FRACTURES OF THEFRONTAL SINUS

CURRENT TREATMENT PROTOCOL

mouthjawsfaceneck

oral &maxillofacial

surgery

Adnan AslamAssistant Professor & Consultant

Department of Oral & Maxillofacial SurgeryMargalla Institute of Health Sciences & affiliated hospitals

Rawalpindi

docadnanaslam@hotmail.com

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oral &maxillofacial

surgery

Embryology• Begin as an outgrowth from nasal chamber in utero• Absent at birth• Do not develop until 2nd year of life• Develop from ethmoidal infundibular air cells by invagination of

frontal bone through frontal recess or from superior meatus• Cannot be identified radiographically until about age of 8

years

mouthjawsfaceneck

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surgery

mouthjawsfaceneck

oral &maxillofacial

surgery

ClassificationType 1: Anterior table fracture with minimum comminution

Type 2: Anterior Wall comminuted fracture with possible NOE or Orbital rim fracture

Type 3: Anterior & Posterior Wall fracture (Posterior wall fracture without significant displacement or ductal injury)

Type 4: Anterior & Posterior Wall fracture with dural injury & CSF leak

Type 5: Anterior & Posterior Wall fracture with dural injury, CSF leak, soft tissue or bone loss and/or severe disruption of anterior cranial fossa

Gerbino G, Roccia F, Benech A, et al. Analysis of 158 frontal sinus fractures: Current surgical management and complications. J Craniomaxillofac Surg 2000; 28:133

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oral &maxillofacial

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Clinical evaluationGeneralFacial pain

Forehead paraesthesia or anaesthesiaForehead laceration

Visible and/or palpable frontal bone depressionCSF rhinorrhoea

Neurological injuriesCerebral contusion

Subdural & epidural haematoma

Ophthalmic injuriesPupillary defect

Optic neuropathyHyphaemaDisc edema

Corneal defectLoss of globe integrity

Associated maxillofacial InjuriesNOE fracture

Orbital fractureZygomatic fracture

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Radiographic evaluation

(Diagnostic Imaging)

Plain radiographsCaldwell viewLateral view

Evidence of air fluid levelClouding of frontal sinus

Pneumocephalus

High Resolution CT Scan

MRI

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oral &maxillofacial

surgery

Objectives of management• To avoid immediate and short-term complications such as

CSF leak, meningitis, spreading infection.

• To avoid long-term complications such as frontal bone osteomyelitis, chronic frontal sinusitis, mucocele, mycopyocele, and brain abscess.

• To provide adequate exposure for anatomic reduction of naso-orbito-ethmoid (NOE) fractures.

• To restore proper aesthetic contour of the forehead

mouthjawsfaceneck

oral &maxillofacial

surgery

Management generally based onthree clinical factors:

• Fracture location and displacement• Dural and cerebral involvement

• Damage to the frontal sinus drainage system

Treatment optionsConservative

Fracture reduction & fixationSinus obliteration

Sinus cranialization

mouthjawsfaceneck

oral &maxillofacial

surgery

Anterior table fracture(Nondisplaced, linear/isolated)

Conservative treatment

• Local wound care• Antibiotics, Nasal decongestants, Analgesics

• Follow up evaluation

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oral &maxillofacial

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Operative Indication of FS injury

• Nasofrontal duct involvement/obstruction

• Displacement of posterior table with underlying neurologic injury

• Aesthetic forehead deformity

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oral &maxillofacial

surgery

Anterior table fracture

(Displaced)Approach

Existing lacerationButterfly / Seagull / Open sky approaches

Coronal flap

Intraoperative assessmentAny kind of fluid

Nasofrontal duct patency

Nasofrontal duct injuryNasofrontal duct filling with frontal sinus obliteration

Reduction & fixation

Grafting

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surgery

Isolated anterior table #. ORIF

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oral &maxillofacial

surgery

Frontal sinus obliteration

Steps• Sinus exploration

• Mucosal extenteration• Nasofrontal duct obturation

• Frontal sinus obliteration• Fracture reduction

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oral &maxillofacial

surgery

Frontal sinus Filling materials for obliteration and obturation

Autogenous materialsAutologous fat

Cancellous bone Muscle

Pericranial flapsBanked cadaveric tissue

Synthetic materialsPolytetrafluoroethylene (ePTFE)

Methylmethacrylate (MMA)Bioactive glass and calcium-phosphate cements

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oral &maxillofacial

surgery

Indication for bone grafting1. Extensive loss of support at the skull base over the fovea

ethmoidalis and cribriform plate, in combination with a pericranial flap.

2. Superior orbital roof fractures, to avoid pulsatileexophthalmos and orbital deformity.

3. Extensive bone loss of the anterior table, which cannot be replaced with elements of the posterior table.

4. In combination with NOE and orbital reconstructionas layered bone grafts to obliterate the ethmoids and reconstruct the medial orbital wall.

mouthjawsfaceneck

oral &maxillofacial

surgery

Posterior table fracture• CSF leak absent and no displacement: Frontal sinus obliteration

• CSF leak and/or displacement:Frontal sinus cranialization

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oral &maxillofacial

surgery

Frontal sinus cranialization

• Removal of posterior table• Dural repair

• Grafting for bone loss• Internal fixation of anterior

table

mouthjawsfaceneck

oral &maxillofacial

surgery

Complications• Early

Forehead painTransient paresthesia of foreheadWound infectionTransient diplopia

• LateMucoceleMucopyoceleOsteomyelitisBrain abscessPneumocephaloceleMeningitisCosmetic defect

mouthjawsfaceneck

oral &maxillofacial

surgery

Future direction• Endoscopy assisted frontal sinusotomy

• Spontaneous osteogenesis and auto obliteration

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