Frontal Sinus Fractures
Christina L. Corey, M.D.
June 9, 2005

MG is an 18-year-old male who was the restrained driver in a motor vehicle accident with airbag deployment. He was found to have a right femur fracture and a left ankle fracture as well as severe facial lacerations. His exam was otherwise unremarkable except for a complex laceration extending from right medial brow, down to right medial canthus, extending over the frontal sinuses, and multiple facial abrasions.

CT of his face was performed and the anterior table of his frontal sinus was noted to be fractured. He was also noted to have impaction of his nasal bones posteriorly and a right orbital floor fracture. For treatment, he received repair of his right orbital floor fracture, and closed reduction of nasal bone fractures. At surgery, he was found to have bilateral nasofrontal duct injuries and for the repair of his frontal sinus fracture, fascia and muscle were used to plug the nasofrontal ducts. The frontal sinuses were obliterated with abdominal fat.

 In terms of embryology, the frontal sinuses originates either as an expansion of the frontoethmoid air cells in to the frontal bone or by superior extension of the frontal recess. The frontal recess represents the most anterosuperior portion of the infundibulum of the middle meatus. The frontal sinus is not pneumatized until the age of 2 and it can be first appreciated radiographically in individuals aged 6-8 years. Pneumatization is usually asymmetric and may range from partial to incomplete in approximately 20% of the population. Adult size is attained by age 15, but usually attains maximum dimension at age 19. For this reason, fractures of frontal sinus are nearly twice as common in the adult population as in the pediatric population.

In terms of anatomy, the frontal sinus has a thick, strong, arched-shaped anterior wall and a thin, fragile floor and posterior wall. The nasofrontal duct is a foramen rather than the true duct in up to 77% to 85% of the population. The duct is the inferior termination of the sinus floor and is found on both sides of the midline frontal sinus septum. It is the most anterior and superior portion of the anterior ethmoid complex and drains the frontal sinus into the middle meatus. Venous drainage occurs by two routes; supraorbital (and angular) veins, the anterior facial vein, the superior ophthalmic vein to the cavernous sinus. Deep drainage occurs into the subdural venous system through the foramina of Breschet, which are sites of shallow invaginationsof the mucoperiosteum. These are significant because they provide a route for spread of infection directly from the sinus cavity to the epidural space.

The history of the frontal sinus surgery begins with the first recorded procedure on the frontal sinus by Wells in 1870 for a mucopyocele. The first ablative procedure was described by Reidel in 1898 using the overlying skin as the ablative material. Overlaying of the skin on the posterior table created an obvious cosmetic defect, which can be seen on the patient at the right. In order to avoid this cosmetic defect, in 1904 Killian described a similar procedure, which preserved a rim of supraorbital bone, improving the cosmetic results. However, this procedure had significant rates of failure due to incomplete removal of all frontal sinus mucosa. In 1951, Bergara and Itoiz devised the osteoplastic flap procedure in an attempt to improve cosmesis and surgical exposure. They described exposure of the sinus by removing the anterior table, but, unlike Reidel, it was left hinged on an inferiorly based pedicle of pericranium. The flap was replaced at the end of the procedure. This technique resulted in marked improvement in the overall aesthetic result. In the late 1950s and 1960s, Goodale and Montgomery first described the ablative procedures that are the basis for current surgical obliterative management of frontal sinus fractures. They took the osteoplastic flap procedure a step further, and ablated the frontal sinus by grossly removing all sinus mucosa and packing it with autogenous fat. Later work described the involvement of the nasofrontal ducts in chronic complications of frontal sinus trauma, secondary to duct stenosis. It then became clear that simple obliteration as described by Goodale and Montgomery was insufficient to completely prevent the occurrence of the sequelae. Failure to remove all sinus mucosa - even in the nasofrontal ducts - leads to late complications. Donald and Bernstein described the first cranialization procedure in 1978. It involved again stripping the sinus of all mucosa, plugging of the nasofrontal ducts, and removing the posterior table, allowing the brain to expand into the frontal sinus space. .

Frontal sinus fractures comprise between 5% to 15% of maxillofacial traumas. The incidence is approximately nine cases per 100,000 adults per year. Of frontal sinus fractures, one-third affect the anterior table alone, while isolated fractures of the posterior table are rare. Most patients with frontal sinus fractures are young males. Fractures of the frontal sinus most commonly occur as the result of blunt trauma occurring during a motor vehicle accident. The force required to fracture the frontal sinus has been reported to be between 800-2200 pounds of force and is usually sufficient to cause significant associated injuries. As a result, frontal sinus fractures are usually caused by high velocity impact and, given the force required, 75% of patients have associated fractures and reports indicate that up to 42% of patients are unconscious at the time of initial evaluation. Laceration of the forehead is the most common clinical finding of frontal sinus fractures. Bony fragments may protrude through the laceration. Depression of the forehead over the frontal sinus is also common. Other signs or symptoms that should raise suspicion of frontal sinus injury are hematoma and/or ecchymosis over the glabellar region and/or anesthesia or paresthesia of the scalp or forehead. Gross CSF rhinorrhea occurs in approximately 20% of patients. Patients presenting with this type of injury usually have associated craniofacial trauma including the fractures of the naso-orbito-ethmoid complex and midface. Approximately 60% of these patients may also present with some type of orbital trauma.

