Management of frontal sinus fractures requiring surgical intervention: An analysis of a case series.

<b><br>Introduction:</b> Isolated frontal bone fractures constitute 5-15% of traumatic facial fractures cases, with frontal sinus fractures categorized into anterior wall, posterior wall, or complex fractures. The approach is tailored to fracture type and bone fragment displacement. This paper presents the summary of surgical management in patients with isolated and complex fractures of the anterior wall of the frontal sinus.</br> <b><br>Material and Methods:</b> Five patients with different frontal sinus fractures were treated surgically. The same management protocol - diagnosis and surgical intervention was implemented in all cases The retrospective analysis included fracture assessment, surgical approach, and long-term outcomes evaluation.</br> <b><br>Results:</b> The most common cause of fractures was falls, while two complex fractures involved the anterior and posterior walls. External approach, bone fragment removal, endoscopy, and external stabilization were employed in all cases. One patent required delayed revision surgery due to retaining metallic foreign body. Follow-up radiological examinations showed proper healing and cosmetic outcomes were satisfactory in all of the cases.</br> <b><br>Conclusion:</b> Surgical management of isolated fractures of the frontal sinus anterior wall, involving bone fragment removal, realignment, and endoscopy, yielded satisfactory functional and cosmetic outcomes without internal or external stabilization. Long-term monitoring and symptom assessment are crucial, especially in cases with penetrating injuries and foreign body risk.</br>.

The Usefulness of Surgical Titanium Microclips for Mucosal Repair in the Frontal Sinus Using ORBEYE: A Technical Note.

Bifrontal craniotomy frequently involves opening the frontal sinus and mucosal injury. We report a new technique for mucosal repair in the frontal sinus using surgical titanium microclips. Six consecutive patients who underwent bifrontal craniotomy with frontal sinus exposure and mucosal injury underwent mucosal repair using surgical titanium microclips between April 2019 and August 2022. In all cases, the frontal sinus mucosa was peeled from the inner walls of the frontal sinus to ensure sufficient mucosal margin for clipping using ORBEYE. The repair was accomplished with the microclips in all cases. We also sealed the mucosal wound using fibrin glue and sufficiently filled the frontal sinus with bone debris, resulting in zero incidence of postoperative liquorrhea in all cases. Repairing the mucosa using surgical titanium microclips using ORBEYE may be a simple and quick technique when the frontal sinus mucosa is injured during craniotomy.

Treatment Outcomes With Conservative Management of Frontal Sinus Outflow Tract Fractures.

OBJECTIVE: Historically, early surgical management of frontal sinus outflow tract (FSOT) fractures has been standard practice. There has been a paradigm shift toward nonsurgical or delayed management. Unfortunately, clinical indications and treatment outcomes for this approach are poorly understood. This study evaluates radiologic indicators, as well as sinus reaeration and complication rates for FSOT injuries treated nonsurgically. STUDY DESIGN: A retrospective cohort study of FSOT injuries between 2005 and 2019. SETTING: Academic, tertiary care medical center. METHODS: Radiographic fracture patterns of the frontal ostia (FO) and frontal recess (FR) were recorded as either patent, disrupted, or obstructed. Sinus reaeration, surgical rescue, and complication rates were documented. Patients with follow-up imaging >42 days were included. Patients undergoing immediate surgical intervention were excluded. RESULTS: One hundred patients were identified and 44 met the criteria (88 sinuses). Among nonobstructed FSOT injuries (ie, patent or disrupted), reaeration occurred in 91% of the FO and 98% of FR injuries. Two sinuses required surgical rescue including 1 Draf IIB (1%), and 1 obliteration (1%). Two sinuses had complications including 1 mucocele (1%) and 1 cerebrospinal fluid leak (1%). FO and FR fracture patterns had no identifiable correlation with long-term reaeration rates or the need for surgical intervention. CONCLUSION: Among nonobstructive injuries to the FSOT, average reaeration rates in observed patients were high (91%-98%). Rescue surgery (2%) and complication rates (2%) were low, suggesting that nonsurgical management of nonobstructed FSOT is a viable strategy. No radiographic features were clearly identified to be predictive of sinus reaeration.

Autologous Fat Versus Hydroxyapatite Cement for Use in Frontal Sinus Obliteration: Systematic Review and Meta-Analysis.

