Introduction

External force directed to the anterior portion of the forehead can result in injury to the frontal sinus. The frontal bone is the strongest component of the craniofacial skeleton and can withstand between 800 and 2200 lb of force before fracturing. ^{1 , 2} The sinus is roughly pyramidal in shape and often divided by a midline or paramidline septum of bone. The sinus is absent at birth, but begins to actively pneumatize between 7 and 8 years of age to reach an adult volume after puberty. By their mechanism, most injuries produce posterior displacement of the bone into the frontal sinus, although bone at the periphery of the injury can protrude outward. Depending on the force and direction of the injury, fractures can involve either the anterior table of the sinus, both the anterior and posterior tables, or solely the posterior table.

Indications

• 
  

  Surgical treatment, if indicated, should be instituted within the first 12 to 48 hours after the injury, depending on the overall health of the patient. Early treatment reduces the incidence of long-term complications. ^{3 , 4}

  
  
• 
  

  With respect to the anterior table, depressed fractures that will produce noticeable deformity after the resolution of edema or that could potentially result in mucocele formation require repair. If there is no computed tomography (CT) evidence of nasofrontal outflow tract obstruction (opacified sinus, associated anterior ethmoid complex fracture, or frontal sinus floor fracture), observation may be recommended with less likelihood of future complications developing. ⁴

  
  
• 
  

  With respect to the posterior table, the presence of pneumocephalus has been an indication for repair by some authors. ⁵ The pneumocephalus represents communication between the sterile meningeal space and the external environment, which could lead to potentially life-threatening intracranial complications, such as meningitis, encephalitis, and brain abscess. Some authors elect to closely observe patients with a posterior table fracture and associated leakage of cerebrospinal fluid (CSF) for a defined period of time, such as 7 days. ¹

  
  
• 
  

  For nondisplaced posterior table fractures, the management is more controversial. Some authors suggest that all posterior table fractures should undergo exploration and be examined directly via sinuscopy. Others treat these injuries with close observation and explore if complications develop.

  
  
• 
  

  Persistent rhinorrhea indicates leakage of cerebrospinal fluid due to injury to the dura that has not healed with observation alone and requires intervention.

  
  
• 
  

  Secondary correction is indicated for wounds that were observed in lieu of operative intervention and have healed with noticeable deformity.

Preprocedure Considerations

Since the etiology is trauma, and is often of significant force, a full trauma workup should be performed. Initial confirmation that the airway is patent, the patient is breathing, and there is adequate circulation is paramount. The mechanism of frontal sinus fracture places the cervical spine at risk for injury. Careful physical examination of the cervical spine as well as appropriate imaging studies is indicated. Adequate plain films should be obtained and CT added if the initial films are either inadequate or inconclusive.

Radiographic Imaging

• 
  

  CT is the gold standard imaging modality for the craniomaxillofacial skeleton. Historically, plain films were obtained, which were able to identify the presence of fluid in the frontal sinus, but presented difficulty when trying to determine the presence of anterior, posterior, or through-and-through injuries. CT scans are able to provide axial, coronal, and sagittal images that can separately evaluate the anterior and posterior aspects of the sinus ( Figs. 27.1, 27.2, and 27.3 ).

Operative Procedure

Bicoronal Incision (Fig. 27.4)

Related posts:

25 Replacement of Cranial Bone Flap 26 Techniques of Alloplastic Cranioplasty 7 Invasive Neuromonitoring Techniques 18 Treatment of Acute Cauda Equina Syndrome 23 Combat Cranial Operations 29 Special Considerations in Pediatric Cervical Spine Injury

Stay updated, free articles. Join our Telegram channel

Join