In the past, plain radiographs were the basis for diagnosing fractures of the frontal sinus. Even before the advent of CT scanning, the sensitivity of conventional plain films was not considered to be very high. The use of high-resolution, 1.5-mm thin-cut CT scanning is currently the gold standard for evaluating the sinuses. CT provides essential information regarding frontal sinus anatomy, involvement of the anterior and/or posterior wall as well as detail of the degree of comminution and displacement of the fractures. It also provides visualization of any associated craniofacial and cerebral injuries. Unfortunately, involvement of the nasofrontal duct is not clearly definable even with CT imaging. Certain findings on CT scan strongly suggest injury to the nasofrontal duct including: a fracture through the base of the frontal sinus, the anterior ethmoid complex or the superior orbital rim.

The main goals of treatment of frontal sinus fractures are: protection of intracranial structures and the cessation of CSF leakage, prevention of posttraumatic infection, and, restoration of facial aesthetics. The type of treatment required depends on the type of injuries involved. The fracture may involve any combination of injury to the anterior table, posterior table, and nasofrontal ducts.

With regard to anterior table fractures, isolated non-displaced fractures do not require repair. Isolated displaced fractures with external cosmetic deformity require surgical correction. Displaced fracture fragments and damaged mucosa are removed since the presence of improperly reduced segments, retained sinus bony fragments or foreign bodies, and damaged mucosa may later cause infection. After excluding nasofrontal duct injury, the anterior table is repaired, most commonly with titanium mini-plates.

The treatment of posterior table fractures is controversial. There are no prospective randomized studies reported to corroborate the superiority of the different approaches. A review of the literature reveals that some authors advocate sinus obliteration with all posterior table fractures, regardless of displacement or concomitant CSF leak or nasofrontal duct injury. It is argued that fractures of the posterior table, even non-displaced, may result in mucosa trauma and entrapment, and later mucocele formation. In addition, exploration and obliteration are done in order to avoid missing nasofrontal duct injuries or undetected dural tears as well as to prevent dangerous sequelae that may result years later. Others, in contrast, recommend treatment based on fracture displacement and presence of CSF leak and/or nasofrontal duct injury. For isolated non-displaced posterior table fracture, observation is recommended. For non-displaced fractures with CSF leak, these authors recommend medical treatment. More than half of cases resolve without surgery. Prolonged leaks beyond 10 days require repair of the dural laceration and obliteration of the sinus or cranialization for extensive posterior table fractures. For displaced fractures, fractures without injury of the nasofrontal duct and no CSF leak are treated with reduction and fixation of fracture; while displaced fractures with concomitant injury to the nasofrontal duct and/or in the presence of CSF leak are treated with: dual repair for CSF, fracture reduction and fixation, nasofrontal duct obliteration, and then sinus obliteration or cranialization. Cranialization involves separation of intracranial cavity from the aerodigestive tract. Usually it is used for extensive, severely comminuted fractures. It involves nasofrontal duct obliteration, removal of the posterior sinus wall and all frontal sinus mucosa, and repair of the dural laceration. The frontal lobes are then allowed to expand into the dead space previously occupied by the frontal sinus.

The nasofrontal duct is the final structure that must be considered prior to repair of frontal sinus fractures. Fifty five percent of all frontal sinuses fractures have nasofrontal duct injury. This is significant because blockage or disruption of the nasofrontal duct affects mucociliary drainage and predisposes the patient to formation of mucoceles and other infective complications. When injury to the nasofrontal duct has occurred, most authorsrecommend obliteration of the sinus. There have been some attempts at duct restoration in the literature in which duct repair was attempted by cannuating in an attempt to prevent stricture, scarring, and late obstruction. Long-term results of these studies, however, show that duct restoration has been poor secondary to the propensity for mucosal proliferation with subsequent scar formation and stenosis. Failure rates have been shown to be as high as 30%.

The frontal sinus may be approached in a number of ways. The first is the bicoronal incision. This allows the best access to the frontal sinus. Also described are the butterfly or infrabrow incision as well as the use of preexisting laceration, which is usually reserved for isolated fractures of the anterior wall. In terms of frontal sinus obliteration, there is a consensus that certain techniques must be followed to ensure appropriate obliteration of the sinus and prevention of long-term sequelae. First, an osteoplastic flap is created. The sinus is then explored, by completely removing all sinus mucosa and loose, displaced fragments of bone. Next, all inner cortex bone is removed from the sinus with a high-speed drill or loupes, in order to remove mucosal fragments from fracture lines and the foramina of Breschet. Fourth, the nasofrontal ducts are occluded to avoid regrowth of mucosa and prevent contamination. Finally, the sinus is obliterated with autogenous or alloplastic material. Multiple materials, both autogenous and alloplastic, have been described for frontal sinus obliteration. Debate continues concerning the optimal material to use. The common mechanism in obliterative procedures is to stimulate fibrosis and osteoneogenesis in the frontal sinus cavity, eliminate dead space, and separate the frontal from the lower sinuses. Autogenous materials appear to be the more successful and better tolerated. There are reports of more frequent failure with alloplastic materials; however, no significant advantage of one material over another has been demonstrated.

