What is the management and disposition for an open maxillary sinus fracture?

Management and Disposition of Open Maxillary Sinus Fractures

Open maxillary sinus fractures require prompt antibiotic therapy, evaluation for oroantral communication, and surgical repair within 2 weeks for most cases to prevent complications such as sinusitis and oroantral fistula formation.

Initial Assessment and Management

Immediate Evaluation

• Assess for life-threatening conditions:
  • Check vital signs for bradycardia or heart block which may indicate oculocardiac reflex from muscle entrapment 1
  • Evaluate for symptoms of dizziness, nausea, vomiting, or loss of consciousness 1
  • Rule out vision-threatening injuries (present in up to 24% of orbital fractures) 1

Imaging

• CT scan is the preferred initial imaging modality:
  • Provides sufficient information about fracture presence and entrapment
  • Essential if there's concern about possible ferrous-metallic foreign bodies 1
  • Evaluates for muscle/tissue entrapment and sinus involvement

Antibiotic Therapy

• Initiate antibiotic therapy immediately:
  • Amoxicillin/clavulanate or levofloxacin for at least 7-10 days 1
  • Despite high rates of post-fracture sinusitis (>88%), short-course antibiotics alone may not prevent sinusitis symptoms 2

Timing of Surgical Intervention

Immediate Surgical Repair (Emergency)

• Indications for immediate repair:
  • Entrapped muscle/periorbital tissue with nonresolving oculocardiac reflex 1
  • Globe subluxation into the maxillary sinus 1
  • Oroantral communication with persistent infection despite antibiotic therapy 1

Early Surgical Repair (Within 2 Weeks)

• Indications for repair within 2 weeks:
  • Symptomatic diplopia with positive forced ductions or entrapment on CT 1
  • Large floor fractures, hypoglobus, and progressive infraorbital hypoesthesia 1
  • Early enophthalmos or hypoglobus causing facial asymmetry 1
  • Significant fat or periorbital tissue entrapment 1
  • Oroantral communication persisting beyond initial antibiotic treatment 1

Delayed Repair (After 2 Weeks)

• Consider for:
  • Restrictive strabismus and unresolved enophthalmos 1
  • Cases where initial conservative management failed 1

Observation Only

• May be appropriate for:
  • Minimal diplopia (not in primary or downgaze) 1
  • Good ocular motility without significant enophthalmos or hypoglobus 1
  • Non-displaced fractures without symptoms 3

Surgical Approaches

Intraoral Approach

• Modified Caldwell-Luc procedure is preferred when possible:
  • Preserves intranasal anatomy and uncinate process 1
  • Avoids complications associated with functional endoscopic sinus surgery 1
  • May be combined with endoscopic techniques for better visualization 3

Management of Oroantral Communication

• For persistent oroantral communication (beyond 3 weeks):
  • Consider partial or total removal of any bone graft material 1
  • Surgical closure with flap advancement and primary closure 1
  • Collagen membrane placement may be beneficial 1

Post-Surgical Management

Monitoring and Follow-up

• Regular follow-up is essential as complications may develop years after injury 4
• Monitor for:
  • Signs of infection (tenderness, nasal obstruction, purulent discharge)
  • Development of oroantral fistula
  • Persistent sinusitis symptoms

Sinus Care

• Saline nasal irrigation (isotonic preferred) 5
• Avoid activities that create pressure differentials in the sinus until healing is complete 1

Potential Complications

Early Complications

• Wound dehiscence (significantly increased risk in smokers) 1
• Bruising and edema 1
• Postoperative sinusitis (reported in up to 37% of patients after repair) 1
• Epistaxis 1

Late Complications

• Chronic sinusitis
• Oroantral fistula formation 1
• Sinus obliteration 1
• Implant or graft migration into the sinus 1

Special Considerations

Multidisciplinary Approach

• Collaboration between maxillofacial surgeons and otolaryngologists is recommended for:
  • Cases with persistent sinusitis despite treatment 1
  • Complex fractures involving multiple sinuses
  • Cases requiring functional endoscopic sinus surgery 1

Pitfalls to Avoid

• Delaying treatment of oroantral communications beyond 3 weeks significantly increases risk of chronic fistula formation 1
• Overpacking the sinus with graft material can impair normal fluid movement and lead to chronic sinusitis 1
• Failure to recognize and treat muscle entrapment can lead to permanent strabismus 1
• Removing the uncinate process during surgical repair can lead to water entering the sinus during swimming or other activities 1