Jc on frontal fracture

1. PRESENTED BY –
DR. SHEETAL KAPSE
2nd YEAR, P.G. STUDENT
MODERATORS -
DR. M. SATISH
DR. MANISH PANDIT
DR. DEEPAK THAKUR

2. Kalavrezos N. Current trends in the management of
frontal sinus fractures. Injury. 2004 Apr;35(4):340-6.

3. • Nicholas Kalavrezos, FRCS, FFDRRCSI, MD
Consultant in Oral and Maxillofacial Surgery at
University College London Hospitals (UCLH),
LONDON, US.

4. 1. Introduction
2. Development
3. Surgical anatomy
4. Clinical diagnosis and imaging of the injured sinus
5. Principles of treatment
6. To obliterate or not to obliterate?
7. Is there an ideal implant for the sinus obliteration?
8. Complications following treatment of frontal sinus
fractures
9. Conclusions
10. References

5. • Frontal sinus fractures are a rather common problem faced in the trauma
units involved in the management of craniofacial injuries. The incidence of
frontal sinus fractures is estimated between 6 and 12% of all craniofacial
fractures.
• However, severe comminuted fractures with involvement of both anterior
and posterior walls of the frontal sinus occur in only 0.7—2.1% of the
cases of craniocerebral trauma.
• The frontal sinus fracture is not the most pressing immediate concern
during resuscitation and stabilization.
• Ioannides C, Freihofer HP, Friens J. Fractures of the frontal sinus: a rationale of treatment. Br J Plast
Surg 1993;46:208—14.
• Luce EA. Frontal sinus fractures: guidelines to management. Plast Reconstr Surg 1987;80:500—10.
• Sataloff RT, Sariego J, Myers DL, Richter HJ. Surgical management of the frontal sinus. Neurosurgery
1984;15: 593—6.

6. • Nevertheless, it rapidly assumes a prominent position in the
management algorithm of craniofacial trauma, because of the
complications of delayed or improper management: persistent
cerebrospinal fluid (CSF) leak, mucocele/ mucopyocele,
encephalitis or brain abscess.
• Gerbino G, Roccia F, Benech A, Caldarelli C. Analysis of 158 frontal sinus fractures: current surgical
management and complications. J Craniomaxillofac Surg 2000;28:133—9.

7. Fonseca oral & maxillofacial trauma vol. 2
• 5-15 % of all facial fractures.
• Isolated Anterior table fracture = 43 – 61 %
• Isolated Posterior table fracture = 0.6 -6%
• Both anterior & posterior table fracture = 19 – 51%
• Injuries involving nasofrontal duct = 2.5 – 21%

8. • Ossification = 8 – 9 week IUL
• Pneumatization = 4th months IUL
• R/G – 6 yrs
• Completed by =12 – 16 yrs
The two frontal sinuses are the only
paranasal sinuses to be absent at birth,
and they start to develop only after the
second year of life.
They both fail to develop in only 4% of
the population. They arise from one of
several outgrowths originating in the
region of the frontal recess of the nose.

9. • When fully developed they are situated posterior to the superciliary
arches, lying between the outer and inner tables of the frontal bone.
• They are rarely symmetrical, the septum between them usually deviating
from the midline sagittal plane.

10. • The adult average sinus dimensions are:
height 3.2 cm, width 2.6 cm, depth 1.8 cm.
The entire surface area is approximately
720 mm2.
• Each sinus opens into the anterior part of the
corresponding nasal middle meatus by the
ethmoidal infundibulum or nasofrontal
duct, traversing the anterior part of the
ethmoid labyrinth.
• Anatomically this duct is a funnel shaped
constriction that passes between the
cancellous part of the anterior wall
underlying the glabella and the anterior
ethmoidal cells.
• Blows of sufficient magnitude to displace
the anterior sinus wall have a high
probability of injuring the nasofrontal duct.
• Haug RH, Likavec MJ. Basics of stable internal fixation of
cranial surgery. In: Greenberg A, editor.
Craniomaxillofacial fractures: principles of internal
fixation using the AO/ASIF technique. New York:
Springer; 1993. p. 179—83.
• Som PM, Brandwein M. Sinosanal cavities: anatomy,
physiology and plain film normal anatomy. In: Som PM,
Curtin HD, editors. Head and neck imaging. St. Louis:
Mosby; 1996. p. 61—96.

