04 frontal sinus FRACTURE
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This document discusses the current treatment protocol for fractures of the frontal sinus. It begins by covering the embryology and classification of frontal sinus fractures. Type 1 fractures involve minimal comminution of the anterior table, while type 4 fractures involve injuries to the dura and CSF leak. Management is based on fracture location, dural involvement, and damage to drainage. For nondisplaced anterior table fractures, conservative treatment is used. Displaced fractures may require open reduction, fixation, and frontal sinus obliteration. Posterior table fractures with CSF leak or displacement are treated with frontal sinus cranialization or obliteration. Complications can include infection, mucocele, and brain abscess.
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04 frontal sinus FRACTURE
- 1. FRACTURES OF THE FRONTAL SINUS CURRENT TREATMENT PROTOCOL mouth jaws face neck oral & maxillo facial surgery Adnan Aslam Assistant Professor & Consultant Department of Oral & Maxillofacial Surgery Margalla Institute of Health Sciences & affiliated hospitals Rawalpindi docadnanaslam@hotmail.com
- 2. mouth jaws face neck oral & maxillo facial 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
- 4. mouth jaws face neck oral & maxillo facial surgery Classification Type 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
- 5. mouth jaws face neck oral & maxillo facial surgery Clinical evaluation General Facial pain Forehead paraesthesia or anaesthesia Forehead laceration Visible and/or palpable frontal bone depression CSF rhinorrhoea Neurological injuries Cerebral contusion Subdural & epidural haematoma Ophthalmic injuries Pupillary defect Optic neuropathy Hyphaema Disc edema Corneal defect Loss of globe integrity Associated maxillofacial Injuries NOE fracture Orbital fracture Zygomatic fracture
- 6. mouth jaws face neck oral & maxillo facial surgery Radiographic evaluation (Diagnostic Imaging) Plain radiographs Caldwell view Lateral view Evidence of air fluid level Clouding of frontal sinus Pneumocephalus High Resolution CT Scan MRI
- 7. mouth jaws face neck oral & maxillo facial 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
- 8. mouth jaws face neck oral & maxillo facial surgery Management generally based on three clinical factors: • Fracture location and displacement • Dural and cerebral involvement • Damage to the frontal sinus drainage system Treatment options Conservative Fracture reduction & fixation Sinus obliteration Sinus cranialization
- 9. mouth jaws face neck oral & maxillo facial surgery Anterior table fracture (Nondisplaced, linear/isolated) Conservative treatment • Local wound care • Antibiotics, Nasal decongestants, Analgesics • Follow up evaluation
- 10. mouth jaws face neck oral & maxillo facial surgery Operative Indication of FS injury • Nasofrontal duct involvement/obstruction • Displacement of posterior table with underlying neurologic injury • Aesthetic forehead deformity
- 11. mouth jaws face neck oral & maxillo facial surgery Anterior table fracture (Displaced) Approach Existing laceration Butterfly / Seagull / Open sky approaches Coronal flap Intraoperative assessment Any kind of fluid Nasofrontal duct patency Nasofrontal duct injury Nasofrontal duct filling with frontal sinus obliteration Reduction & fixation Grafting
- 12. mouth jaws face neck oral & maxillo facial surgery Isolated anterior table #. ORIF
- 13. mouth jaws face neck oral & maxillo facial surgery Frontal sinus obliteration Steps • Sinus exploration • Mucosal extenteration • Nasofrontal duct obturation • Frontal sinus obliteration • Fracture reduction
- 14. mouth jaws face neck oral & maxillo facial surgery Frontal sinus Filling materials for obliteration and obturation Autogenous materials Autologous fat Cancellous bone Muscle Pericranial flaps Banked cadaveric tissue Synthetic materials Polytetrafluoroethylene (ePTFE) Methylmethacrylate (MMA) Bioactive glass and calcium-phosphate cements
- 15. mouth jaws face neck oral & maxillo facial surgery Indication for bone grafting 1. 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 pulsatile exophthalmos 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 reconstruction as layered bone grafts to obliterate the ethmoids and reconstruct the medial orbital wall.
- 16. mouth jaws face neck oral & maxillo facial surgery Posterior table fracture • CSF leak absent and no displacement: Frontal sinus obliteration • CSF leak and/or displacement: Frontal sinus cranialization
- 17. mouth jaws face neck oral & maxillo facial surgery Frontal sinus cranialization • Removal of posterior table • Dural repair • Grafting for bone loss • Internal fixation of anterior table
- 18. mouth jaws face neck oral & maxillo facial surgery Complications • Early Forehead pain Transient paresthesia of forehead Wound infection Transient diplopia • Late Mucocele Mucopyocele Osteomyelitis Brain abscess Pneumocephalocele Meningitis Cosmetic defect
- 19. mouth jaws face neck oral & maxillo facial surgery Future direction • Endoscopy assisted frontal sinusotomy • Spontaneous osteogenesis and auto obliteration
- 20. A Q&Q u e s t i o n s A n s w e r s
- 21. Thank you for choosing us for academic interest!
Editor's Notes
- Nasofrontal ductal system: Drain FS exclusively into middle meatus Located in the posteromedial floor of frontal sinus Run caudally from few millimeter upto 2 cm Air filled cavity lined by ciliated respiratory epithelium Pyramidal shape Average Dimensions of an Adult Frontal sinus: 28mm height 27mm Width 17mm Depth Average volume:6-7ml Anterior wall is thicker & stronger than Posterior wall Anteriorly: FS overlies ant. Ethmoidal sinus & Nasal cavity Posteriorly: Cribriform plate & Dura mater of Frontal lobe Inferiorly : Roof Of Orbit, Nasofrontal duct Intersinus septum separate FS into two sides Drainage system of frontal sinus: Variable: 34% drain thru ethmoidal infundibulum 62% drain into frontal recess 15% drain thru nasofrontal drainage into middle meatus