This document discusses the treatment of frontal sinus fractures. The goals of treatment are to manage any intracranial injuries, seal off the aerodigestive tract from the cranial cavity, and make the frontal sinus functional or safe. Displaced fractures requiring open reduction and internal fixation. Determining the status of the duct and posterior table indicates if obliteration or cranialization is needed, with CSF leak indicating cranialization. Surgical techniques include coronal or endoscopic approaches to access the frontal sinus for procedures like internal fixation, obliteration by removing mucosa and grafting, or cranialization by removing the posterior table and placing a pericranial flap. Potential complications are also discussed.

1. Frontal sinus fracture
Dr jameel kifayatullah

2. Functional goals of treatment
• managing intracranial injuries
• sealing off the aerodigestive tract from the
cranial cavity
• rendering the frontal sinus either functional
or safe

3. Displaced Fracture
• Displacement of the bone more than the
width of the outer table is typically considered
displaced and is likely to require open
reduction and internal fixation (ORIF).

4. Cranialise or obliterate?
• Determining the status of the duct and the
posterior table determines the need for either
obliteration or cranialization
• The presence of rhinorrhea or CSF leak is an
indication for cranialization

5. Surgical technique (frontal sinus)
• Preoperative planning:
Visual and neurologic examinations
CT imaging
• Prep and patient positioning: supine position
on the operation table.
the upper and middle face is kept exposed

6. Surgical Technique
• Surgical approach: The coronal flap
the gullwing incision
endoscopic techniques use a Lynch incision

7. Surgical procedure
• Open reduction and internal fixation of
anterior table :If the posterior table and nasofrontal duct
are sufficiently intact, then ORIF of displaced frontal bone
fragments may be the only required treatment.

8. Obliteration
• If the nasofrontal duct is severely disrupted, the
sinus must be either obliterated or cranialized.
With the posterior table intact, obliteration may
be indicated.
• The goals of obliteration include:
Complete removal of the frontal sinus mucosa
Occlusion of the nasofrontal outflow tract
Obliterating dead space with allogenic,
alloplastic, or autogenous graft

9. Cranialization
• If the nasofrontal duct and posterior table are
significantly disrupted, cranialization is
indicated

10. Coronal flap
• The coronal flap is elevated in a subgaleal
plane, leaving the pericranium attached to the
skull. Once the flap is elevated, creation of
anteriorly based pericranial flap is performed.
An incision is made in a box pattern extending
far enough in the anteroposterior direction to
cover the sinus floor and enter into the
anterior cranial fossa and with enough width
to cover the floor of the frontal sinus

11. Cranialization
• The dura and frontal sinus are then accessed via a
craniotomy performed by neurosurgery
• The sinus mucosa is removed, peripheral ostectomy
performed, and the ducts are occluded, similar to an
obliteration. In cranialization, the posterior table is
removed.
• Once the frontal sinus is cleaned and the duct occluded
, the pericranial flap is placed overlying the sinus cavity
floor extending into the anterior cranial fossa to
separate the intracranial cavity from the aerodigestive
tract . The anterior table is then reconstructed and
replaced followed by closure of the scalp

12. Endoscopic techniques
• gaining popularity for access to the frontal
sinus and can even be used for ORIF of the
anterior table and cranialization by qualified
surgeons.
• Useful for monitoring the status of the duct
and the sinus postoperatively without the
need for CT radiation.

13. Potential complications
Short-term complications:
persistent CSF leak
meningitis
sinusitis
intracranial bleeding
infection.

14. Potential complications
Long-term sequelae
• mucocele
• mucopyocele formation from incomplete
removal of the mucosa
• frontal bone osteomyelitis
• brain abscess
• scarring.