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14. What are the classic clinical findings in a patient with a nasoethmoidal (NOE)
fracture?
The NOE fracture usually results from a direct blow to the bridge of the nose by a blunt object, such
as a steering wheel or dashboard during a motor vehicle accident. Patients classically present with a
widened nasal bridge, periorbital edema and ecchymosis, epistaxis, cerebrospinal fluid (CSF) rhinorrhea (42%), and traumatic telecanthus (12% to 20%). Epiphora as an early or late finding indicates
injury or outflow obstruction to the nasolacrimal apparatus. Treatment goals include restoration of
normal intercanthal distance, fixation of the nasal bones, and careful evaluation and possible repair of
the bony orbit and nasolacrimal apparatus.
15. Why is the placement of a nasogastric tube sometimes contraindicated in a
midface fracture patient?
Midface fractures commonly extend through the nasal cavity and may result in soft tissue disruption
in the nasopharynx with concomitant cranial injuries and fractures of the cribriform plate. Placement
of a nasogastric tube in these patients may result in the inadvertent intracranial placement of the tube
or soft tissue dissection in a previously traumatized region.
NASOETHMOIDAL FRACTURES
16. What is a nasoethmoidal (NOE) fracture?
Fractures of the central midface that involve the nasal bones, the medial walls of the orbit, and the
ethmoid complex constitute the group of fractures known as nasoethmoidal fractures or NOE fractures, a term coined by Epker in 1973.
17. How are fractures of the NOE region classified?
Markowitz and Manson have classified NOE fractures into three patterns of fracture. They are:
• TypeI:single-segmentcentralfragment
• TypeII:comminutedcentralfragmentwithfracturesremainingexternaltothemedialcanthal
tendon insertion
• TypeIII:comminutedcentralfragmentwithfracturesextendingintobonebearingthecanthal
insertion. Injuries are further classified as unilateral and bilateral and by their extension into other
anatomic areas.
18. How do you diagnose NOE fractures?
Diagnosis of NOE fractures is based on physical examination and CT images. A bimanual examination
is performed to determine the mobility of the fracture and need for open reduction. On examination,
patients typically exhibit telecanthus, severe shortening, and rotation of the distal aspect of the nose.
CT imaging produces accurate detail of the hard and soft tissues involved in NOE fractures. Axial and
coronal sections are helpful to determine the extent of injury. These sections are especially useful for
diagnosing orbital floor and medial orbital blowout fractures. A three-dimensional CT scan can also
be helpful to diagnose and plan treatment. CT images can detail the comminuted areas of the central
fragment but may not reveal the true extent of the comminution. The most accurate way to evaluate
the central fragment is when it is exposed intraoperatively to determine if the canthal attachment is
disrupted.
19. What is the normal intercanthal distance?
Normal intercanthal distance can be influenced by gender, age, and race. In adults, it can range from
28.6 to 33 mm in women and 28.9 to 34.5 mm in men.
20. What is the difference between telecanthus and hypertelorism?
Telecanthus refers to a widening of the distance between the medial canthi, usually traumatic, such
as in NOE fractures. Hypertelorism is the widening of the orbits themselves and is measured as the
interpupillary distance. Hypertelorism is more common in congenital craniofacial anomalies such as
craniosynostoses or syndromes.
21. What is the bowstring test?
The bowstring test is a simple means of assessing the status of the medial canthal ligament in
NOE fractures. Commonly, the ligament remains intact and attached to the lacrimal bone, which
†
†
Written by Deepak G. Krishnan and Michael J. Grau Jr.
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may be fractured with displacement. The bowstring test is performed by placing gentle lateral
traction over the lateral canthus while palpating the medial canthal region to assess mobility. A
positive test confirms bony fracture with displacement of the medial canthal ligament or traumatic
telecanthus.
22. What are some surgical approaches to the NOE area?
Isolated NOE fractures can be approached via a superior surgical approach alone (coronal) or
combined with an inferior (transconjunctival) access. A maxillary vestibular incision is used for those
fractures extending to the inferior maxilla along the nasal slope. Existing lacerations over the nasal
bridge can be utilized but often require extensions. Other skin approaches in the central midface are
generally avoided due to poor aesthetics.
