frontal sinus fracture management

1. Frontal sinus fracture
Dr jameel kifayatullah

2. Frontal sinus anatomy. The anterior table of the frontal sinus is thick bone and
provides forehead contour. The posterior table is thinner and constitutes a portion of
the anterior cranial fossa. The floor or the sinus makes up a portion of the orbital roof.
The frontal sinus ostia is located in the medial, posterior, and inferior portion of the
sinus floor

3. Frontal sinus fracture patterns. (a) Normal relationship. (b) Anterior
table.
(c) Comminuted anterior and posterior table.

4. Management
• Treatment Goals
• Surgical access
• Osseous Recovery And Access
• Intraoperative Evaluation of Nasofrontal outflow
• Anterior Table fracture
• Posterior Table fracture
• Orbital roof and supraorbital Bar reconstructon
• Nasofrontal outflow tract obstruction
• Sinus obliteration
• Endoscopy in Management of frontal fracture

5. Classification of frontal sinus fracture
• Anterior Table fracture
• Posterior Table fracture
• Combination of posterior table fracture and anterior
table fracture
• Combinations of fracture that compromise the NFOT
Fractures of the anterior table and posterior table
Fractures of anterior table and NOE
Fractures of anterior table and medial superior orbital
rim

6. Anatomic parameters that need to be assessed when developing a treatment plan for
frontal sinus fractures. Yellow—anterior table; Red—posterior table; Blue— frontal
recess; Green—dural integrity.

7. Indication of isolated Anterior Table
fracture
• To prevent cosmetic deformities

8. Indication of posterior table fracture
alone or in combination with anterior
table fracture
• To avoid neurologic sequelae including
meningitis and brain abscess

9. Combination of fractures that
compromise the NFOT Indications
• Prevention of mucoceles and pyoceles

10. Treatment Goals
The primary goals of treating frontal sinus
fractures
• creation of a safe sinus so that risk of long
term complications is minimized and
protection of the brain

11. Surgical Access
• Coronal Approach: provides best access to frontal
bone and sinus
• Gull wing or spectacle incisions: Unattractive
scars
• “Open sky” Approach : H-shaped scar over brows
and nasion
• Butterfly: combination of gull wing and open sky
• Sewall : a single side medial orbital incision
• Existing laceration

12. Surgical Access

13. Osseous recovery and Access
• Reflection of coronal flap
• Release of fragments of anterior table from perisoteum
• Organising the fragments
• Cleaning of bone fragments
• Anterior table removed
• Sinus exploration
• Posterior table inspection
• Sinus floor (NF outflow) evaluation
• More extensive neurosurgical procedure:osseous
recovery performed in concert with a craniotomy flap

14. Intraoperative Evaluation of NFOT
• Condition of the frontal sinus floor and
nasofrontal outflow-assessed by direct
visualisation
• Evaluaton of patency of nasofrontal duct by
placing an angiocatheter and injection of
methylene blue or flourescein—emergence of
methylene blue observed beneath the medial
turbinate or its collection in posterior pharynx

16. Anterior Table Fractures
• Simple green stick or non-displaced anterior
wall fracture: donot require operative
treatment
• Displaced anterior table fracture: require
reduction
• Rule of thumb: displacement> thickness of
anterior table

18. Anterior Table Fractures
• Closely inspect the sinus floor,the posterior
wall and patency of nasofrontal duct
• If posterior wall and floor free of injury-Fix the
pieces of anterior wall with bone plates
voids remaining in anterior wall after
reconstruction closed by Titanium mesh,MMA
or other bone sustitutes
• Soft tissue injury repair

19. Posterior Table fracture
• Three categories
1) Non displaced
2) Displaced
3) Displaced with gross neurologic injury

20. Posterior Table fracture
• Joint management with neurosurgeon
• Antibiotic coverage
Surgeon should check for
• Any displacement of the fracture
• CSF leak
• Entrapment of sinus membrane
• Dural tears

21. Posterior Table fracture
• Injury not substantial Nasofrontal duct patent
Anterior Table replaced and fixed and soft
tissue injuries repaired

22. Posterior Table fracture
• Comminution of posterior table penetrating
injury CSF leak with extensive dural damage or
frontal lobe damage : Frontal sinus cranialization
–removal of posterior table-dura repair with
primary closure,a fascia or synthetic patch or
galeal/pericranial flap
• Wound closure in layers: Meticulous removal of
all the mucosal elements from the walls,cul-de-
sacs,and septa of the sinus and from all bone
fragments
• Failure to remove such elements:mucocele or
pyocele

23. Posterior Table fracture
• Mucosa then reflected down into the
nasofrontal outflow
• Orifice obstructed by local bone or muscle
• Harvested fat placed into sinus and packed
until sinus is full
• Anterior table reassembled(ORIF)

