What is the treatment for a maxillary sinus fracture?

Treatment of Maxillary Sinus Fractures

Most isolated maxillary sinus fractures can be managed conservatively without surgical intervention, but displaced anterior wall fractures require open reduction and fixation to prevent long-term complications including chronic sinusitis, rhinitis, and purulent secretion.

Initial Assessment and Classification

Determine fracture severity and location through clinical examination and CT imaging to guide treatment decisions. 1

• Anterior wall fractures: Assess for displacement, comminution, and cosmetic deformity 2
• Posterior wall involvement: Evaluate for CSF leak, intracranial injury, and degree of displacement 1
• Associated injuries: Check for Le Fort fractures, zygomatic fractures, and orbital involvement 1
• Sinus status: Document presence of hemosinus, air-fluid levels, and mucosal integrity 1

Treatment Algorithm

Non-Displaced or Minimally Displaced Fractures

Conservative management is appropriate for asymptomatic, non-displaced fractures without significant cosmetic deformity. 2

• Nasal saline spray for sinus hygiene 3
• Observation with clinical follow-up 2
• Avoid prophylactic antibiotics - a 3-day course of amoxicillin/clavulanate or levofloxacin does NOT prevent acute sinusitis after maxillary sinus fractures (95% developed sinusitis with antibiotics vs 88% without, p=0.58) 3
• Monitor for delayed complications including sinusitis, which occurs in approximately 90% of cases regardless of antibiotic use 3

Displaced Anterior Wall Fractures

Surgical reduction via Caldwell-Luc approach is indicated for displaced anterior wall fractures to restore contour and prevent complications. 2

Surgical Technique (Double Balloon Catheter Method):

• Expose fracture site through Caldwell-Luc approach 2
• Insert two urinary balloon catheters through the maxillary ostium under nasal endoscopic guidance 2
• Inflate catheters to gently reduce fracture fragments from within the sinus 2
• Fix fragments with fibrin glue to minimize damage to bony fragments and sinus mucosa 2
• This technique achieved successful reduction in 38 patients with no infections, rhinitis, or chronic sinusitis, though 15% had residual hypoesthesia 2

Postoperative Management:

• Antibiotics: Amoxicillin/clavulanate or levofloxacin for 7 days (though evidence shows limited benefit for preventing sinusitis) 3
• NSAIDs: Ibuprofen 600 mg TID for 3-7 days 4
• Nasal precautions: Avoid nose blowing, forceful sneezing (sneeze with mouth open if unavoidable), and pressure changes for 7-10 days 4
• Follow-up imaging: CT scan at 3+ months to assess healing and sinus function 1

Posterior Wall Fractures

Posterior wall fractures require evaluation for CSF leak and intracranial injury, with surgical intervention reserved for severe displacement or persistent CSF leak. 1

• Conservative management for non-displaced posterior wall fractures 1
• Neurosurgical consultation for CSF leak or intracranial involvement 1
• Consider cranialization only for severely comminuted posterior wall fractures with persistent CSF leak (analogous to frontal sinus management) 5, 6

Long-Term Monitoring

Follow patients for up to 10 years as complications can occur late after initial injury. 6

• Clinical examination with maxillary sinusitis evaluation at 3,6, and 12 months 1
• CT imaging at 3-6 months post-treatment to assess sinus patency and bone healing 1
• SPECT imaging can identify ongoing bone remodeling and complications (showed positive uptake in 53% of patients at average 19.8 months follow-up) 1
• Monitor for: chronic sinusitis, mucocele formation, contour deformity, and persistent hypoesthesia 2, 1

Critical Pitfalls to Avoid

• Do NOT routinely prescribe prophylactic antibiotics - they are ineffective at preventing post-fracture sinusitis 3
• Do NOT underestimate the need for reduction in displaced anterior wall fractures - conservative management leads to chronic complications 2
• Do NOT use aggressive fixation techniques that further damage sinus mucosa - balloon catheter reduction with fibrin glue minimizes tissue trauma 2
• Do NOT assume early healing means long-term success - complications can develop years after injury, requiring extended surveillance 6