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Dr. Volshteyn performs repair and reconstruction of acute and chronic frontal sinus fractures using open, limited, endoscopic and below brow incisions.
Unfortunately, algorithm of frontal sinus fracture treatment can be quite confusing. The reason is that frontal sinus fractures, especially anterior table fractures, are managed somewhat differently by plastic surgery, ENT, neurosurgery, and oromaxillofacial surgery.
Information below is provided for referring physicians as the general guideline for initial evaluation and management. Please note, it is not designed as a comprehensive review and reading this article does not constitute professional consultation.
Our Practice is happy to assist you with management of acute and chronic frontal sinus fractures and other facial fractures.
SAME DAY APPOINTMENTS ARE AVAILABLE FOR ACUTE FACIAL AND FRONTAL SINUS FRACTURES. WE ALSO ACCEPT DIRECT INTER-HOSPITAL TRANSFERS TO CENTRAL NJ MAJOR TRAUMA CENTERS: RWJUH and JSUMC.
PLEASE, GET REFERRING PHYSICIAN TO CALL OUR OFFICE FIRST AND WE WILL ASSIST YOU WITH TRANSFER PROCESS.
Frontal sinus fractures are very common. Some studies report that they account for up to 12% of all facial fractures.
Overall, about 71% of frontal sinus fractures come from motor vehicle accidents, assaults account for about 10%, industrial accidents account for about 5%, recreational injuries and other causes constitute about 14%.
Frontal sinus has anterior and posterior tables. Looking at all injuries to frontal sinus, in two thirds of all cases, both anterior and posterior tables are fractured. Isolated anterior table fractures constitute about one third of all frontal sinus fractures. CSF fluid leak is present in one third of all patient's with frontal sinus fractures.
Most common symptoms of frontal sinus fracture include forehead swelling, forehead and pain, changes in sensation of the forehead, concave or indented frontal bone contour, and cerebrospinal fluid, also known as CSF, fluid leak.
It is very important not to focus exclusively on frontal sinus fracture. In 75% of cases additional facial fractures are present, three quarters of patients with frontal sinus fractures also sustain loss of consciousness.
Therefore, treating physician must examine the eye globe itself, other portions of the face,skull and neck.
VERY IMPORTANT: Any lacerations or cuts overlying frontal sinus have to be examined under sterile conditions in the operating room because of possibility of associated CSF leak or communication with the brain cavity.
Nose has to be examined for possible associated fractures. Patient must be asked about salty postnasal drainage or presence of a watery runny nose.
Medial attachments of the upper and lower eyelids needs to be checked by pulling upper and lower eyelids laterally. It is very common to have nasal orbital ethmoid fracture together with frontal sinus fracture and detachment of medial insertion of the lids.
It is also important to have detailed examination of the extraocular movements of the eye. With injuries to the roof of the orbit, the superior oblique muscle can be injured or its attachment to the medial aspect of the inner orbit displaced. Patient may complain of pain or discomfort, or catching with upward and downward gazes. To better isolate superior oblique muscle the patient needs to look to the most medial position toward the nose. Doing that will neutralize superior and inferior rectus muscles. Then the patient is asked to look downwards to better assess the function of superior oblique.
Usually, isolated anterior plate fractures of the frontal sinus are treated by plastic surgeon, ENT specialist, OMFS or neurosurgeon. Posterior plate fractures are treated by neurosurgeon. Combination fractures may require more than one specialist. Ophthalmologic examination is mandatory.
ANATOMY AND DEVELOPMENT
Frontal sinus is usually not present at the time of birth. It slowly develops from about 2 years old and reaches full size at about 15. Usual measurements are 3 cm height, 2.5 cm wide and about 2 cm deep. Average volume of frontal sinus is about 10 cubic centimeters. In 80% of the patients there are 2 sinuses, right and left. In 20% of the patients, sinus may be absent, decreased in size, or located only on one side.
Anterior table of the frontal sinus provides shape for the forehead, brow and glabellar. On average, it is about 4 -12 mm in thickness. It is more resistant to fracture than ANY OTHER facial bone.
Posterior table separate frontal sinus from cranial fossa, where the brain is. It can be as thin as 0.1 mm or as thick as 5 mm and is much less resistant to injury.
Frontal sinus has 2 openings located on the inferior and posterior aspect of the frontal sinus. They are medial to the orbit. Each opening is about 3 or 4 mm. This is the only drainage path for frontal sinus. Damage to it usually requires surgery to eliminate the sinus.
