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.
Explore This IssueJuly 2006
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.
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. – -David Kriet, MD
Frontal Sinus Fracture Reduction
Once a fracture has been identified, treatment can vary greatly depending on the location and extent of the fracture. Fractures of the frontal sinus can involve the anterior table, the posterior table, the frontal sinus ostia, or any combination of these areas. The treatment options will vary greatly depending upon which portion of the sinus is involved, and to what degree. Reduction and fixation may be easy or difficult depending on the degree of comminution and the degree of displacement, writes Dr. Rice.
Nondisplaced or minimally displaced isolated anterior table fractures can often be managed nonoperatively with local wound care and analgesics, as noted in the eMedicine article. Displaced fractures greater than 1 to 2 mm have an increased risk of aesthetic deformity and mucocele formation, and open reduction and internal fixation (ORIF) with frontal sinus obliteration is generally required.
E. Bradley Strong, MD, Associate Professor of Otolaryngology at the University of California-Davis, said in a phone interview that the improved quality of CT scanning and the option of endoscopic repair make it reasonable to consider delaying reduction of the fracture in some cases of isolated anterior table injuries. He stated, 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.
Dr. Strong has made tremendous progress in using a porous polyethylene sheeting to camouflage defects. The material can be custom designed based on CT images, or it can simply be layered into the contour defect and secured with a single screw. This procedure can be performed several weeks after the injury, allowing time for reduction of swelling and soft tissue healing.
Safe vs. Functional Sinus
One of the primary treatment goals in treatment of frontal sinus fractures is creating a safe sinus while avoiding long-term complications. A critical clinical question is whether there is injury to the frontal sinus outflow tract that may result in long-term complications if left untreated. These complications can include, but are not limited to, mucocele and meningitis. Additionally, mucosal lining, which can be trapped in the fracture line at the time of repair, can erode through the sinus walls over time, possibly into the cranial cavity or orbit.
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
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).
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
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.
In the Laryngoscope study, fourteen patients who had sustained acute traumatic frontal sinus fractures were evaluated. Seven patients fulfilled the criteria set forth by the authors and elected to follow the modified treatment algorithm. Of the seven patients treated in accordance with the algorithm, only two needed follow-up surgical intervention, which was performed successfully using endoscopic procedures in both cases.
Not every patient will be a candidate for these less invasive procedures. However, many patients may now realize a potential benefit from alternative, less invasive treatment options.
Improvements through Technology
Dr. Kriet cited the increased use of endoscopy as a huge advance in caring for fractures of the sinus. He called it an example of taking procedures that were being used initially for dealing with chronic sinusitis and applying that technique to the trauma patient. Dr. Kriet said, This is an example of using techniques from within our specialty or other subspecialties.
Dr. Strong added, When I started thinking about endoscopic approaches, I thought, can we do it better, and if we can do it less invasively, is it safe? He noted the reasons doctors can consider a different approach than they did 15 years ago are the availability of improved CT scans and better potential for delayed treatment endoscopically.
By utilizing less invasive endoscopic techniques to treat some frontal sinus fractures, a cosmetic and reconstructive advantage can be recognized by the reduction in scarring. Many potential long-term complications can be avoided, and a high percentage of patients are left with a functioning sinus. Not every patient will be a candidate for these less invasive procedures. However, many patients may now realize a potential benefit from alternative, less invasive treatment options.
Treatment Algorithm for Managing Anterior Table Fractures
- Preoperative assessment of the frontal outflow tract by high-resolution, thin-section CT with sagittal reconstructions;
- Accurate restoration of the displaced bony fragments with internal rigid fixation;
- Adjunctive postoperative broad-spectrum antibiotics for four weeks to treat potentially contaminated sinuses;
- Serial postoperative CT scans to check for ventilation and restoration of mucociliary clearance of the frontal sinus; and
- Endoscopic frontal sinus surgery for persistent frontal outflow tract obstruction.
Source: Laryngoscope. 2002;112:784-790.
©2006 The Triological Society