Disclaimer: The information contained within the Grand Rounds Archive is intended for use by doctors and other health care professionals. These documents were prepared by resident physicians for presentation and discussion at a conference held at Baylor College of Medicine in Houston, Texas. No guarantees are made with respect to accuracy or timeliness of this material. This material should not be used as a basis for treatment decisions, and is not a substitute for professional consultation and/or peer-reviewed medical literature. FRONTAL SINUS FRACTURES Since the industrialization and mechanization of modern society the most common cause of frontal sinus fractures is motor vehicle accidents accounting for 52 to 72% followed by assault, industrial accidents, recreational accidents and gunshot wounds. The frontal sinus is absent in neonates and begins to develop by 2 years of age. It is the size of a pea at 4 to 5 years, approximates the adult configuration by 15 years, and is fully developed by 19 years of age. Ten percent of frontal sinuses are unilateral, 5% are rudimentary structures and 4% are absent altogether. Pathophysiologically damaged frontal sinus mucosa is much different from intact mucosa. The submucosa tends to be thickened, fibrotic and infiltrated with chronic inflammatory cells and the mucosa tends to encyst, thins to a single cuboidal layer and is heaped up. There are large areas of mucosa devoid of cilia and there is a tendency for the cysts to expand and secrete fluid into their lumens. These cysts can erode bone by pressure or enzymatic digestion and they are prone to infection. Mucocele formation may result from injury to mucosa, fracture of the frontonasal duct or mismanagement of a frontal sinus injury. Due to the high force required to cause frontal sinus fractures there is a high incidence of associated injuries therefore all patients need a thorough evaluation on presentation. Initial evaluation is directed toward management of the airway, circulation and other organ systems. All patients need ophthalmologic and neurologic examinations and the cervical spine should be cleared radiographically in all cases. Once the patient has been stabilized evaluation of the frontal sinus injury should proceed with computerized tomography because it clearly depicts fractures, the amount of depression, the contents of the sinus cavity and adjacent brain and overlying soft tissue. Historically the first operation for fracture of the frontal sinus was described by Reidel in 1898 and involved ablation of the frontal sinus allowing the skin of the forehead to rest against the posterior wall of the sinus or against the dura. Killian in 1904 performed a similar operation but left a 10mm rim of supraorbital bone for cosmesis. In 1921 Lynch devised the external frontoethmoidectomy in an attempt to improve aesthetics. He resected only the floor of the sinus, the ethmoid bone and middle turbinates. An indwelling catheter was inserted for prolonged drainage. The osteoplastic flap procedure for gaining access to the frontal sinus was originally described by Schonborn and Brieger in 1894 and 1895 respectively. Goodale and Montgomery in 1958 carried the procedure one step further obliterating the exposed cavity by packing it with autogenous fat and essentially removing the sinus as a functioning unit. Cranialization is a more recent innovation introduced in 1978 by Donald and Bernstein. This technique involves removal of the posterior table to allow the brain to expand into the sinus space and is generally reserved for only the most serious frontal sinus injuries with comminuted displaced posterior wall and a persistent CSF leak. The goals of treatment are the elimination of any factors predisposing to infection, restoration of normal sinus function and repair of cosmetic deficit. Frontal sinus fractures can be classified into anterior wall, posterior wall, frontonasal duct and through and through injuries. Anterior wall fractures that are linear and minimally displaced can be observed. Depressed anterior wall fractures should be explored, elevated and fixated if indicated. Compound anterior wall fractures should be explored and foreign bodies removed. Comminuted fractures present a management problem when bone is missing. The sinus should be obliterated with fat and reconstruction of the anterior wall undertaken with free iliac, rib or split calvarial bone grafts or methyl methacrylate. Donald advocates leaving gaps if bone deformity is less than 1.5cm in diameter since the deformity that results is minimal. Linear fractures of the posterior wall require exploration and should be considered for obliteration if there is displacement or entrapment of mucosa. All depressed posterior wall fractures should be obliterated. Extensively comminuted posterior wall fractures should be cranialized and if a CSF leak is present dural closure accomplished through the sinus if it is small or via anterior craniotomy if it is large. The posterior wall is thin and only minor deflections of the fragment are necessary to allow for the ingrowth of sinus mucosa into the anterior cranial fossa which can be a potentially lethal situation if a mucopyocele develops. For this reason many authors advocate obliteration of the sinus for all posterior wall fractures. Nasofrontal duct injuries are the most difficult to diagnose and may not be visualized even on CT scan. The presence of a persistent fluid level in the frontal sinus is a reliable sign of a nasofrontal duct injury and if there is no resolution after 2 weeks of conservative therapy a trephine should be done and the fluid evacuated. The patency can be determined by instilling methylene blue or fluorescein dye into the sinus and observing for drainage into the nose. Exploration is indicated if there is no egress of dye. Fractures located adjacent to the nasofrontal duct on CT scan should be explored because of the high incidence of nasofrontal duct injury. Anterior wall fractures with concomitant nasoethmoidal complex or supraorbital rim fractures are usually associated with nasofrontal duct injuries. Unilateral injuries can be treated by removing the intersinus septum or reconstructing the duct with mucosal flaps or stents. Most authors do not recommend the use of mucosal flaps or stents because of the high failure rate and removal of the intersinus septum is controversial as well and not uniformly advocated. Obliteration, however is a safe and reliable method of treatment. All bilateral injuries should be obliterated. Through and through injuries are the most serious and associated with a 50% mortality rate at the scene of the accident or in transport. Another 25% die in the early postoperative period. These injuries involve a tear in the forehead skin, fracture to both the anterior and posterior walls, laceration of the dura and often contusion of the adjacent frontal lobes. Ablation is used only if absolutely necessary with cranialization being the treatment of choice. Reconstruction of the anterior wall is attempted using fragments of the anterior and posterior wall that have been scrubbed with betadine solution. Early complications of frontal sinus surgery consists of frontal sinusitis which is initially treated medically with decongestants and antibiotics, however if painful swelling of the forehead or eye develops prompt surgical intervention and obliteration is indicated. Meningitis, deformity, pain and hypesthesia are other early complications that may be observed. Late complications of frontal sinus surgery consists of mucocele, mucopyocele and brain abscess and are treated with either obliteration or cranialization. Case Presentation A 29-year-old man sustained blunt trauma to his forehead and nose by a softball traveling at high velocity. He had no loss of consciousness and his only symptoms were pain over the forehead and a small amount of epistaxis. Physical examination was remarkable for superficial abrasions over the glabella and nasion, periorbital and frontal edema and periorbital ecchymosis, crepitance on palpation of nasal bones, and left septal deviation. Computerized tomography revealed anterior and posterior wall frontal sinus fractures, nasoethmoid complex fracture, and pneumocephalus. Neurosurgical consultation was obtained and the patient was cleared for surgery after a period of observation. The patient was taken to the operating room and underwent frontal sinus exploration utilizing a bicoronal incision and osteoplastic flap. At exploration he was found to have anterior and posterior wall fractures as well as bilateral nasofrontal duct injuries. After removing all the mucosa and burring down the inner table of bone the nasofrontal ducts were plugged with temporalis fascia and obliterated with abdominal fat. 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