BACKGROUND: Frontal sinus obliteration is a possible terminus for the management of chronic sinusitis, frontal bone trauma, cancer extirpation, or mucocele. The mucosa of the sinus is stripped and space obliterated with either autogenic, allopathic, or synthetic materials. This study aimed to compare the outcomes of autologous fat and hydroxyapatite cement (HAC) for frontal sinus obliteration. METHODS: A multidatabase systematic review was conducted to collect outcomes on frontal sinus obliterations with either autologous fat or HAC. Outcomes collected included infection of the frontal sinus or obliteration material, mucocele formation, skin infection at the operative site, hematoma or seroma, cosmetic defect, donor site infection, and need for revision procedure. Prevalence of outcomes was analyzed through meta-analysis of proportions. RESULTS: Twenty studies were ultimately included in the meta-analysis. Sixteen studies reported outcomes for 667 patients obliterated with autologous fat, and 7 studies reported outcomes for 100 patients obliterated with HAC. Prevalence of infection of the frontal sinus or obliteration material, mucocele formation, skin infection at the operative site, hematoma or seroma, and cosmetic defect did not differ statistically between the cohorts. Donor site infection secondary to fat harvesting for fat obliteration had a prevalence of <0.01. Revision rate was 0.04 (95% confidence interval, 0.01-0.8) for fat obliteration and 0.10 (95% confidence interval, 0.00-0.33) for HAC obliteration. CONCLUSIONS: No statistically significant differences in the studied outcomes were detected between obliterations with autologous fat and HAC, suggesting that either is equally suitable and may be up to the surgeon's preference.

Balloon Sinuplasty and Stenting in the Management of Complex Frontal Sinus Outflow Tract Fractures.

OBJECTIVE: Classical management of complex fractures involving the frontal sinus outflow tract (FSOT) favors obliteration or cranialization to avoid delayed complications. We aim to exhibit success with a novel application of balloon sinuplasty and frontal stenting in the management of complex injuries disrupting the FSOT, which might have otherwise required more invasive interventions. STUDY DESIGN: Retrospective review. SETTING: Single institution, level 1 trauma center. METHODS: Retrospective review of patients presenting to a level 1 trauma center with fractures involving the FSOT. Outcomes include patency of the FSOT on imaging and endoscopy, rate of complications, degree of residual tabular displacement, and need for revision surgery. RESULTS: Twenty-five patients met inclusion criteria, with complete FSOT obstruction seen in all cases on computed tomography. All patients underwent balloon sinuplasty with frontal sinus stenting; 48% underwent concurrent anterior table repair, and 36% open repair of nasoorbitoethmoid complex fractures. The mean follow-up length was 13.9 months, at which time 91.3% of patients demonstrated radiographic and endoscopic FSOT patency. No residual sinus opacification or pneumocephalus was observed. CONCLUSION: Balloon sinuplasty with frontal sinus stenting is a straightforward and minimally invasive technique that can create a safe sinus in complex fractures disrupting the FSOT while avoiding the need for more invasive procedures.

Management of Aesthetic and Functional Deficits in Frontal Bone Trauma.

Frontal bone trauma has an increasing incidence and prevalence due to the wide-scale use of personal mobility devices such as motorcycles, electric bicycles, and scooters. Usually, the patients are involved in high-velocity accidents and the resulting lesions could be life-threatening. Moreover, there are immediate and long-term aesthetic and functional deficits resulting from such pathology. The immediate complications range from local infections in the frontal sinus to infections propagating inside the central nervous system, or the presence of cerebrospinal fluid leaks and vision impairment. We review current trends and available guidelines regarding the management of cases with frontal bone trauma. Treatment options taken into consideration are a conservative attitude towards minor lesions or aggressive surgical management of complex fractures involving the anterior and posterior frontal sinus walls. We illustrate and propose different approaches in the management of cases with long-term complications after frontal bone trauma. The team attending to these patients should unite otorhinolaryngologists, neurosurgeons, ophthalmologists, and maxillofacial surgeons. Take-home message: Only such complex interdisciplinary teams of trained specialists can provide a higher standard of care for complex trauma cases and limit the possible exposure to further legal actions or even malpractice.

A Clinical Case of Delayed Posttraumatic Frontal Sinus Cerebrospinal Fluid Leakage Management Via External Surgical Approach.