23. How are NOE fractures treated?
The complexity of reduction and fixation depends on the severity of fracture patterns and associated
injuries. Type I and II fractures allow for direct internal fixation of large bone fragments following
exposure and reduction. In type III fractures extending through the medial canthal tendon insertion,
the bone fragment is isolated by subperiosteal dissection. The canthus is detached to allow for bone
reduction. A wire passing bur is used to create two holes superior and posterior to the lacrimal crest
in the central fragment. A drill guide is helpful to avoid damage to the globe. Care is also taken to
prevent damage to the contralateral globe during this procedure. A single 25-gauge wire is secured
to the central fragments. A 3-mm vertical incision just medial to the eyelid commissure facilitates
passing a permanent suture through the canthus without damage to the lacrimal drainage apparatus.
These sutures are placed bilaterally and secured to the transnasal wire. The wire is then tightened
until the desired intercanthal narrowing is achieved. Alternatively, a permanent suture may be used for
the transnasal reduction.
24. How does one test for patency of the lacrimal drainage system?
Impairment of the lacrimal drainage system following NOE injuries can lead to epiphora and symp-
toms of lacrimal obstruction. Jones tests can be utilized to assess the patency of the lacrimal system.
There are two components to the Jones tests. In the Jones 1 test, or the primary dye test, fluorescein
dye is applied into the lower cul-de-sac of the affected eye. After adequate time, a cotton tip applicator is placed under the inferior turbinate of the lateral nasal wall on the same side. Failure to see any
dye under the inferior turbinate indicates blockage of the nasolacrimal flow.
The Jones 2 test, or the secondary dye test, helps assess the location of the blockage. The
Jones 2 test is performed following irrigation of the inferior cul-de-sac for any remnant dye from
the Jones 1 test. The lacrimal punctum is anesthetized, and an irrigation catheter is inserted to
allow thorough irrigation of the system. If no fluid at all is detected in the nose, the obstruction is
complete. If it is possible to detect some of the fluorescein in the inferior meatus with this flush, then
the obstruction is partial. If only clear saline flushes out, this indicates an obstruction of the upper
collecting system, because the dye was not collected into the system, but it was possible to irrigate
the saline through.
25. What is dacrocystorhinostomy?
Dacrocystorhinostomy (DCR) is the repair of the lacrimal drainage system through the creation of
a new “ostomy” from the lacrimal canaliculi to the nasal cavity. It can be done via an endonasal
approach or an open approach.
LE FORT FRACTURES
‡
26. Who was Le Fort?
René Le Fort (1869–1951) was a French surgeon little remembered for creating a classification for
fractures of the face. In 1901, he published a treatise called Étude expérimentale sur les fractures
de la mâchoire supérieure involving his experiments with maxillary fractures of the skull. To perform
these experiments, Le Fort used intact cadaver heads and delivered blunt forces of varying degrees
of magnitude, as well as from different directions. From these tests, he determined that predictable
patterns of fractures are the result of certain types of injuries and concluded that there are three
predominant types of midface fractures.
‡
Written by Deepak G. Krishnan and Michael J. Grau Jr.
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27. What are the types of Le Fort fractures?
Le Fort’s experiments provided us with a classification system that helps us diagnose and manage
injuries of the maxilla, midface.
• LeFortI:MaxillaryfracturesatlevelItraverseabovethealveolarridgeandteeth,fromthepiriform
aperture, along the lateral walls of the maxillary antrum, and extend posteriorly to involve and
separate the pterygoid plates. Medially they pass along the lateral nasal wall and the lower third
of the septum. These fractures allow the maxillae and hard palate to move as a single block. It is
possible to have a unilateral fracture at this level. This would often involve separation along the
mid-palate.
• LeFortII:MaxillaryfracturesatlevelIIinvolvemostofthenasalbones,themaxillarybones,the
palatine bones, and the lower two-thirds of the nasal septum, the dentoalveolar structures and the
pterygoid plates. Le Fort II fractures are referred to as pyramidal fractures. The fracture disconnects superiorly at the nasofrontal junction and continues along the medial inferior third of the orbit
and laterally along the zygomaticomaxillary suture and on toward the pterygoid plates. The nasal
septum is separated superiorly causing a pyramidal disjunction of the midface.
