December 2015. Patients with poor follow-up and/or incomplete medical records were excluded from analysis.

Main outcomes and measures: Presence of an aerated frontal sinus and aesthetically acceptable forehead contour. Secondary outcome measures were complications related to frontal sinus fractures.

Results: A total of 39 patients were treated under our minimally disruptive protocol, and 25 patients were included in the study; 18 (72%) were male and 7 (28%) were female. Their ages ranged from 6 to 62 years. After review, 22 patients had both clinical and radiographic follow-up. No patients underwent immediate frontal sinus repair. Five of 22 patients underwent surgery for indications other than their frontal sinus fracture: 1 of 5 patients underwent immediate surgical repair due to bilateral LeFort fractures, and 4 of 5 underwent delayed surgery due to nasal polyps (1 patient), scar revision (1 patient), and concomitant LeFort fractures (2 patients). Two of 22 patients (9%) underwent frontal sinus repair after outpatient surveillance due to persistent cerebrospinal fluid leak (1 patient) and orbital roof fracture (1 patient). The remaining 20 patients were treated nonoperatively, and 19 of 20 (95%) had spontaneous improvement in opacification and/or contour deformity. Twelve of 20 patients (60%) had improvement or resolution in both. One patient had ongoing partial opacification and deformity at the 3-month follow-up but was asymptomatic and had bony contour that was aesthetically acceptable to the patient. There were no complications. The median of all follow-up was 3 months.

Conclusions and relevance: Frontal sinus fractures treated nonoperatively had a high rate of spontaneous ventilation and bony autoreduction with aesthetically acceptable frontal bone remodeling. There were no complications in the nonoperative group. The initial results of this study support further study of the safety and efficacy of a minimally disruptive protocol for frontal sinus fractures.

Level of evidence: 4.

Figure 1.. Algorithm for Frontal Sinus Fracture (FSF) Treatment

This was the treatment algorithm for FSFs that has been applied at our medical center. CSF indicates cerebrospinal fluid; CT, computed tomography. ^aImmediate repair occurred during the initial hospitalization, while delayed repair occurred any time after discharge from the tertiary medical center.

Figure 2.. Spontaneous Reventilation and/or Autoreduction of Frontal Sinus Fractures via Computed Tomographic Imaging

A, Type 3A frontal sinus fracture. B, Three-month postinjury imaging of patient in panel A, revealing improvement in opacification with ongoing contour deformity. C, Type 3A frontal sinus fracture. D, Two-month postinjury imaging of patient in panel C, revealing improvement in contour deformity with ongoing opacification. E, Type 2B frontal sinus fracture. F, One-month postinjury imaging of patient shown in panel E, revealing improvement in opacification and contour deformity.