24. Orbital Roof and Supraorbital Bar
Reconstruction
• Once posterior wall and sinus floor
explored,inspected and evaluated for damage;
any orbital roof and supraorbital bar fracture
reconstructed with titanium mesh

25. NFOT OBSTRUCTION
• One of the methods of isolating the sinus(or
brain) from nasal contmination,by plugging it ith
another material
• NFOT obstruction necessary to seal off the frontal
sinus from nasal contaminants
• If NFOT is obstructed
sinusitis,meningitis,osteomyelitis may develop
• Consider condition of Nasofrontal outflow in
fractures of NOE Complex, supraorbital rim or
the sinus floor

26. OUTFLOW NOT PATENT
• Thorough removal of every possible remnant
of sinus mucosa by curettage
• Any remaining remnants of nasofrontal
mucosa then inverted into nose

27. Materials used to obstruct NF outflow
• Temporal fascia
• Temporalis muscle
• both
• Tensor fascia lata
Bone graft material
• Sinus septum,inner table or any elsewhere on
cranium
• Fibrin sealants
• Autologous platelet gel
• Autologous fibrin glue

28. Sinus Obliteration
• Adds one more layer to NFOT Seal
• Also eliminates the “dead space” or air within
the sinus that may permit fluids to accumulate
causing a seroma or hematoma

29. Methods of obliterating frontal sinus
• Inserting no substance or object
• Insertion of hydroxylapatite, glass wool, bone,
cartilage, muscle, absorbable gelatin sponge ,
absorbable knitted fabric ,acrylic or fat
• Use of pericranial flap or galeal flap for
obliteration of frontal sinus

30. Endoscopy in Management of frontal
sinus fracture
• For reduction and fixation of anterior table
fracture
• Management of frontal sinus drainage system
• Secondary management of contour defects of
frontal bone

31. Aim in treatment of frontal sinus
fracture
• To create a safe sinus(ie minimize the risk of
complications related to injury)

32. Concerns in frontal sinus fracture
1) infections particularly Meningitis 6%
mortality
2) acute and chronic frontal sinusitis
3) mucocele
4) Mucopyolocele
5) Osteomyelitis

33. Classification
• Anterior wall fracture
• Posterior wall fracture
• The floor of the frontal sinus
• Combination of the three

34. Anterior Wall fracture

36. Anterior wall fracture
• Undisplaced- treated conservatively
• Displced,depressed anterior wall fractures-
reduction and fixtion plus sinus preservation

38. Fractures of the floor of the frontal
sinus
• Aim of management: reduce the possibility of
development of a frontal mucocele and its
sequelae
• Two views
1) obliteration of sinus and sealing the
frontonasal duct(renoval of sinus mucosa and
filling with autogenous material)
2) reconstruction of floor of the sinus and
attempting to re-establish drainage by placing
a stent

39. Posterior wall fractures
• Posterior table fracture with significant
comminution ,displacement,or CSF leaks :
cranialization of the frontal sinus indicated
• Cranialization: persistent CSF leak with
comminuted displaced posterior wall fracture

40. Cranialization procedural steps
1) coronal approach with frontal craniotomy
2) Preservation of anterior pericardial flap
3) Treat intracranial injury /dural repair
4) Remove all sinus mucosa
5) Obliterate frontonasal duct
6) Remove posterior wall and septum
7) Pericardial flap to floor of sinus

41. Alternative Strategies
• Re-establish fronto-nasal duct patency if the
posterior wall is intact(Gerbino et al)
• Dural repair,posterior wall
reconstruction,sinus obliteration with
lyocartilage(Sialer et al)

42. Summary
• Undisplaced fractures should be managed
conservatively
• Uncomplicated anterior wall fractures should be
managed with reduction and fixation plus sinus
preservation
• Frontonasal duct involvement should be
managed with sinus obliteration
• Comminuted ,displaced anterior and posterior
wall fractures with CSF leak and frontonasal duct
involvement best managed with frontal sinus
cranialization

43. Summary
• Displaced ,comminuted fractures of the posterior
wall of the frontal sinus are associated with a
high incidence of dural tears
• The sinus is cranialised by removing the posterior
wall and sinus mucosa,sealing the frontonasal
ducts, and using a vascularised galeal frontalis or
pericranial flap to cover the sinus floor
• Separating the anterior cranial fossa from nasal
cavity

44. The posterior table bone is removed with a rongeur;
cottonoids protect the frontal lobes.

45. Mucosa is removed from the anterior table using a diamond
burr drill under loupe magnification.

46. A sagittal view of layered closure employed in
cranialization.

47. Anterior table frontal sinus fracture
• Comminuted segments reduced and fixated

48. Isolated posterior table frontal sinus
fracture
• Posterior table # with no brain injury or dural
tear :conservative management including non
treatment is recommended