11. • Improper functioning or obstruction of the nasofrontal duct after frontal
sinus fractures increases the risk of development of late infectious
complications because of the potential cystic degeneration of the sinus
mucosa.
• Invasive mucoceles as a result of a traumatically obstructed nasofrontal duct
may extend into the orbits and the anterior cranial fossa causing gradual
destruction of the osseous confines of the frontal sinus.
• Bordley JE, Bosley WR. Mucoceles of the frontal sinus: causes and treatment. Ann Otol 1973;82:696—
702.
• Constantinidis J, Steinhart H, Schwerdtfeger K, Zenk J, Iro H. Therapy of invasive mucoceles of the
frontal sinus.

12. 20 mm long
15 % true duct

14. • Blunt and penetrating trauma to the frontal sinus encompasses a wide
spectrum of injury which may range from mucosal contusion to severe
disruption of the sinus, dura and brain.
• Clinical diagnosis of a frontal sinus fracture is often difficult because of
the presence of oedema.
• Clinical signs may include anaesthesia of the supraorbital nerves,
cerebrospinal rhinorrhoea, subconjuctival ecchymosis, air in the orbit,
depression over the frontal sinus, or bony fragments showing through
lacerations.
Adkins WY, Cassone RD, Putney FJ. Solitary frontal sinus
fracture. Laryngoscope 1979;89:1099—104.

15. • The initial evaluation of the injury includes the basic general rules of
emergency care. Airway management and control of bleeding have to be
attended to first.
• Frontal sinus fractures are assessed as part of the general head injury
evaluation.
• Injury to the posterior wall with possible penetration and/or dural tear or
concomitant intracerebral injury should be considered in any case of
rhinorrhoea with suspected cerebrospinal fluid leak. Dural tears may also
be present without CSF rhinorrhoea if the sinus outflow is obstructed.
Newman MH, Travis NL. Frontal sinus fracture. Laryngoscope
1973;83:1281—92.

16. • Abnormal vision and restriction of the movements of the extraocular
muscles have to be considered as potential signs of an associated
neurological or ophthalmic injury and must be ascertained by appropriate
neurological and ophthalmological evaluation.
• Virtually, all patients with severe head injury require computed
tomography (CT) scan for assessment of their intracranial status, and the
frontal sinuses can be included in the examination with little modification.

17. • Plain films are of little value
• 1-1.5 mm thin cut CT
• Contrast medium : hemorrhage
• Axial view : location, severity &
degree of comminution
• Coronal view : floor fracture
• Sagittal view : nasofrontal duct

18. • CT scans are useful in the
assessment of the sinus and the
presence of pneumocranium
indicates posterior frontal sinus
wall and/or base of skull fracture
which most of the time is
associated with significant
intracranial haemorrhage.
• The level of fracture and the
degree of disruption of the floor
of the sinus may also be
predictive of nasofrontal duct
obstruction.
8
Frontal sinus fracture with involvement of
both anterior and posterior walls. White
arrow on the left indicates bony spicule
causing dural tear. Double black arrow on the
right indicates extensive intracranial
haemorrhage in the same patient.

19. • Ioannides & Freihofer : Type I, Type II, Type III, Type IV
• Stanley’s modification of Gonty’s classification :
Type I : anterior table fracture
Type II : anterior & posterior table fractures
Type III :posterior table fracture
Type IV : through & though frontal sinus fracture

20. Treatment of frontal sinus fractures is aiming at:
1. Isolation of the neurocranium and cessation of any CSF leak.
2. Prevention of early and avoidance of delayed postoperative
complications from the central nervous system.
3. Restoration of the preoperative facial aesthetics.
Ioannides C, Freihofer HP, Friens J. Fractures of the frontal sinus: a rationale of
treatment. Br J Plast Surg 1993;46:208—14.

