Technology Improves Management of Frontal Sinus Fractures

Technological advances in recent years are creating a shift in the paradigm regarding the management of frontal sinus fractures. These advances have made it possible for some patients to be managed in a more conservative and expectant manner, reducing the chance of morbidity and long-term sequelae, and increasing the chance of a more desirable cosmetic outcome.

Frontal sinus fractures are not at all uncommon, accounting for 5% to 12% of all facial fractures, reported frontal sinus fracture expert E. Bradley Strong, MD, in an eMedicine article (available online at www.emedicine.com/ent/topic419.htm ). How to best treat frontal sinus fractures has been debated for years; however, the management of these injuries has become highly advanced in recent years through the use of endoscopic procedures, CT and computer enhancement, and improved radiographic technology.

Initial Trauma Assessment

Because significant force is required to fracture the frontal sinus, other life-threatening injuries may exist, wrote Dale H. Rice, MD, in an article titled Management of frontal sinus fractures (Curr Opin Otolaryngol Head Neck Surg. 2004;12:46-48). Serious injuries are associated with frontal sinus fractures in 75% of cases. The first consideration is to identify and treat life threats and accompanying injuries that may cause significant morbidity, writes Dr. Strong. As always, airway, circulation, and breathing must be assessed and stabilized if necessary. Stabilization of the cervical spine must be maintained until related injuries are ruled out. A thorough head and neck examination must be performed to evaluate injuries to the brain, spine, and orbits.

Once the patient has been stabilized, evaluation of frontal sinus can be performed, initially by visualization and gentle palpation. It is important to remember that the appearance of the patient may not be a valid indicator, immediately following injury, of the extent or severity of injury. Blood, debris, and overlying soft tissue injuries can mask even significant underlying fractures, caution Dr. Rice.

Diagnostic Radiographic Studies

Plain radiographs may reveal if there is opacification of the frontal sinus or gross bony step-offs. However, CT scan has long been the choice for optimal assessment of these injuries. Traditionally, both frontal and axial plane images were necessary. Frontal images could be difficult to get without tilting the patient’s head, which is not always an option given the potential for accompanying neurologic injuries. Reformatted versions of these planes were not of sufficient quality to be of much use diagnostically. However, advances in the equipment used for CT imaging can now produce reformatted images of a much higher quality. Furthermore, patients can often be scanned in one plane with thin cut (1.5 mm) CT, resulting in excellent diagnostic images.

The Laryngoscope published a study in 2002 suggesting that sagittal CT reconstruction might be a valuable diagnostic tool (Laryngoscope. 2002; 112: 784-790). The study suggests that sagittal CT may be a more accurate predictor at the time of injury regarding the patency of the frontal outflow tract than traditional CT. In a phone interview, John Rhee, MD, Associate Professor of Otolaryngology and Communication Sciences at the Medical College of Wisconsin in Milwaukee and co-author of this study, said, Sagittal reconstruction CT can help predict whether or not the frontal sinus will spontaneously ventilate. It demonstrates whether or not there is a patency of the frontal nasal duct. We’re trying to use this more often as predictive. Determining the patency of the frontal outflow tract at diagnosis can be an important consideration when determining treatment options.