Frontal Sinus Fractures Flashcards
3.1 Description
3.1 Large, (oblique) forehead laceration extending down to bone
On imaging, (left) frontal sinus fracture involving the anterior and posterior tables
3.2.1 On history, the MOI would be important to
determine severity and type of injury
Explore change in vision, loss of vision, or double vision, as
orbital injuries must be ruled out prior to considering operative intervention
Numbness of the forehead would suggest
injury to cranial nerve V1 distribution
Presence of rhinorrhea would suggest
concerns for dural injury and CSF leak
On PE, I would start by
identifying any potentially life-threatening conditions
I would identify lacerations over the forehead, glabella, or supraorbital ridge
which may be used for direct assess for repair
I would also evaluate for
palpable step-offs and/or depressions in the frontal area
I would evaluate for sensibility changes in
supraorbital/supratrochlear nerve distribution
I would examine for CSF rhinorrhea
- at the bedside, with a ring test
- testing for b-transferrin in nasal discharge
I would also test for function of
frontalis and corrugator muscles
3.2.3 On imaging I would obtain a high-resolution maxillofacial CT
and assess in both axial and coronal planes
On CT I would evaluate the
involvement of the anterior and posterior tables, determining the degree of comminution and displacement
I would evaluate the nasofrontal outflow tract for ability to
drain the frontal sinus
On CT I would also evaluate for
intracranial injuries (pneumocephalus) and other facial fractures
Intracranial injury is suspected if there is
- significant displacement of the posterior table
- pneumocephalus
- CSF rhinorrhea
3.2.4 If intracranial injury is suspected, I would
obtain a neurosurgical consultation
3.3 Management is guided by the injury pattern as
nondisplaced fractures of the frontal sinus may not need operative repair
3.2.1 Isolated, displaced anterior table fractures are managed with
- initially with irrigation and debridement
- followed by ORIF through a pre-existing laceration or coronal incision, with preservation of the sinus
If the anterior table fracture is associated with nasofrontal duct injury
the frontal sinus must be obliterated and the nasofrontal ducts permanently blocked
The frontal sinus mucosa is completely removed with
a high speed drill and diamond burr
The frontal sinus is obliterated with
a pericranial flap, fat, fascia, bone chips, or spontaneous osteogenesis
Isolation of the frontal sinus from the sinonasal tract is required to
prevent contamination and mucosal regrowth from the ethmoids into the frontal sinus
After the frontal sinus mucosa is removed and frontal sinus obliterated
the anterior table is replaced, reduced, and plated
ORIF of the anterior table is performed only is there is
minimal or no posterior table displacement and no CSF leak
3.3.2. If the posterior table is involved there is concern for
dural injury, which must be addressed by a neurosurgeon before fracture repair
Posterior table injuries with displacement of less than one table width may be observed if there is
no clear evidence of dural tear
If the posterior table is minimally involved but the nasofrontal ducts are injured
frontal sinus obliteration is indicated
If the posterior table is significantly displaced or comminuted
cranialization of the frontal sinus with obliteration of the nasofrontal outflow tract (duct) is necessary
In combined anterior/posterior table fractures where there is significant displacement/comminution of the posterior table
cranialization of the frontal sinus with complete removal of the posterior table and placement of a pericranial flap along the anterior cranial fossa is performed
In cranialization, a pericranial flap is placed along the floor of the anterior cranial fossa to
separate the nasal and intracranial cavities
3.4 Complications: meningitis/encephalitis, brain/epidural abscess
-prevented by obliterating the nasofrontal outflow tract to prevent bacterial contamination of intracranial contents
3.4 Complications: mucocele/mucopyocele
- due to inadequate removal of sinus mucosa
- may present years after trauma
3.4 Complications: cavernous sinus thrombosis
-which requires management high-dose antibiotics, and possibly steroids and anticoagulation. I would ensure neurosurgery was involved in the care of the patient.