21. • In order to achieve these goals it is necessary to classify the sinus fractures
so that an algorithm of management can be applied.
• The key factors influencing any proposed system of classification and the
subsequent treatment are:
a) Integrity of the posterior wall - The decisive factor for the separation of
the intracranial contents from the outer environment.
b) Involvement of the nasofrontal duct – The decisive factor for the
potential dysfunction of the respiratory type epithelium of the sinus
mucosa.

22. • Most authors agree to a classification scheme including:
1. anterior wall fractures;
2. posterior wall fractures;
3. anterior and posterior wall fractures;
4. ‘‘through and through’’ fractures;
5. fractures involving the nasofrontal duct.
• Gerbino G, Roccia F, Benech A, Caldarelli C. Analysis of 158 frontal sinus fractures: current surgical
management and complications. J Craniomaxillofac Surg 2000;28:133—9.
• Gonty AA, Marciani RD, Adornato DC. Management of frontal sinus fractures: a review of 33 cases. J Oral
Maxillofac Surg 1999;57:372—9.
• Rohrich RJ, Mickel TJ. Frontal sinus obliteration: in search of the ideal autogenous material. Plast Reconstr Surg
1995;95:580—5.
• Sailer HF, Gratz KW, Kalavrezos ND. Frontal sinus fractures: principles of treatment and long term results after
sinus obliteration with the use of lyophilized cartilage. J Craniomaxillofac Surg 1998;26:235—42.

23. 4 key question to be addressed -
1. Penetrating or concurrent intracranial injury
2. Patency of nasofrontal duct
3. Comminution or displacement of anterior table
4. Concurrent craniomaxillofacial injuries

25. Preoperative management
• Goal :
1. Protect intracranial structures
2. Control CSF
3. Prevent post traumatic inflammatory complications
4. Restore contour & symmetry
• Antibiotics :
1. Extended spectrum penicillins, cephalosporins, clindamycin (for open
frontal sinus injuries)
2. Nafcillin & gentamycin for injuries communicating with neurocranium
3. Cefazolin, Nafcillin & gentamycin : debalable in CSF leak (to prevent
meningitis)

26. Operative management
• Approaches

28. • Closed, undisplaced fractures of the anterior wall do not require surgical
treatment. The treatment of depressed fractures of the anterior wall depends
upon the involvement of the nasofrontal duct.
• If the duct is intact simple elevation of the fracture and plate fixation is all
that is required. However, if the duct is involved in the fracture the
treatment should include the obliteration of the sinus cavity after the
hermetic sealing of the injured duct.
• Frontal sinus obliteration is defined as the obliteration of the frontal sinus
cavity when maintaining or restoring the bony sinus walls.
• The essential principles of successful obliteration include the meticulous
removal of all visible mucosa, the removal of the inner cortex of the sinus
wall and the permanent occlusion of the nasofrontal duct. In this way the
frontal sinus is treated as an isolated cavity precluding any potential
mucosal regrowth from the nasal epithelium.

29. • The frontal sinus is accessed using a coronal approach dissecting in a
supraperiosteal plane and preserving the pericranium which remains
pedicled on its caudal border.
• Loose and displaced fragments of bone along the supraorbital margins and
orbital roofs are removed and kept.
• The mucosal lining of the frontal sinus and the intersinus septum is
removed with, preferably, the use of a rotating cutting burr.
• The nasofrontal duct is occluded with the use of bone and the pedicled
pericranium flap is rotated into the sinus.