• LeFortIII:Inthispatternofmidfacefracture,thefracturesrunatthemidlineeitheracrossthe
nasal bones or disjoint at the nasofrontal junction, laterally traversing through the medial orbital
wall and the superior orbit extending along the inferior orbital fissure and the lateral orbital wall
to the zygomaticofrontal suture. The zygomaticotemporal suture is separated as well. The septum
separates at the cribriform ethmoid plate. There is separation of the pterygoid plates causing an
entire craniofacial disjunction.
Le Fort level II fractures are associated with increased mortality. Furthermore, Le Fort II and III fractures
are associated with serious intracranial injury, even in the absence of alterations in consciousness.
Patients with complex midface fractures were 57% more likely to die.
28. What are some of the clinical signs of midface fractures?
• Mobilityofmidface:bestdetectedbymovementelicitedwhileholdingthepatient’smaxillary
anterior teeth with one hand while palpating the nasofrontal junction
• Painandedemaofthemidface
• Anterioropenbite,orothermalocclusion
• Nasalbleeding,subconjunctivalecchymosis,infraorbitalnervehypoesthesia,tendernessalongthe
bony buttresses, step deformities palpable on the face
• Periorbitalecchymosis(raccoon’seyes)
29. What is Battle’s sign?
Battle’s sign refers to postauricular ecchymosis. It is indicative of a basilar skull fracture involving the
middle cranial fossa that are not infrequently associated with complex midfacial injuries.
30. What imaging modality is most appropriate for diagnosing Le Fort fractures?
Maxillofacial CT scans with axial, coronal, and sagittal cuts are most useful in the diagnostic and
preoperative treatment planning phase when midface fractures are suspected. When evaluating for
the presence of Le Fort fractures and determining the level, it is helpful to look at certain key areas,
and the examiner can either include or exclude the appropriate level of fracture. The pterygoid plates
should be visualized first; a fracture of the pterygoid process is almost always indicative of the
presence of a Le Fort fracture. Next, the examiner determines the level by visualizing three key areas:
(1) the anterolateral margin of the nasal fossa (Le Fort I level); (2) the inferior orbital rim (Le Fort II
level); and (3) the zygomatic arch (Le Fort III level). It is important for the examiner to remember that
fractures may be present at multiple levels on the ipsilateral or contralateral sides and the presence of
one does not exclude that of another.
31. How can one achieve an airway in patients with midface injuries?
Midface fractures can cause extensive soft tissue injuries in the nasopharynx and often with concomi-
tant cranial base injuries. Attempts to place nasotracheal tubes for intubation can cause more injury,
bleeding or intracranial perforations, or contamination. The same is applicable when attempting to
place nasogastric tubes. If airway is attempted in the field, oral endotracheal intubation is the safest
route of intubation. When intubation is not possible, surgical airway such as cricothyrotomy may be
attempted. After skull base fractures are ruled out and for purpose of administering anesthesia for
management of the fractures, nasotracheal intubation is the preferred airway of choice unless otherwise contraindicated. If a nasal intubation is contraindicated, a tracheotomy or a submental intubation
technique may be utilized.
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32. What are the surgical approaches for accessing maxillary fractures?
Most maxillary fractures (Le Fort I) can be approached using an intraoral maxillary vestibular incision.
Wide exposure of the midface superiorly up to the infraorbital rims and laterally beyond the zygomatic
buttresses can be achieved through the mouth. Lateral nasal slope fractures and orbital rim fractures can
often be reduced and fixated through this approach in combination with orbital rim or sub- conjunctival
incisions. However, orbital rim and zygomaticofrontal sutures often need periorbital incisions for access.
Existing lacerations can be utilized wherever possible. Nasal bridge and nasofrontal disjunction, zygomatic arches, and zygomaticofrontal fractures as in Le Fort III are best approached via coronal incisions.
33. What are some of the complications associated with maxillary fractures?
• Infraorbitalnerveparesthesia
• Enophthalmos
• Infection
• Exposedhardware
• Deviatedseptum
• Nasalobstruction
• Alteredvision
• Nonunion
• Malunionormalocclusion
• Epiphora
• Foreignbodyreactions
• Scarring
• Sinusitis
34. What is the blood supply to the maxillae and palatine bones?
The blood supply to the maxilla and palatine bones is through the periosteum, incisive artery, and greater
and lesser palatine arteries as well as the ascending pharyngeal and ascending palatine arteries.
