Frontal Sinus Fractures

Abstract

Management of frontal sinus fractures is controversial with no universally accepted treatment protocol. Goals of management are to correct aesthetic deformity, preserve sinus function when it is deemed salvageable, prevent sequela related to the injury, and minimize complications associated with intervention. Studies suggest that frontal sinus injuries, including disruption of the nasofrontal outflow tract (NFOT), can be managed nonoperatively in many cases. Advances in the utilization of endoscopic techniques have led to an evolution in management that reduces the need for open procedures, which have increased morbidity compared with endoscopic approaches. We employ a minimally disruptive protocol that treats the majority of fractures nonoperatively with serial clinical and radiographic examinations to assess for sinus aeration. Surgical intervention is reserved for the most severely displaced and comminuted posterior table fractures and unsalvageable NFOTs utilizing endoscopic approaches whenever possible.

Keywords: cerebrospinal fluid; endoscopic; frontal sinus fractures; navigation; transorbital.

Fig. 1

Anatomy of the frontal sinus. Left: sagittal view illustrating the anterior and posterior tables as well as the nasofrontal outflow tract (NFOT). Right: coronal view illustrating the left and right NFOT.

Fig. 2

Contour defect as a result of a depressed fracture of the left anterior table.

Fig. 3

Intraoperative photos of the same patient in Fig. 2 demonstrating reduction of the fracture through an open bicoronal approach using titanium plate fixation.

Fig. 4

Comparison of preoperative and postoperative three-dimensional computed tomography scans demonstrating correction of the depressed frontal sinus fracture for the same patient described in Fig. 2 and Fig. 3. Reconstruction demonstrates excellent correction of the contour defect.

Fig. 5

Left: comminuted anterior and posterior table fractures of the frontal sinus with CSF leak. Middle: blepharoplasty incision marking for planned transorbital endoscopic approach to the frontal sinus utilizing navigation. Right: superior transorbital approach to the frontal sinus. Note the posterior wall fracture with protruding brain tissue. CSF, cerebrospinal fluid.

Fig. 6

Left: endoscopic transorbital visualization of the fractured frontal sinus, mucosa removed and dura exposed. Middle: view following coverage of defect with allogenic dermis before sealing with fibrin glue. Right: healed blepharoplasty incision demonstrating the well-healed and positioned scar. Same patient as described in Fig. 5 .

Fig. 7

Left: preoperative axial and sagittal CT cuts of an anterior table fracture of the frontal sinus. Right: 2-year postoperative axial and sagittal CT cuts following transorbital endoscopic reduction. CT, computed tomography.

Fig. 8

Transorbital endoscopic view of a (left) prereduction and (right) postreduction anterior table fracture of the frontal sinus.

Fig. 9

Multiview navigation windows demonstrating utilization of the normal unaffected side of the frontal sinus mirrored and overlaid on the affected side for intraoperative navigation to verify reduction of the fracture.

Fig. 10

Left: bicoronal approach using subgaleal plane with pericranium exposed and outlined for an anterior-based pericranial flap. Right: harvest of an anteriorly based pericranial flap that can be used for both sinus obliteration and cranialization.

Fig. 11

Top left: comminuted and displaced fracture of the nasofrontal outflow tract (NFOT) and nondisplaced fracture of the posterior table requiring frontal sinus obliteration. Middle left: frontal sinus mucosa obliterated. Bottom left: frontal sinus packed with bone graft. Top right: anteriorly based pericranial flap lining the bone graft and obliterated frontal sinus. Bottom right: repair of the frontal craniotomy using plates.

Fig. 12

Top left: comminuted and displaced fracture of the nasofrontal outflow tract (NFOT) and displaced fracture of the posterior table requiring frontal sinus cranialization. Top right: frontal bone with sinus removed as patient also required dural repair demonstrating the anatomy of the frontal sinus and fracture pattern after obliteration of the sinus mucosa. The posterior table was then removed. Bottom left: anterior cranial base defect packed with bone graft harvested from the cranium. Bottom right: repair of the frontal craniotomy using plates.

Fig. 13

Minimally disruptive protocol for frontal sinus fractures used at our institution. CSF, cerebrospinal fluid leak. CT, computed tomography. (Reprinted with permission from Patel et al. 7 )