49. Posterior table fracture with
concomitant anterior table #
• Treatment objectives: determined by
displacement and potential for cosmetic
deformity

50. Posterior table fracture
• Significant posterior table fracture leading to
brain injury or patients with suspected or
established NF duct injury-additional surgical
procedures required

51. Anterior Table and nasofrontal duct
injury
• Debridement of sinus membrane and
obliteration of sinus and ducts
• Reconstruction of anterior table

52. Material used for frontal sinus
obliteration
• Pericranial flap
• Temporalis muscle
• Abdominal fat

53. Materials used for obliteration of NF
ducts
• Abdominal fat
• Temporalis muscle
• Bone fragments

54. Reconstruction of Anterior Table
Options
Original fragments pieced together for
reconstruction
Severe comminution/avulsion:autogenous
bone/mesh

55. Cranialization
• Posterior and anterior tables of the frontal
sinus are removed
• Removal allows edematous brain to expand
within volume of frontal sinus thus decreasing
intracranial pressure and further brain injury
• Severely fractured posterior table:
cranialisation

56. OBJECTIVES OF TREATMENT OF
FRONTAL SINUS FRACTURE
a) Elimination of any factors predisposing to
infection
b) Preservation of normal sinus infection or,if
this is not possible,obliteration of sinus cavity
c) The repair of any cosmetic defect

57. Classification of frontal sinus fracture
A) Anterior wall fracture
i) frontonasal drainage intact
ii) frontonasal drainage compromised
B) Combined anterior and posterior wall fracture
C) Posterior Wall fracture
B and C almost certainly involve NF duct with the
need for active management

58. Frontal sinus fracture
• Isolated posterior wall # is rare
• Occur in association with Naso-
ethmoidal,orbital roof or other anterior
cranial base fracture.

59. Anterior wall fracture
• Undisplaced fracture: do not need treatment
• Simple depressed fracture: managed by
elevation of fragments and fixation with
microplates or low profile plates
• Significant gaps in frontal contour following
bone loss in compound injuries: reconstructed
with outer table calvarial grafts

60. Anterior Wall fracture
• Inspect the sinus by removing a loose
fragment
• Irrigate it and excise damaged or
contaminated mucosa
• Inspect NF duct : if intact left alone
• If NF duct not patent :treat it
(patency of NF duct checked by instilling
methylene blue or flourescein into it checking
the dye by swabbing the nasal cavity)

61. Fractures with Frontonasal duct
involvement
• Duct injury should be suspected when there
are associated NOE or orbital roof fracture
• Combined fracture of anterior and posterior
wall almost always extend into the sinus floor
to involve the duct
• Treatment must either i) Re-establish the
drainage or ii) eliminate the sinus as a
functional unit

62. Nasofrontal duct drainage
• How to re-establish the drainage: Placement
of a silicon drainage tube following the
removal of obviously damaged mucosa
• Tube placed for several weeks
• Problem with tube: scarring and stenosis
common

63. Obliteration of sinus
More reliable procedure
a) Complete stripping of sinus mucosa to prevent
mucocele formation
b) Removal of the surface of cortical bone with a
suitable bur to eliminate any remnants of
mucosa
c) Occlusion of nasofrontal duct with
muscle,pericranium or bone chips to prevent
ingrowth of mucosa from the nose
d) Obliteration of sinus cavity with fat,
muscle,bone chips,lyophilised cartilage or
alloplastic material

64. Posterior wall fracture
• May involve the underlying dura leading to a
CSF leak
• Particularly likely in comminuted or displaced
fractures
• Undisplaced or minimally displaced fracture
with no evidence of CSF leak

65. Displaced and comminuted posterior
wall fracture
• Cranialization of sinus
• a) coronal flap raised with a separate pericranial
flap
• B) Frontal craniotomy performed to expose the
surface of the frontal lobes
• C) If the anterior wall is fractured loose fragments
of bone are carefully removed
• D) Any intracranial injury is treated and dural tear
repaired with a pericranial graft
• E) the posterior wall of sinus removed as well as
the intersinus septum and other septa

66. Displaced and comminuted posterior
wall fracture
• F) The sinus mucosa is stripped from the anterior
wall fragments and any intact anterior wall and
the inner cortex debrided as before
• G) The Nasofrontal duct is occluded with calvarial
bone dust or chips
• H) the pericranial flap is turned back to line the
sinus floor and floor of anterior cranial fossa.This
gives additional protection to the exposed dura
and separation from nasal cavity

67. Displaced and comminuted posterior
wall fracture
• Fractures of the anterior wall are repaired
with bone plates.The frontal craniotomy is
replaced and plated in position.