How to evaluate for CSF fluid leak. First ask patient about salty postnasal drip. Then do a halo sign test. A portion of bloody nasal drainage is placed on filter paper and observed. If cerebrospinal fluid leak is present, it diffuses faster than blood cells and results in a clear halo around the central bloody stain.
Chemistry analysis of the nasal drainage may reveal elevated levels of glucose contents consistent with cerebrospinal fluid.
Beta 2 transferrin test is the definitive test for CSF leak. Nasal drainage is collected in a red top tube. Positive test for beta 2 transferrin documents CSF leak. The only other areas in the body that have beta 2 transferrin are the vitreous fluid of the eye and perilymph of the ear. The problem is that for most institutions this test has to be sent out and it may take up to 5 to 7 working days to get the results back.
To diagnose frontal sinus fractures usually requires CT scan. Some people obtain plain sinus x-rays, which I find remotely helpful.
CT scans have to be done with a very thin cuts, at least 1.5 mm. Axial cuts are better for examining injury to anterior and posterior tables. Coronal images are mostly used to evaluate the floor of the sinus and the roof of the orbit. To better evaluate patency of the frontal recess and nasal frontal duct may require sagittal reconstructions with 3-dimensional reconstruction.
Because of complex anatomy, three-dimensional reconstruction is usually helpful in surgical planning. Because other skull and facial bone fractures are commonly present with frontal sinus fractures, head, neck and facial CT scans is recommended to rule out associated neck, skull base, orbital and midface fractures.
The treatment of the frontal sinus fractures is not very straightforward. There are a lot of opinions depending on specialty and the training of the surgeon. For example, some surgeons consider anterior table fractures purely cosmetic and others reconstruct it immediately.
WHAT TO LOOK FOR DURING INITIAL EXAM:
1. The degree of displacement and comminution of the anterior table as well as presence of bony particles inside the frontal sinus that can potentially interfere with nasofrontal duct function. Also, evaluate for possibility of mucosal entrapment in between the fractured fragments.
2. Degree of displacement and comminution of the posterior table.
3. Involvement of the medial structures in the proximity of the nasofrontal duct.
4. Presence of CSF leak and integrity of the dura
5. Medial canthus detachment
6. Pain, discomfort with changes of function of superior oblique muscle.
7. Degree of external deformity
8. Changes in sensation, or loss of sensation of supraorbital and supratrochlear nerves.
9. Evaluate for associated nasal, facial, skull, or neck fractures.
10. Evaluate for possible intracranial hemorrhage
11. Evaluate for changes in orbital volume
12. Evaluate for superior orbital rim involvement
ANTERIOR TABLE FRACTURES
Anterior table frontal sinus fractures that are not displaced can be usually observed. The fractures with displacement of over 2 mm can result in significant aesthetic deformity and depending on location can present problems to outflow. Therefore, consideration for repair should be given to patients with over 2 mm displacement of the anterior table, especially if bony fragments are present inside of the frontal sinus, or if the fracture is more medial.
The traditional approach repair is coronal incision, which we rarely use, except in most complex cases. We usually use mid forehead, supra-brow, or below brow incision, or endoscopic approach. Usually the scars around the brow are better accepted by the patients compared to traditional coronal incision.
If the fracture is old, in the frontal deformity is visible, endoscopic placement of the onlay graft, or open placement of bone powder or other materials can result in significant improvement of overall appearance.
Some surgeons prefer to treat most anterior table fractures conservatively and deal with cosmetic deformity later on. With below brow incisions' superb camouflage, we prefer to address anterior plate frontal sinus fracture acutely.
If the CSF leak is present, depending on degree of displacement of the posterior table, most patients can be managed conservatively for 5-7 days. In about 50% of them the leak will stop. It CSF leak does not stop, additional surgical intervention is required.
The treatment of the posterior table fractures depends on degree of displacement, presence of CSF leak, associated risks of mucocele formation and meningitis. Even though there is some disagreement on the required degree of posterior table displacement, most people agree that posterior table displacement less than one table with no CSF leak can be managed conservatively. The patient required to have repeat CT scan at 2 or 3 months and then at 12 months to rule out mucocele formation.
It CSF leak is present after one week, open reduction, repair of the dura and sinus obliteration or cranialization is required. More comminuted posterior table fractures with or without CSF leak and / or with more then one table displacement usually require additional surgery.
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We recommend antibiotics treatment for 7-10 days