What is the management of frontal sinus fracture?

Management of Frontal Sinus Fracture

The primary goal is to create a safe sinus by following an anatomically-based treatment algorithm that assesses five key parameters: frontal recess patency, anterior table integrity, posterior table integrity, dural integrity, and presence of CSF leak, with definitive surgical intervention performed as early as safely possible after stabilization of life-threatening injuries. 1, 2

Initial Assessment and Diagnostic Workup

Imaging Protocol

• Obtain multidetector CT (MDCT) maxillofacial without contrast as the gold standard, which provides superior delineation of osseous structures and detection of subtle nondisplaced fractures 1
• Complementary CT head without contrast is mandatory since 56-87% of frontal bone fractures have associated intracranial injuries, with 8-10% requiring surgical intervention for subdural or epidural hematoma 1
• Request 3D reconstructions for surgical planning, as these significantly improve surgeon confidence in characterizing complex fractures 1
• Evaluate for cervical spine injury, present in 6-19% of significant maxillofacial trauma cases 1

Critical Anatomic Parameters to Assess

The treatment algorithm depends on evaluating these five specific features 2:

• Frontal recess/nasofrontal duct patency - obstruction leads to mucocele formation and osteomyelitis 1
• Anterior table integrity - determines need for contour restoration 1
• Posterior table integrity - displacement indicates dural disruption and intracranial communication 1
• Dural integrity - assess for CSF leak 1
• Cribriform plate involvement - medial fractures typically involve this structure 1

Treatment Algorithm by Fracture Pattern

Isolated Anterior Table Fractures

• Non-displaced or minimally displaced: observation with close surveillance is safe 3
• Displaced with cosmetic deformity: open reduction and internal fixation to restore frontal bony contour to premorbid state 4
• The anterior table can withstand up to 1,000 kg of force, so significant displacement indicates high-energy trauma 1

Posterior Table Fractures (With or Without Anterior Table Involvement)

• Non-displaced without CSF leak or nasofrontal duct obstruction: conservative management with close surveillance 3
• Displaced posterior table fractures: these almost always indicate dural disruption and require surgical exploration 1
• Combined anterior and posterior table fractures with CSF leak or nasofrontal duct obstruction: surgical exploration via bifrontal craniotomy with sinus cranialization or obliteration 1

Nasofrontal Duct Involvement

• Any injury to the nasofrontal duct mandates surgical intervention to prevent mucocele formation and osteomyelitis 1
• Failure to address duct obstruction leads to recurrent frontal sinusitis and potential progression to osteomyelitis 5

Cribriform Plate Involvement

• Surgical exploration is mandatory due to high risk of CSF leak and chronic sinusitis 1
• Medial frontal sinus floor fractures typically involve the cribriform plate, requiring heightened vigilance 1

Orbital Roof Involvement

• Evaluate for globe injury and extraocular muscle entrapment 1
• These fractures penetrate the lateral part of the frontal sinus floor 1

Surgical Principles and Techniques

Four Basic Principles of Management

All surgical interventions must accomplish these goals 4:

1. Reestablish frontal bony contour to premorbid state
2. Restore normal sinus mucosa with patent drainage if possible
3. Eradicate the sinus cavity if normal mucosa or drainage cannot be reestablished
4. Create permanent barrier between intracranial and extracranial systems

Surgical Timing

• Perform definitive treatment as early as safely possible once life-threatening injuries are stabilized 1
• Management of ongoing hemorrhage or intracranial hypertension takes precedence over frontal bone fracture repair 1

Obliteration Considerations

• Avoid obliteration when possible due to higher complication rates 5
• If obliteration is required, fat is the material of choice with fewer complications than other materials 5
• Patients who underwent cranialization experienced as many or more long-term complications including abnormal frontal bone contour, bony discontinuity, and altered trigeminal nerve sensation 3

Critical Pitfalls and Caveats

Common Errors Leading to Complications

• Failure to explore open fractures leads to recurrent frontal sinusitis and progression to osteomyelitis 5
• Not exploring posterior table fractures results in meningitis and epidural abscess 5
• Performing obliteration for anterior wall fractures increases risk of frontal sinus abscesses 5
• The posterior table is thin and delicate, easily fractured despite the anterior table's strength 1

Long-Term Complications Without Proper Management

Life-threatening intracranial infectious complications include 4:

• Meningitis, encephalitis, and brain abscess (most common intracranial complications)
• Persistent CSF leakage
• Mucopyoceles and frontal osteomyelitis
• Meningoencephalocele and frontal bone nonunion
• Orbital complications: ophthalmoplegia, orbital abscess, diplopia, enophthalmos, proptosis, preseptal cellulitis, partial or complete vision loss

Surveillance and Follow-Up

• Extended surveillance is mandatory as part of the management protocol 4
• Monitor for delayed complications including mucocele formation, osteomyelitis, and chronic sinusitis 1
• The trend toward nonsurgical management of selected frontal sinus fractures appears safe with appropriate surveillance 3