35. How are palatal fractures treated?
Fractures to the maxilla can be greatly complicated via the involvement of the palate. Fractures involv-
ing the palate may occur in varying subtypes and combinations adding varying degrees of difficulty
to the restoration of form and function. Failing to appreciate the presence or implications of palatal
fractures may lead to less than optimal outcomes including generalized widening of the maxilla and a
resultant malocclusion, especially if these fractures occur in combination with mandible fractures that
predispose to increasing facial width, that is, symphysis fractures. These injuries are best approached
by obtaining preoperative models and performing model surgery with the fabrication of a surgical
stent similar to model surgeries that are performed prior to planned osteotomies. The surgical guide
may be utilized to establish the planned preinjury occlusion and may be left in place throughout the
postoperative healing phase.
BiBliography
Nasal Fractures
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AO, Benson KJ, editors: Secrets of oral and maxillofacial surgery, ed 3, Philadelphia, 2007, Mosby and Elsevier.
Colton JJ, Beekhuis GJ: Management of nasal fractures, Otolaryngol Clin North Am 19:73–85, 1986.
Dodson BT: Zygomatic, maxillary, and orbital fractures. In Jafek BW, Murrow BW, editors:.
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Evans G, Manson PN, Clark N: Identification and management of minimally displaced nasoethmoidal orbital fractures, Ann
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Surg 13:325–339, 1961.
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mol 35:280–292, 1991.
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11:43–56, 1995.
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Wolfe SA, Berkowitz S: Maxilla. In Plastic surgery of the facial skeleton, Boston, 1989, Little.
FRONTAL SINUS FRACTURES
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A. Omar Abubaker
1. Describe the functional anatomy of the frontal sinus.
The frontal sinus is generally absent at birth, but its growth is complete at about 15 years of age in
most individuals. As a result, fractures of the frontal sinus are less common in children than in adults.
The anterior table is thicker than the posterior one and more resistant to injury, and that is why it
requires greater force to fracture than any other facial bone. The size and shape of the sinus varies
among individuals and on the right and left sides in the same individual, the anterior wall of the
sinus being stronger than the posterior wall. The frontal sinus drains via a small outflow tract into the
ethmoid sinus/nasal cavity tract, which is hourglass shaped with the true ostium at the narrowest portion, the infundibulum. A true frontonasal duct (FND) exists in only 15% of the population, varying from
a few millimeters to 1 cm in length. In the remaining 85% of the population, the frontal sinus drains
directly into the anterosuperior portion of the middle meatus via an ostium without a true duct or
occasionally by a communication through the ethmoids. Because of the lack of duct in these individuals, some authors believe that the significance of FND in frontal sinus fractures is overrated.
2. What type of epithelium lines the frontal sinus, and how does it relate to its
pathology?
The frontal sinus is lined with pseudostratified columnar ciliated respiratory epithelium covered by a
layer of mucin. Some authors theorize that the frontal sinus drainage is impaired after the nasofrontal
duct becomes damaged or obstructed as a result of frontal sinus fracture. The mucus can subsequently build up behind the obstructed duct. A mucocele may develop and act as an expanding tumor.
With development of an anaerobic environment in the presence of a mucocele, there is an increased
risk of frontal sinusitis involving the intracranial contents. As such, assessment of the patency and
subsequent management of the nasofrontal duct are important decision-making elements in the
management of frontal sinus injuries.
3. What is the epidemiology of frontal sinus fractures?
The majority of frontal sinus fractures are the result of high-velocity impacts such as motor vehicle
accidents, assaults, and sport injuries. These fractures are relatively uncommon fractures (5% to 15%
of all maxillofacial ones) with a preponderance of male patients aged 20 to 30.
The most common fractures involve the combination of the anterior and posterior tables with
or without frontal recess involvement (about two-thirds). Isolated anterior wall fractures account for
approximately one-third, and isolated posterior table fractures are rare (<1%).
4. How is the risk for fracture of the frontal sinus in children compared
with adults?
