An Endonasal Incision Adds a Second Vector of Manipulation During Percutaneous Reduction of Fractures Involving the Frontonasal Region

Abstract

Study design: A case report.

Objective: To describe a modification of percutaneous reduction of frontal sinus and/or naso-orbito-ethmoid (NOE) fractures, adding an endonasal intercartilaginous incision to provide a second vector of manipulation.

Methods: Case report with particular attention paid to surgical technique, followed by a brief review of relevant literature.

Results: Technique: A Carroll-Girard screw is used to engage the thickest part of the anterior wall of the frontal bone through a stab incision just superior to the frontonasal junction. An endonasal intercartilaginous incision is then made and a Cottle elevator is introduced to manipulate the fracture from the inferior aspect of the frontonasal junction. The percutaneous screw and the endonasal elevator provide perpendicular vectors for manipulation, thereby improving ability to reduce fractures when percutaneous traction alone is not successful. The technique is described here in a patient with anterior table frontal sinus fractures combined with posteriorly displaced Markowitz type 1 NOE fractures.

Conclusion: While percutaneous reduction of frontal sinus fractures has been previously described, this report adds a subtle but important modification both in indication and technique for optimizing reduction while maintaining surgical simplicity and minimizing morbidity.

Keywords: Carroll-Girard; NOE; frontal sinus; intercartilaginous incision; percutaneous.

Figure 1.

Nineteen-year-old male with marked flattening of the nasal bridge, loss of projection at the nasal root with indentation of the frontonasal junction. There is also mild left-sided telecanthus.

Figure 2.

Sagittal and 3D views of the maxillofacial CT scan show a fulcrum point in the anterior wall of the frontal sinus (yellow arrows) and posterior displacement of a type 1 NOE fracture (red arrows). CT indicates computed tomography.

Figure 3.

Placement of Carroll-Girard screw, reduction of fracture using 2 perpendicular vectors, and immediate postreduction result showing favorable forehead and nasal root contour.

Figure 4.

Postoperative clinical photos and lateral cephalogram showing good projection of the frontonasal region with acceptable scarring.

Figure 5.

Pinching technique for identification of the site of the intercartilaginous incision. Lower lateral cartilage is pinched between thumb (intranasal) and index finger (extranasal). Thumb palpates superomedially until the inferior aspect of the upper lateral cartilage is felt.