Fat is the most widely used autogenous material. There are less than 1% of infectious complications reported. It is hypothesized that a portion of the fat becomes vascularized and resists infections while the portion of the graft that does not survive is replaced by fibrous tissue. Cancellus bone is not widely used because of associated donor site morbidity. Usually cancellus bone from the iliac crest is used. Other autogenous materials that have been used for sinus obliteration include: muscle, which has been found to be as effective as fat for obliteration; and soft tissue flaps. The most commonly used soft tissue flaps are pericranial flaps, which are reliable, well-vascularized, and resistant to infection.

A plethora of different alloplastic materials have been used in frontal sinus obliteration. Lyophilized cartilage has shown good results, given its tendency to ossification and resistance ti volume reduction. However, it has fallen out of favor given the risk of HIV transmission. Methyl methacrylate had been used extensively in cranial reconstruction, but it is no longer as widely used given its exothermic drying reaction, significant foreign body response in host tissue, and its association with up to 50% failure rate when in contact with paranasal sinus mucosa. Hydroxyapatite cement has superseded methyl methacrylate as the alloplast of choice. This is a mixture of calcium tetraphosphate and dicalcium phosphate salts. It can be contoured to the defect and dries under physiological conditions. It is also osteoconductive. The reports of success rate have been as high as 82% to 93%.

Complications of frontal sinus fractures may be life threatening. Both early and late complications may arise. Early complications occur usually within six months. These include frontal sinusitis, most commonly resulting from retained foreign bodies or bony chips; meningitis; and, CSF leak, as high as 10% in some studies. Late complications may occur up to a decade after injury. These include mucocele and mucopyocele, delayed CSF leak, or brain abscess, which is caused by spread of infection from the frontal sinus intracranially through foramina of Breschet. For these reasons, patients who have undergone repair and/or obliteration of the frontal sinus should be monitored closely for the fist year and then yearly thereafter. Any complaints of frontal pressure, pain, or headaches should be worked up with CAT scan. Long-term follow-up care is mandatory for these patients.

The future of frontal sinus fracture repair is in flux with introduction of newer biocompatible synthetic replacement materials as well as the development and evolution of different techniques. First, an alloplast that shows great promise is a synthetic cancellus bone product made of beta tricalcium phosphate. It is an osteoconductive, porous implant that resembles the porosity of cancellus bone. It has been shown to have superior osteoconductiveproperties to that of other synthetic bone alternatives. It is nearly completely replaced by native bone in weeks, according to preliminary studies. Resorbable plates are another alloplast that show great promise. It is composed of polymers of lactic acid and is developing encouraging results. They are amorphous, non-toxic, and inert. They have greater pliability than metal plates and are completely resorbed within 18-36 months.

With advances in surgical instrumentation and computer assisted navigation technology, endoscopic treatment has expanded and is still expanding. Its application in frontal sinus fracture repair is limited to treatment of isolated anterior table fractures. The endoscopic brow-lift technique is used expose the fracture and following fracture exposure, one of the three techniques are used for sinus repair: fracture reduction and internal fixation with microplates; transcutaneous reduction screws without internal fixation; and, filling the defect with hydroxyapatite cement.

In summary, there are no uniform treatment guidelines for patients with fractures of the frontal sinus. Controversies exist regarding timing and indications for surgical intervention as well as the best types of surgical ablative materials to use. For anterior table fractures, displaced fractures require treatment to correct aesthetic deformity. With injury to the nasofrontal duct, it is treated with duct occlusion and frontal sinus obliteration. Treatment of posterior table fractures is fraught with controversy. Some authors advocate sinus obliteration whenever there is a posterior table fracture in order to avoid complications with undetected nasofrontal duct injury or CSF leak. Other authors, on the other hand, recommend treatment based on displacement, or the presence of CSF leak or nasofrontal duct injury. For non-displaced fractures, surgical treatment is not required. For displaced fractures, sinus obliteration is only recommended if there is simultaneous injury to the nasofrontal duct and/or presence of CSF leak.

Case Presentation:

M.G. is an 18 year-old male who was the restrained driver in a motor vehicle accident with airbag deployment. He was found to have a right femur fracture and a left ankle fracture, as well as severe facial lacerations. CT scan of his face revealed an anterior table fracture of his frontal sinus, as well as impaction of his nasal bones posteriorly.

Past medical history was unremarkable.

He is currently not taking any medication.

His physical examination was unremarkable except for a complex laceration on his face extending from the right medial brow, down to the right medial canthus, and extending over the frontal sinuses. His face also had multiple abrasions; right intertrochanteric fracture and left bimalleolar fracture.

A CT maxillofacial scan revealed an anterior table fracture of the frontal sinus and impaction of the nasal bones posteriorly.

The patient was treated with frontal sinus obliteration with abdominal fat and complex wound closure.

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