Management of Posterior Table Fracture
Posterior table fractures of the frontal sinus require surgical removal of the fractured posterior table when significantly displaced or comminuted, with the removed fragments potentially serving as autograft for anterior table reconstruction. 1
Initial Assessment and Imaging
- CT imaging is essential to evaluate the extent of posterior table involvement, degree of displacement, and presence of dural injury or CSF leak 1
- Assess for associated anterior table fractures, nasofrontal duct involvement, and intracranial complications 1
Surgical Indications
Posterior table fractures require surgical intervention when:
- Displacement is present with risk of CSF leak or intracranial complications 1
- The posterior table is more severely fractured than the anterior table 1
- There is evidence of dural tear or ongoing CSF leak 1
Surgical Management Algorithm
When Posterior Table is Removed:
- Primary approach: Remove the fractured posterior table completely when it cannot be adequately reconstructed 1
- Utilize the removed posterior table fragments as autograft for reconstruction of the anterior table if the anterior table is more severely damaged 1
- This technique is specifically indicated when the posterior table, despite requiring removal, remains more intact than the anterior table 1
Frontal Sinus Management:
- Obliteration or cranialization of the frontal sinus is typically required after posterior table removal 1
- The choice depends on the extent of injury and involvement of the nasofrontal duct 1
Critical Pitfalls to Avoid
- Never attempt to reconstruct a severely comminuted posterior table in situ - removal is safer to prevent long-term complications including mucocele formation and intracranial infection 1
- Do not discard removed posterior table fragments - they serve as excellent autograft material for anterior table reconstruction 1
- Failure to address CSF leaks at the time of surgery leads to increased risk of meningitis and requires reoperation 1