ABSTRACT: Cerebrospinal fluid rhinorrhea is frequently encountered after a fracture of the skull base. Individual fractures of the posterior wall of the frontal sinus after brain injury are uncommon. The authors present a case of a 33-year-old man with a distant history of skull base injury after a traffic accident, 12 years ago. He presented with intermittent rhinorrhea and reported 2 episodes of bacterial meningitis the last 7 years since the injury. Cerebrospinal fluid leakage was confirmed with ß2-transferrin testing. Computed tomography and magnetic resonance imaging revealed a small defect of the posterior and superior wall of the left frontal sinus and an ipsilateral meningoencephalocele.Finally, there was a communication between intracranial space and frontal sinus that caused meningitis.A coronal incision and frontal craniotomy with preservation of anterior pericranium was performed (frontal sinus cranialization using osteoplastic flap). In order to determine the precise margins of the frontal sinus and allow an accurate anterior table bone osteotomy and complete exposure of the sinus, the authors used a coronal view of skull X-ray. Scissors are then used to cut along the margins of the sinus. An "R" is scratched into the right side of template to record orientation. The template was sterilized and brought onto the surgical field and then placed over the left sinusAn external surgical approach (anterior table bone osteotomy) with the modern technique of osteoplastic flap access was performed. An elevator was used to separate the dura from the posterior table along the entire margin of the defect. Meningoplasty (cauterization of the meningoencephalocele) and closure of the osseous defect was followed. The authors repaired the defect of the posterior wall of the left frontal sinus using a combination of underlay and overlay technique. Femoral fascia from right thigh and fibrin glue were placed in order to cover the leak of the posterior wall of the left frontal sinus, respectively.Patients who present with a short or/ and distant history of traumatic brain injury should be evaluated for complication of a cerebrospinal fluid leak.

Global avulsion of the globe associated with frontal sinus and naso-orbital-ethmoid (FSNOE) complex fracture. A rare case report and short literature review.

INTRODUCTION: Post-traumatic avulsion of the globe is a rare and uncommon pathology with serious morpho-physiological, cosmetic and aesthetic implications. The association with complex fractures of the skull increases the morbidity and complexity of the case. CASE REPORT: We present a rare case of FSNOE complex fracture associated with avulsion of the left globe, with complete sectioning of the optic nerve and loss of vision. DISSCUSION: The prompt diagnosis and the immediate establishment of a correct multidisciplinary treatment, led to the favorable evolution of the case. Three-dimensional reconstruction of the skull architecture and resizing of the orbital contour, as well as successful prosthesis of the eyeball concured for a satisfactory anatomic and cosmetic result. CONCLUSION: The therapeutic decision to reposition the globe in the case of complete avulsion should be made depending on the severity of associated lesions, the patient's general state, age, and the risk of potential postoperative complications. KEY WORDS: Word, Post-traumatic, Avulsion of the globe, Frontal sinus, Naso-orbito-ethmoid, NOE, Fracture.

Supramuscular upper blepharoplasty approach to orbital roof and/or lower anterior table frontal sinus fractures: A meta-narrative review.

BACKGROUND: An approach to orbital roof fractures (ORFs) and/or lower anterior table frontal sinus fractures (LATFSFs) is a challenging task. The conventional coronal approach (CCA) appears to suit multiple/complex fractures of the upper face, while periorbital transcutaneous incisions (PTIs), e.g. gull wing, open sky, butterfly, and Lynch incisions, often impair aesthetic outcomes. The aims of this paper were to provide an overview of the supramuscular upper blepharoplasty approach (SUBA) to ORFs/LATFSFs. METHODS: Using a meta-narrative review study design, the investigators enrolled published data extracted from PubMed/Medline, Embase, Cochrane Library, and Google Scholar concerning SUBA to ORFs/LATFSFs. Only publications with the highest and most recent level of evidence (LoE) in English, French or German available until 6 May 2022 were included. The LoE were evaluated using the 2011 Oxford Centre for Evidence-Based Medicine (OCEBM)'s classification. RESULTS: In total, 70 articles were included; however, most contained low LoE. Under general and local anaesthesia, SUBA to ORFs/LATFSFs can be performed safely and appeared to be superior to its submuscular counterpart in terms of fewer risks of adjacent tissue injuries, and speedy operative time (maximal 5 min. in experienced hands). CONCLUSIONS: In contrast to CCA and PTIs, the SUBA is a minimally invasive approach to the ORF/LATFSF with favourable aesthetic outcomes, direct visualisation of the fracture, quick operative time, rare complications, and easy learning.

Application of a bilateral temporal fascia free graft in a dog with multifragmented frontal sinus and nasal bone fracture.