30. • The rest of the sinus cavity is packed,
usually with autologous cancellous bone.
The use of fat or muscle along with the
technique of spontaneous osteogenesis are
also well documented.
• The anterior wall then is reduced, the
supraorbital bony bar is repositioned and
stabilized with micro- or bioresorbable
plates.
‘‘Through and Through’’ fracture (F)
associated with bone loss and
concomitant dural tear.
• Rohrich RJ, Mickel TJ. Frontal sinus obliteration: in search of the ideal autogenous material. Plast Reconstr Surg
1995;95:580—5.

31. • If the posterior wall is involved the
determinant of the successful management
of the frontal sinus fracture is the restoration
of the dural integrity and the complete
isolation of the brain from the potential
communication with the nose through the
injured frontal sinus.
• The access is the same as previously
described. Formal removal of an intact
supraorbital margin is often of help in
exposing basal dural tears extending
posteriorly.
• Before the dural repair is undertaken the
displaced bony fragments of the posterior
sinus wall have to be removed,
‘‘cranialization’’ the frontal sinus and
aiding the access to the anterior cranial
fossa.
• Gerbino G, Roccia F, Benech A, Caldarelli C.
Analysis of 158 frontal sinus fractures: current
surgical management and complications. J
Craniomaxillofac Surg 2000;28:133—9.

32. • Afterwards, the dura can be sutured under the microscope. It is expected
that the swollen brain will partially cover the space provided by the
discarded posterior wall.
• The mucous lining of the frontal sinus is removed and the pedicled
pericranium flap is rotated into the sinus to seal off the frontal basis and the
nasofrontal duct.
Reconstruction of the posterior wall of the
sinus with split thickness calvarial bone (B).
Surgicel (S) on top of the pericranium flap
covering the exposed dura.
• An additional layer of separation can
be provided by the use of split
thickness calvarial bone or sheets of
lyophilized cartilage. In order to avoid
any dead space the residual cavity can
be obliterated with an autologous
material.

33. Postoperative axial CT scan: white arrow
indicating the reconstructed bony layer of
separation between dura and frontal sinus.
Obliteration of the sinus cavity and the
‘‘burr holes’’ with cancellous bone (C) and
‘‘bony dust’’. Fixation of the bony segments
with bio-resorbable plates (P).

34. • Spontaneous postoperative obliteration of the frontal sinus was reported
initially by Samoilenko MacBeth, whereas Bosley provided radiographic
evidence that sinus obliteration was by new bone formation in 93 out of
100 patients treated with the method.
• Improved results by spontaneous osteogenesis have been reported after
occlusion of the nasofrontal duct with bone - a modification which was not
included in the original MacBeth procedure.
Bosley WR. Osteoplastic obliteration of the frontal sinuses: a review of 100 patients.
Laryngoscope 1972;82:1463—76.
• Mickel TJ, Rohrich RJ, Robinson Jr JB. Frontal sinus obliteration: a comparison of fat, muscle, bone, and
spontaneous osteogenesis in the cat model. Plast Reconstr Surg 1995;95:586—92.
• Owens M, Klotch DW. Use of bone for obliteration of the nasofrontal duct with the osteoplastic flap: a cat
model. Laryngoscope 1993;103:883—9.

35. • Since the frontal sinus after removal of all of its mucosa and occluding the
nasofrontal duct is nothing more than an isolated bone cavity, it is not
irrational to expect the gradual ossification of the whole cavity.
• It is supposed, though, that the use of an osteoconductive material such as
Cancellous bone may accelerate this process and therefore obliteration of
the sinus is still advisable.

