Frontal Sinus Fractures: Evolving Clinical Considerations and Surgical Approaches

Abstract

Frontal sinus fractures are an uncommon injury of the maxillofacial skeleton, and account for 5-15% of all maxillofacial fractures. As the force of impact increases, fractures may extend beyond the anterior table to involve adjacent skull, posterior table and frontal sinus outflow tract (FSOT). Fractures at these subsites should be evaluated independently to assess the need for and type of operative intervention. Historically, these fractures were managed aggressively with open techniques resulting in obliteration or cranialization. With significant injuries, these approaches are still indispensable. However, the treatment of frontal sinus fractures has changed dramatically over the past half-century, and recent case series have demonstrated favorable outcomes with conservative management. Concurrently, there has been an increasing role of minimally invasive endoscopic techniques, both for primary and expectant management, with a focus on sinus preservation. Here, we review the diagnosis and management of frontal sinus fractures, with an emphasis on subsite evaluation. Following a detailed assessment, an appropriate treatment strategy is selected from a variety of open and minimally invasive approaches available in the surgeon's armamentarium.

Keywords: endoscopic sinus surgery; frontal sinus; frontal sinus fractures; frontal sinus outflow tract; minimally invasive.

Fig. 1

(a) CT in the sagittal plane of the frontal sinus outflow tract (FSOT). (b) Corresponding illustration of the frontal sinus outflow tract (dotted arrow) bordered anteriorly by the agger nasi cell and posteriorly by the suprabullar and bullar cells.

Fig. 2

CT in the axial plane demonstrating a comminuted, displaced bilateral fracture of the anterior table of the frontal sinus fracture. In the acute setting, significant soft tissue edema may obscure a palpable deformity.

Fig. 3

A coronal flap offers wide exposure of the frontal sinus. In this case, a mesh aids in reapproximating a significantly comminuted anterior table fracture.

Fig. 4

The anterior table may be reduced via medial sub-brow trephine incisions. An external splint maintains the dome-shaped contour of the anterior table.

Fig. 5

(a) CT in the sagittal plane demonstrating a displaced, comminuted fracture of the posterior table. There are also associated fractures of the anterior skull base along with obstruction of the FSOT with bony fragments. (b) CT in the coronal plane of the same fracture.

Fig. 6

CT in the coronal plane demonstrating a right frontal sinus mucocele. The right frontal sinus is completely opacified with associated bony resorption at the superior orbit.

Fig. 7

Intraoperative, endoscopic view of a posterior table frontal sinus fracture with CSF leak. After adequate exposure, the fracture is manually reduced and surrounding mucosa is removed prior to graft placement.

Fig. 8

CT in the coronal plane of a 33-year-old male who underwent left frontal sinus obliteration with abdominal fat and temporalis fascia ten years prior due to trauma. There is osteoneogenesis with soft tissue densities representing fat. While no mucocele is identified, this patient underwent re-exploration due to persistent left sided frontal pain.