OBJECTIVE: To describe the use of temporal fascia free grafts to treat dorsal open comminuted frontal sinus and nasal fractures. ANIMAL: One Belgian shepherd dog. STUDY DESIGN: Case report METHODS: A 5-year-old spayed female Belgian shepherd was admitted with severe facial deformation due to trauma. A deep, 3 cm wide wound was present between the nose and the frontal sinus. No abnormalities were detected on neurological examination. On computed tomographic examination, comminuted open fractures of the frontal and nasal bones were associated with a severe depression of the dorsal wall and presence of bone fragments in the sinus cavities. Bone fragments were apposed with polydioxanone monofilament suture. Bilateral temporal fascia grafts were placed over the bone fragments. RESULTS: The integrity of the frontal and nasal cavities, and the facial profile of the dog were restored. No short-term or long-term complications were observed after 4 months follow up. CONCLUSION: The innovative combination of suture apposition of bone fragments and a temporal fascia free graft resulted in very satisfying long-term outcomes in a dog with open sinus and nasal bone fractures.

Repair of frontal sinus fractures: clinical and radiological long-term outcomes.

OBJECTIVE: The long-term clinical and radiological outcomes of patients surgically treated for frontal sinus fracture were assessed. METHODS: A retrospective, single-centre analysis was conducted of patients treated for frontal sinus fracture in a tertiary trauma centre between 2000 and 2017. Patients who underwent surgical repair for frontal sinus fracture followed by clinical and radiographical evaluation for at least six months were included. RESULTS: Of 338 patients admitted with frontal sinus fracture, 77 were treated surgically. Thirty patients met the inclusion criteria for long-term follow-up. The average follow-up duration was 37 months (range, 6-132 months). Reconstruction, obliteration and cranialisation of the frontal sinus fracture were performed in 14, 9 and 7 patients, respectively. Two patients with a reconstructed frontal sinus and one with an obliterated frontal sinus developed mucoceles. One patient developed forehead disfigurement following obliteration. CONCLUSION: Long-term complications of frontal sinus repair using the chosen repair techniques are rare, but patients need to be made aware of these potential complications.

Reconstructive Management of Gunshot Wounds to the Frontal Sinus: An Urban Trauma Center's Perspective.

INTRODUCTION: In the last decade, we have seen a steady increase in the incidence of frontal sinus trauma due to gunshot wounds and a decrease in motor vehicle trauma. Penetrating gunshot wounds to the frontal sinus present a unique challenge to the reconstructive surgeon because they require careful consideration of the management principles of plastic surgery. Despite previous reviews on frontal sinus trauma, there are no studies examining the management techniques of frontal sinus fractures due specifically to gunshot wounds. In this study, we aim to retrospectively evaluate the use of a variety of tissue flaps in intervention and associated outcomes. METHODS: A retrospective chart review was completed on all patients with gunshot wound(s) to the frontal sinus from January 2010 to January 2018 at a single institution. The patients were classified based on the fracture pattern (anterior vs posterior table vs both), degree of displacement, presence of nasofrontal outflow tract injury, and evidence of cerebrospinal fluid leak. Patients were then stratified according to the type of reconstruction performed (cranialization, obliteration and need for free flap) and evaluated for major and minor complications after reconstruction. RESULTS: In this study, we present outcome data from 28 cases of frontal sinus trauma due to gunshot wounds. There was a statistically significant difference (P = 0.049) in the type reconstructive strategy employed with each type of flap, with pericranial flaps primarily used in cranialization, temporal grafts were more likely to be used in obliteration, and free flaps were more likely to be used in cranialization. The overall major complication rate was 52% (P = 0.248), with the most common acute major complication was cerebrospinal fluid leak (39%) and major chronic was abscess (23.5%). CONCLUSIONS: This report explores the management of frontal sinus trauma and presents short-term outcomes of treatment for penetrating gunshot wounds at a tertiary referral center.

Thermal Conductance Through the Skull Base From Endoscopic Surgery Cauterization Instruments: Cadaver and Goat Model.

OBJECTIVE: Cauterization prevents hemorrhage and optimizes the surgical field during endoscopic sinus surgery but may cause injury to nearby structures. The objective of this study is to examine thermal conductance from cauterization equipment across the skull base. STUDY DESIGN: Cadaver and animal model. SETTING: Surgical skills laboratory of an academic tertiary medical institution. METHODS: A pilot study was conducted with a deidentified cadaver head and expanded to a goat head animal model. Endoscopic dissection was performed to expose the lamina papyracea, ethmoid roof, sphenoid roof, and frontal sinus. Cautery was applied to the frontal sinus of goat heads, and temperatures were measured via thermocouple sensors placed along the intracranial skull base. Surgical instruments studied included monopolar, bipolar, and endoscopic bipolar devices at various power settings. RESULTS: Temperature increase, as averaged across all cautery powers and measurement positions, was highest for the monopolar cautery (17.55 °C) when compared with the bipolar and endoscopic bipolar devices (<2 °C for bipolar, Endo-Pen, Stammberger, and Wormald; P < .001). Monopolar cautery reached 30.86 °C at high power when averaged over all positions (P < .001) as compared with <3 °C for the other instruments. Temperatures rose as power of cautery was increased from low to medium and high. Temperatures decreased as the distance of the thermocouple sensor probe from the cautery origin increased. CONCLUSION: Thermal conductance across the skull base varies depending on equipment and power of cautery, with monopolar resulting in the largest temperature increase. Choice and implementation of cauterization instruments have implications on inadvertent transmission of thermal energy during endoscopic sinus surgery.