36. • Autogenous materials such as fat, muscle and bone have been used for the
obliteration of the frontal sinuses.
• Cancellous bone used as frank osteoconductive material enhances bony
consolidation when the fractured sinus is obliterated. However, it has not
become widely used–—possibly because of the associated donor site
morbidity.
• In order to overcome the problem of donor site, allografts such as
lyophilized cartilage have been successfully used.
Hardy JM, Montgomery WW. Osteoplastic frontal sinusotomy: an analysis of 250
operations. Ann Otol Rhinol Laryngol 1976;85:523—32.
Kalavrezos ND, Gratz KW, Warnke T, Sailer H. Frontal sinus fractures: computed tomography evaluation of sinus
obliteration with lyophilized cartilage. J Craniomaxillofac Surg 1999;27:20—4.
Sailer HF, Gratz KW, Kalavrezos ND. Frontal sinus fractures: principles of treatment and long term results after
sinus obliteration with the use of lyophilized cartilage. J Craniomaxillofac Surg 1998;26:235—42.

37. • Nevertheless, the possibility of infectious complications following
allogeneic cartilage grafting, although remote, cannot be ignored.
• Lately, the use of alloplastic materials such as micropore hydroxyapatite
cement or ionomer cement has gained increasing popularity. Obliteration
with alloplastic materials may be considered as a formidable alternative
especially when the integrity of the posterior wall is not breached.
Kalavrezos ND, Holmes SB. Treatment of an invasive frontal mucocele: long term
results after sinus obliteration with hydroxyapatite cement. J R Coll Surg Edin, in
press.
Weber A, May A, von Ilberg C. Bone replacement by ionomer cement in osteoplastic
frontal sinus operations. Eur Arch Otorhinolaryngol 1997;254(Suppl 1):162—4.

38. EARLY COMPLICATIONS : within 6 months
• Inflammatory & aesthetic
• Sinus opacification
• Oedematous painful forehead & eye
• Meningitis
• Concomitant neurological injuries / death
• CSF leak & fistulae
• Displacement of frontal bone into orbit and ocular injury
(diplopia/blindnes)
• Injury to supratrochlear nerve
decongestants & antibiotics
Surgical interventions

39. LATE COMPLICATIONS : AFTER 6 months
postoperative contour deformity, acute and chronic sinusitis, delayed
mucocele/mucopyocele formation, osteomyelitis, meningitis or even brain
abscess. Pain & headache without identifiable cause may also be noted.
Deformity of the contour of the frontal bone requiring surgical correction is
the most common cause of surgical ‘‘second look’’.
The use of hydroxyapatite cement for remodeling of the contour during the
initial operation may reduce this need.
Gerbino G, Roccia F, Benech A, Caldarelli C. Analysis of 158 frontal sinus fractures: current
surgical management and complications. J Craniomaxillofac Surg 2000;28:133—9.
Ioannides C, Freihofer HP, Friens J. Fractures of the frontal sinus: a rationale of treatment. Br J
Plast Surg 1993;46: 208—14.

40. Late appearance of mucoceles remains always a possibility and therefore
long-term clinical and CT follow-up of 10 years has been suggested.
This should be the case when the treatment includes ‘‘through and
through’’ or compound posterior and anterior wall fractures.
Smoot EC, Bowen DG, Lappert P, Ruiz JA. Delayed
development of an ectopic frontal sinus mucocele after
pediatric cranial trauma. J Craniofac Surg 1995;4:327—31.

41. It is evident from the preceding review that the treatment of frontal sinus
fractures is of paramount importance because of the close relationship of
the sinus to the brain and the anatomically complex naso-orbito-ethmoidal
(NOE) region.
The potential of devastating complications many years after the treatment
emphasizes the need for the formulation of a clear therapeutic plan at the
initial assessment.
The main factors influencing the decision-making process and the final
outcome are disruption of the posterior wall of the sinus with concomitant
breach of the dural integrity and involvement of the nasofrontal duct.

42. There is no consensus with regard to the surgical treatment of fractures of
the frontal sinus, mainly because of the lack of randomized studies and
because of the short-term follow-up in most of the published reviews.
Nevertheless, most authors would agree that, with the exception of the
isolated undisplaced anterior (or posterior linear) wall fracture, an early
surgical intervention using a coronal flap and preserving the pericranium as
potential sinus lining following the removal of the traumatized mucosa are
mandatory prerequisites for a favorable outcome.