The frontal sinus starts at birth and begins to appear as a pneumatic expansion at age seven from the
nasal cavity, with complete development by ages 18 to 20. The remnants of this embryonic connection between sinuses are the nasofrontal ducts. These bilateral structures (foramina ducts) drain the
frontal sinus from its posteromedial aspect, through the ethmoidal air cells and out to the nasal cavity,
usually at the middle meatus ducts. Because the frontal sinus is small or nonexistent in children and
young adolescents, it is less likely to be involved in a fracture in this age group.
5. How are frontal sinus fractures classified?
Although there are many classifications that describe the pattern of frontal sinus fractures, there is
no universally accepted classification of these fractures. Most classifications are based on location,
extent of injury, involvement of the nasofrontal duct, and concurrent injury of the dura. Gonty’s Classification, which has been adopted by many, combines several previous classifications into one.
Type 1: Fractures of the anterior wall
1. Isolated to anterior table
2. Accompanied by supraorbital rim fractures
3. Accompanied by nasoethmoidal complex fractures
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Type 2: Anterior and posterior table fractures
1. Linear fractures
• Transverse
• Vertical
2. Comminuted fractures
• Involving both tables
• Accompanied by nasoethmoidal complex fractures
Type 3: Posterior table fractures
Type 4: Very severe comminuted fractures of the whole frontal area, involving the orbit, the nasal base
and the ethmoid—Through-and-Through Frontal Sinus Fracture
6. What are the signs of frontal sinus fracture?
History of a blow to the forehead resulting in lacerations, contusions, or hematoma should be
suspected to be associated with a possible injury of the frontal sinus. Palpable or visible depression
of the brow or the forehead should raise suspicion of frontal sinus involvement, although a visible
or palpable depression is not always appreciated initially after injury because of swelling, edema, or
hematoma. Supraorbital numbness, subconjunctival hematoma, eyelid ecchymosis, and subcutaneous
air crepitus and cerebrospinal rhinorrhea are other signs of possible frontal sinus fracture.
7. What is the best radiographic modality used for diagnosis of frontal sinus
fractures?
Although plain radiographs and Waters’ view of the skull may show displaced frontal sinus fractures by
depicting cortical malalignment or air fluid levels, they frequently miss smaller fractures and involvement
of the nasofrontal duct. Conventional radiographs can also fail to show the severity of the fracture or the
degree of displacement. The computed tomography (CT) scan has become the standard for evaluation of
frontal sinus fractures because it allows for visualization of even small and minimally displaced fractures
of the floor, septum, and anterior or posterior tables of the frontal sinus (Fig. 33-1). Direct visualization of
the ducts and possible injury to the ducts also can be determined by visualizing fractures of the floor that
run near the midline, cross the midline, or involve the nasoethmoidal complex. Coronal CT and threedimensional reconstruction images may allow direct visualizing of the duct involvement in the fractures.
8. What are the possible complications associated with frontal sinus fractures?
Most authors agree that most of the complications associated with frontal sinus injury are second-
ary to interference with drainage of the sinus due to obstruction of the nasofrontal duct, entrapment
of mucosa in the fracture lines, or dural tears. Most complications of frontal sinus fractures occur in
patients in whom such fractures go undetected or untreated. These complications can be divided into
early and late complications.
Early complications: occur within the first 6 months after injury
• Epistaxis
• Cerebrospinaluid(CSF)leakageandstulae
• Frontalsinusitis
• Meningitis
• Intracranialhematomasandorintracranialabscess
• Empyema
• Cavernoussinusthrombosis
• Concomitantneurologicinjuriessecondarytopenetratingtraumaordisplacementofthefrontal
bone into the neurocranium
• Diplopiatoblindness
• Limitationofextraocularmotions
• Damageofthesupraorbitalorsupratrochlearnerves
Late complications: occur 6 months or more after the initial injury
• Mucocele/mucopyoceleformation
• Latefrontalsinusitisleadingtoorbitalabscesses
• Brainabscesssecondarytofrontalsinusinfection
• Frontalcontourdefects
• Osteomyelitisofthefrontalbone
9. What are the overall goals and the basis for management of frontal sinus
fractures?
The overall goals of management of frontal sinus fracture are to create a safe sinus, restore facial
contour, and avoid short- and long-term complications.
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A
Figure 33-1. Computed tomography scan showing a displaced anterior and posterior table fracture of the left frontal
sinus. (From Fattahi T: Management of frontal sinus fractures. In Fonseca RJ, Marciani RD, Turvey T, editors: Oral maxillofacial
surgery, vol 2, St Louis, 2009, Saunders.)