Asystole due to stimulation of the supraorbital nerve: abrupt and potentially fatal presentation of the trigeminocardiac reflex.

We present a case of sudden asystole that was elicited via the trigeminocardiac reflex in a patient undergoing surgery for a frontal sinus fracture. Asystole occurred after mild stimulation of the supraorbital nerve during dissection along the superior orbital rim. Anticholinergics were administered and lidocaine-soaked gauze was applied to the exposed wound. The patient was an athlete and had pre-existing sinus bradycardia. We hypothesise that the severe reflex response was associated with his underlying increased vagal tone. When performing surgery in patients with increased vagal tone, preventative measures to diminish the trigeminocardiac reflex are recommended. Further studies are needed.

Pediatric Frontal Bone and Sinus Fractures: Cause, Characteristics, and a Treatment Algorithm.

BACKGROUND: The purpose of this study was to assess the incidence, cause, characteristics, presentation, and management of pediatric frontal bone fractures. METHODS: A retrospective cohort review was performed on all patients younger than 15 years with frontal fractures that presented to a single institution from 1998 to 2010. Charts and computed tomographic images were reviewed, and frontal bone fractures were classified into three types based on anatomical fracture characteristics. Fracture cause, patient demographics, management, concomitant injuries, and complications were recorded. Primary outcomes were defined by fracture type and predictors of operative management and length of stay. RESULTS: A total of 174 patients with frontal bone fractures met the authors' inclusion criteria. The mean age of the patient sample was 7.19 ± 4.27 years. Among these patients, 52, 47, and 75 patients were classified as having type I, II, and III fractures, respectively. A total of 14, 9, and 24 patients with type I, II, and III fractures underwent operative management, respectively. All children with evidence of nasofrontal outflow tract involvement and obstruction underwent cranialization (n = 11). CONCLUSIONS: The authors recommend that type I fractures be managed according to the usual neurosurgical guidelines. Type II fractures can be managed operatively according to the usual pediatric orbital roof and frontal sinus fracture indications (e.g., significantly displaced posterior table fractures with associated neurologic indications). Lastly, type III fractures can be managed operatively as for type I and II indications and for evidence of nasofrontal outflow tract involvement. The authors recommend cranialization in children with nasofrontal outflow tract involvement. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Frontal sinus fractures and cerebrospinal fluid leaks: a change in surgical paradigm.

PURPOSE OF REVIEW: Traditionally, frontal sinus trauma has been treated using open incisions to access the anterior and/or posterior table. Mounting evidence indicates frontal sinus trauma can be managed using an endoscopic endonasal approach (EEA) with less morbidity. Such an approach permits preservation of a functional sinus and less reliance on computed tomography for postoperative follow up. The goal of this article is to highlight a shift in paradigm away from open approaches using external incisions towards an EEA to repair cerebrospinal fluid (CSF) leaks and fractures of the frontal sinus. RECENT FINDINGS: In a prospective case series of 46 patients undergoing EEA to frontal sinus fractures, 41 patients had active CSF leaks arising from the posterior table of the frontal sinus. A successful endoscopic repair was achieved in 97.6% with only one patient requiring revision Draf IIB surgery. Anterior table fractures were also successfully reduced with excellent cosmesis. SUMMARY: Endoscopic repair of frontal sinus fractures and CSF leaks is effective and well tolerated. In select patients, it is the preferred treatment as it maintains normal sinus structure and function, minimizing both early and late complications.

Management of Frontal Sinus Fractures.

Fractures of the frontal sinus occur from extreme forces and are often associated with other injuries. Management of frontal sinus fractures is variable and dependent on involvement of the anterior table, posterior table, and frontal outflow tract. Severe complications can developed from poorly managed fractures, such as meningitis, mucocele, mucopyocele, and brain abscess. Surgeons should be aware of appropriate management and surgical techniques for addressing frontal sinus fractures. Herein, we review the presentation and management of frontal sinus fractures, including conservative, endoscopic, and open surgical techniques.