68. Displaced and comminuted posterior
wall fracture
• i) Fractures of the anterior wall are repaired
with bone plates.The frontal craniotomy is
replaced and plated in position.

69. Frontal sinus fracture
• Prophylactic antibiotics indicated
aqueous penicilliin G+ antistaphylococcal
penicillin
• Nondisplaced anterior wall # : Requires no TX
• Displaced anterior wall # :reduction and
fixation

70. Management of nasofrontal duct
• Controversial
• Two options
• 1) Lynch frontoethmoidectomy procedure and
attempts at splinting the duct with a drainage
tube –accompanied by significant
complications
• 2) complete removal of mucous membrane
followed by obliteration with a fat graft should
be considered

71. • Nondisplaced posterior wall fracture:require
observation for signs of CSF fluid leak
• Displaced and/or comminuted fracture:should
be managed with the neurosurgical service
• Coronal approach
• Management of posterior wall fracture
controversial : varies from repair of duramater
and reduction of wall fractures to complete
cranialization and obliteration of ducts

72. Classification of frontal sinus fracture
• Anterior Table fracture
• Posterior Table fracture
• Status of Nasofrontal ducts

73. Isolated anterior wall fracture
• Displacement greater than width of anterior
table:depressed segment carefully reduced
and fixation with titanium miniplates or
resorbable plates
• Nondisplaced or minimally displaced isolated
anterior table fracture(less than the width of
anterior table) :don’t require surgical repair

74. Anterior wall and NFD injury
• Decision made based on the health of NFDs
• Fractured anterior wall segments must be
carefully removed and saved .
• Status of NFDS is uncertain:confirm patency
by injecting a dye directly into ducts at the
base of the frontal sinus
• If dye visualised in middle meatus or in
nasopharynx-NFDS intact:donot require
obliteration

75. Anterior wall fracture and NFD injury
• NFD grossly involved in fracture or results of
dye injection equivocal:NFDs obliteration
• Procedure: remove the sinus lining from the
opening of NFDS
• Plugging the ducts with autogenous material
such as fat,pericranium,temporalis
muscle,fascia or bone
• Sinus obliteration done at the same time

76. Sinus obliteration
• Remove all remnants of respiratory epithelium
from the injured sinus
• Remove all sinus epithelium from fractured
anterior wall as well.
• Purpose of sinus obliteration
• i) to close the dead space created by occluding
the NFDS
• ii) Offers one more layer of protection against
retrograde nasal contaminants

77. Common materials used for sinus
obliteration
• Abdominal fat
• Bone
• Pedicled pericranial flap
• Fibrin sealants

78. Management of posterior wall
fractures
• Poses the greatest risk of complications
because of potential for brain injury
• If posterior wall fracture present first ascertain
dural tears and CSF leaks
• Most non-displaced posterior wall fracture will
not cause injury to dura
• Grossly comminuted and displaced fragments
of posterior wall : cause dural tears in frontal
lobe and initiate a CSF leak

79. Posterior wall fracture
• Intraoperative evaluation is necessary to ensure
absence of CSF leakage
• CSF can be seen as a clear fluid leaving through
the fractures segments of posterior wall
• If there is no CSF leakage ,one can proceed as
stated previously with any NFD injuries or
anterior wall injury
• Fibrin sealants :excellent option to seal any small
fractures in the posterior wall

80. Posterior wall fracture
• Posterior wall displacement or gross
contamination  significant dural tears can
occur
• Frontal sinus fractures with displaced or
grossly comminuted posterior wall fracture:
cranialization procedure required
• Entire damaged posterior wall removed,all
dural tears are repaired and the frontal lobe is
allowed to expand into sinus

81. Craniotomy
• Required depending on extent of dural injury
• The anterior cranial fossa essentially increased
• If Cranialisation is undertaken,The NFDS and
sinus are obliterated
• If gross comminution of the anterior wall:large
titanium mesh or split calvarial bone to
reconstruct the anterior wall

82. Two separate frontal sinuses
• Instances in which patient has two separate
frontal sinuses separated by a thin bony
septum
• If only one side injured,and there is no
radiographic or clinical evidence of
involvement of other sinus,surgically repair
only the injured sinus

84. • The appropriate treatment strategy for the management of
frontal sinus fractures can be made by
assessing four anatomic parameters . These parameters
include the presence of: (a) an anterior table fracture, (b) a
posterior table fracture, (c) a nasofrontal recess fracture,
(d) a dural tear (cerebrospinal fluid leak). These findings
can be applied to the algorithm presented to determine
appropriate treatment . The treatment options include:
observation, endoscopic repair, open reduction and
internal fixation, sinus obliteration, sinus cranialization, and
rarely sinus ablation (Reidel procedure). The indications
and techniques for each of these procedures are discussed
below.