In my opinion, it’s much better to have a functioning sinus that you can monitor than to have an obliterated sinus that is more difficult to monitor. – -John Rhee, MD
Explore This IssueJuly 2006
Some of these complications may not occur for a long time, so the patient may not even associate the effects they are currently experiencing with an injury they sustained possibly 10 to 15 years in the past. Because of the significant morbidity of these potential complications, traditional management nearly always included obliteration of the sinus with fascia, fat, or other material, destroying sinus function.
According to David Kriet, MD, Associate Professor and Director of Facial Plastic and Reconstructive Surgery in the Department of Otolaryngology-Head and Neck Surgery at the University of Kansas Medical Center in Kansas City, the traditional mindset has been, It’s better to destroy the function [of the frontal sinus] and have a safe situation than to take the chance of preserving function and running into the mucocele problem down the road. He said this sometimes remains true, but for many patients, there may be other options for treatment that can preserve the function of the sinus as well.
As Dr. Rhee observed, We didn’t have the backup of effective intranasal frontal sinus surgery in the past, so the sinuses were obliterated initially at the time of the fracture in an attempt to create a ‘safe’ sinus.
Changing the Paradigm
Unrecognized frontal recess injury is thought to occur in one-third or more of frontal sinus trauma, according to the Laryngoscope article. Part of the reason these injuries can remain unrecognized is that blood, debris, and soft tissue edema can complicate radiographic evaluation. If the patency of the frontal outflow tract can be determined more accurately early in the diagnostic process, it may be possible to manage the injury in a more conservative and expectant manner.
The Laryngoscope study suggests a modified treatment algorithm for management of anterior table fractures. By all accounts, the primary criterion for consideration of the modified treatment algorithm is a high likelihood of the patient to comply with close follow-up. The treatment team must have a reasonable expectation that the patient will follow through with physician orders as directed. A discussion with the patient regarding informed consent should ensue, allowing the patient to consider all treatment options for his or her specific situation. The modified treatment protocol outlined by the authors of the Laryngoscope study can be seen in the box (left).