Treatment of frontal sinus fractures is complex and sometimes controversial and often is based
on the author’s experience and training. However, most authors agree that appropriate treatment
rationale should be made based on the clinical and radiographic findings and other clinical variables.
Of these variables, assessment of at least five anatomic parameters should be included. These are the
presence of:
• Ananteriortablefracture(A)
• Aposteriortablefracture(B)
• Anasofrontalrecessfracture(C)
• Aduraltear(CSFleak)(D)
• Fracturecomminution
10. What are the surgical approaches to exploration and repair of frontal sinus
fractures?
Coronal incision provides the best access to the whole frontal sinus and frontal bone, as well as
the ethmoidal, orbital, and intracranial regions, and provides the most cosmetic results. Exploration
and reduction of anterior table fractures alone usually can be performed through this approach,
allowing unroofing of the remaining anterior table for complete access to the sinus and reduction
and fixation of the fractured segments. Posterior table fractures may require a frontal craniotomy
in conjunction with a neurosurgical team to assess and repair dural or parenchymal injuries if
necessary. If the frontonasal duct is involved, and the sinus needs to be obliterated with material
such as fat, muscle, or bone, a coronal approach also provides access to harvest cranial bone,
temporalis muscle, fat, or fascia to be used for such purpose. Other approaches to the treatment
of frontal sinus fractures include presence of a forehead laceration overlying the fractures and
open sky approach. These approaches, however, are mostly useful when only the anterior table is
involved. Some surgeons use endoscopic surgery in selected cases for conservative care and sinus
preservation.
11. What are the different management considerations and the treatment options for
treatment of frontal sinus fractures?
Management considerations following frontal sinus fractures include assessment of the following:
degree of fracture displacement; injury to the nasofrontal duct; and presence of CSF leak. Treatment
options would include:
• Observation
• Openreductioninternalxation(ORIF)
B
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• Obliteration
• Cranialization
Fractures of the anterior table alone without involvement of the nasofrontal duct can be simply
reduced and stabilized with microplates to prevent cosmetic deformities.
12. What is the difference between obliteration and cranialization?
• Obliteration: Fractures involving the nasofrontal duct have historically been treated with
obliteration of the sinus. This procedure consists of removing all sinus mucosa from the sinus and
upper duct with a high-speed burr and then packing the duct and the entire sinus with material that
encourages scarring and ossification of the sinus and the duct. Many materials have been used,
including autologous tissue such as bone, muscle (temporalis), fat (temporal or abdominal), fascia,
and periosteal flaps; alloplastic materials such as Gelfoam and synthetic bone have also been used.
All methods have been shown to have comparable success, but cancellous iliac bone and abdominal
fat remain the two most popular tissues used.
• Cranialization: Fractures that involve a displaced or comminuted posterior table can be associated
with dural tear or parenchymal brain injury and may require a craniotomy. Fractures involving only
the inner table with no CSF leak are seldom treated. If a CSF leak is present, cranialization and
repair of the dura are recommended. In this procedure, after any neurosurgical repair of the dura is
completed, the posterior table is removed, the floor is reduced and stabilized, the remaining
mucosa and inner cortices of the sinus and duct are burred, and the duct is packed with an appropriate material, as mentioned. The brain is then allowed to resume its proper location in a newly
enlarged anterior cranial fossa. Finally, the anterior table is reduced and stabilized with microplates
and screws.
13. What are the indications for surgical intervention in treatment of frontal sinus
fractures?
Over the years, despite some of the controversy over the management of frontal sinus fractures,
most surgeons base the decision to operate to treat frontal sinus fractures, or merely observe these
fractures, mostly on degree of displacement of the anterior and posterior tables and the status of the
nasofrontal ducts. Some authors developed treatment algorithms for such treatment based on these
variables (Figs. 33-2 and 33-3). Nondisplaced or minimally displaced anterior table fractures can be
safely observed. However, displaced anterior table fractures may require surgery if the displacement
is determined to cause a cosmetic deformity at the time of presentation or later, after the swelling
resolves. Similarly, minimally or nondisplaced posterior table fractures can be observed if there is no
CSF leak or if the displaced posterior table fracture is less than the thickness of the cortical plate of
the sinus wall. Fractures of the posterior wall that are greater than the thickness of the cortical bone,
those associated with CSF leak, or those with suspicion of nasofrontal duct injury may merit surgical
exploration and reduction.
