Linear, nondisplaced fractures involving the anterior wall without any cosmetic deformity can be managed conservatively. No complications happen to be reported for nonoperative treatment of such fractures. Persistent opacification from the frontal sinus may indicate frontonasal duct obstruction or even CSF leakage and may mandate endoscopic evaluation.
Displaced anterior wall fractures ought to always be surgically explored and repaired. The objectives of surgery for displaced anterior table fractures are: (1) aesthetically acceptable reconstruction from the anterior table; (2) elimination of damaged sinus mucosa; and (3) direct inspection from the nasofrontal duct for injury. Displaced anterior table fractures are ideally reconstructed within 7 to 10 days to avoid a forehead deformity. Surgical access could be gained with a bicoronal approach, a supraorbital brow incision, or extension of an existing laceration.
In nonfragmented or minimally fragmented cases, reduction of the fractures and stabilization with 1.0 or 1.3 mm titanium adaptation plates is enough. Plating is preferable over wiring because wiring has a tendency to flatten the standard arched contour of the frontal bone. In the management of severely comminuted fractures with bone loss, an attempt is made to achieve maximal bone preservation. The painstaking procedure for replacing the comminuted fractures is necessary to prevent cosmetic deformity.
Gaps bigger than 4 or 5 mm are reconstructed with bone grafts. Using synthetic material for reconstruction from the anterior table continues to be met with complications for example mucopyocele, infection, flap breakdown and extrusion of implant material. This is probably related to the direct communication from the frontal sinus using the nasal cavity.
The relation between obstruction of the frontonasal duct and formation of frontal mucoceles is well established. The very best evaluation of frontonasal duct integrity and patency is created intraoperatively. Patency from the duct could be evaluated with fluorescin, benzylpenicillin solution, or methylene blue. Attempts to repair or reconstruct the duct have not been shown to be reliable and, therefore, obliteration from the sinus to make it nonfunctional is recommended.
Obliteration of the frontal sinus involves meticulous removal of the sinus mucosa while leaving the bony walls intact. Removal of all mucosa of the sinus is undertaken with a curet first, and then followed by drilling by having an otologic drill.
Obliteration continues to be accomplished using a number of materials including fat, fascia, muscle, pericranium and cancellous bone. Obliteration eradicates the air-filled sinus cavity and nasofrontal duct making the sinus nonfunctional. This prevents subsequent infection of the sinus and mucocele formation.
Posterior table fractures which are nondisplaced, or minimally displaced under the width of the posterior table without CSF leakage, could be observed safely with prophylactic antibiotic treatment. If your CSF leak is present, then patients are put at bed rest with head elevation and given the opportunity for spontaneous resolution.
A lumbar drain may be considered when the leak is profuse. If your leak persists after 5 to 7 days, a cranialization procedure should be considered to prevent intracranial complications including meningitis and pneumocephalus.
Cranialization of the frontal sinus involves excision from the posterior sinus wall. Cranialization is approached using a bicoronal frontal craniotomy, preserving an anterior pericranial flap for separating the nasal cavity from the intracranial space. Once any intracranial injury and dural lacerations are addressed, elimination of all sinus mucosa is carried out, such as the inner cortex of the anterior table. Elimination of any residual posterior sinus wall and intersinus septum is accomplished as well.
The nasofrontal duct orifices are obliterated with temporalis fascia, muscle, or bone in order to prevent retrograde spread of infection. Finally, the anterior pericranial flap is placed along the floor from the sinus. The anterior wall is then reconstructed using plates and bone grafts as necessary.
Fractures displaced more than one table width without nasofrontal duct involvement or CSF leak are explored, and fracture reduction and stabilization is performed. When the nasofrontal duct is injured but no dural tears or CSF leaks are present, sinus obliteration with occlusion from the nasofrontal duct is completed. In the presence of persistant CSF leak or a significantly comminuted posterior wall fracture, cranialization from the sinus is needed.
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