With a better diagnosis of the fracture and better potential treatment of any infections that may occur of the sinus, I felt we could take a less aggressive approach in treating the sinus fracture. – -E. Bradley Strong, MD
Explore This IssueJuly 2006
Cosmetic and Functional Benefits
According to Dr. Rhee, this algorithm makes is possible to now focus on the fracture repair first to optimize the likelihood of an excellent cosmetic outcome, while still expectantly managing the status of potential frontal sinus outflow obstruction.
This study also suggests that increased use of sagittal CT, as mentioned earlier, may help with the initial diagnostic evaluation for obstruction and subsequent treatment decisions. Where obstruction exists, the authors concluded that patients who fit the criteria may be able to maintain function of the sinus without having to undergo immediate sinus obliteration, as would traditionally be done.
Even in the event that sinus obliteration becomes necessary at a later date, there are distinct advantages to performing the procedure in a delayed fashion.
Patients choosing this treatment option undergo restoration of the displaced bony fragments with internal rigid fixation without obliteration and expectant management of the frontal outflow tract. They are then prescribed broad-spectrum antibiotics for four weeks along with oral and/or topical steroids. The antibiotics are used because of the risk of contamination of the sinus at the time of injury and repair. The steroids are utilized in the hope that reduced edema and inflammation of the soft tissues may cause the sinus to spontaneously ventilate. The patients are also asked to undergo serial CT evaluation at 8 weeks, 16 weeks, 6 months, and 1 year to check for ventilation and restoration of mucociliary clearance of the frontal sinus.
Dr. Rhee stated, 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.
Delayed Sinus Obliteration
If after four weeks the frontal outflow tract has not spontaneously ventilated, a repeat attempt at medical management is recommended, with an additional four weeks of antibiotic therapy, systemic steroid taper, and topical steroid spray. If the frontal outflow tract still fails to ventilate, the patient can undergo endoscopic surgical intervention at that time.
Even in the event that sinus obliteration becomes necessary at a later date, there are distinct advantages to performing the procedure in a delayed fashion. This provides the advantage of having solid, intact bone to hinge for access to the frontal sinus as opposed to working with fractured pieces of bone immediately following the injury. Furthermore, this delayed approach increases the chance for favorable bone healing with potentially less bone resorption due to devascularization of the bony fragments. Dr. Rhee said that, Potential cosmetic outcome may be enhanced by less manipulation of the fractured bone segments using this approach.