Over the past few years, however, with recent large case series publications, there is a strong
trend toward changing the management of frontal sinus fracture philosophies into a more conservative approach, and occasionally even nonoperative management of frontal sinus fractures that previously would have been treated surgically by most authors (see next question).
14. Is there any recent shift in treatment approach to frontal sinus fractures?
Although the goals of treatment for frontal sinus injuries have remained relatively constant over the
years, the strategies of management and surgical treatments have evolved. For instance, traditional
philosophies emphasized either obliteration or cranialization when considering the management
of frontal sinus fractures involving possible impairment of outflow of the drainage of the sinus with
emphasis on involvement of the frontonasal duct, degree of displacement, and the anterior and
posterior tables of the sinus. However, because these treatments are in part based on a concern for
long-term complications, there is often a debate as to the exact incidence of these complications.
Long-term follow-up is not often possible with these patients and, accordingly, such rational is not
considered evidence-based criteria. As a result and by contrast, recent literature is leaning toward a
more conservative approach when treating fractures of the frontal sinus, with preservation as much
of the form and function of the sinus. A study by Bell et al. of 116 patients with frontal sinus fractures
treated over a 10-year period found that in patients who were treated conservatively (nonoperatively,
and patients who were treated with preservation of the normal sinus membrane), the protocol resulted
in functional sinus preservation for the majority of cases with relatively few significant complications.
More recently, Choi et al. and Weathers et al. confirmed the validity of the conservative approach and
signaled a shift in treatment of frontal sinus fractures.
CHAPTER 33 FRONTAL SINUS FRACTURES 351
Frontal sinus fractures
https://t.me/medicina_free
CSF leak
No
Nasofrontal duct
Yes
Observe 4-7 days,
No Yes Stop Persist
+ Sinus preservation
Figure 33-2. Algorithm for the management of frontal sinus fractures. ORIF, Open reduction internal fixation; CSF,
cerebrospinal fluid. (Adapted from Chen K-Te, Chen C, Mardini S, Tsay P-K, Chen Yu-R: Frontal sinus fractures: a treatment
algorithm and assessment of outcomes based on 78 clinical cases, Plast Reconstruct Surg 116:457–468, 2006.)
No
displacement
Observation
No
concomitant
injury
Observation
+ Sinus partial obliteration
Fracture
displacement
0–2 mm 2–5 mm >5 mm
Concomitant
injury
(fractures/NF
D/CSF-leak)
Surgical
repair
No
concomitant
injury
Evaluate
esthetics
(fractures/NF
ORIF of anterior table
CranializationORIF of anterior table
Concomitant
injury
D/CSF-leak)
Surgical
repair
Surgical
repair
Figure 33-3. Metric-dislocation algorithm for treatment of frontal sinus fractures. NFD, Nasofrontal duct; CSF, cerebro-
spinal fluid. (From Torre DD, Burtscher D, Kloss-Brandstätter A, et al.: Management of frontal sinus fractures–treatment
decision based on metric dislocation extent, J Cranio-Maxillo-Fac Surg 42(7):1515–1519, 2014.)
BiBliography
Banica B, Ene P, Dabu A, Ene R, Cirstoiu C: Rationale for management of frontal sinus fractures, Maedica (Buchar)
8(4):398–403, 2013.
Bell RB, Dierks EJ, Brar P, Potter JK, Potter BE: A protocol for the management of frontal sinus fractures emphasizing sinus
preservation, J Oral Maxillofac Surg 65(5):825–839, 2007.
Chen KT, Chen CT, Mardini S, Tsay PK, Chen YR: Frontal sinus fractures: a treatment algorithm and assessment of out-
comes based on 78 clinical cases, Plast Reconstr Surg 118(2):457–468, 2006.
Choi M, Li Y, Shapiro SA, Havlik RJ, Flores RL: A 10-year review of frontal sinus fractures: clinical outcomes of conservative
management of posterior table fractures, Plast Reconstr Surg 130(2):399–406, 2012.
Observation
Surgical
repair
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