Frontal Sinus Fractures web version - Wisdom Teethmaxillofacialsurgeons.org/lectures/Frontal Sinus...
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Frontal Sinus FracturesFrontal Sinus FracturesPeter Aquilina
MBBS(Hons) MS(Head & Neck) BDS(Hons) FRACDS(OMS) Consultant Maxillofacial Surgeon
W t d & R l Child ' H it lWestmead & Royal Children's HospitalsSenior Lecturer University of Sydney
www maxillofacialsurgeons orgwww.maxillofacialsurgeons.org
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Anatomy & EmbryologyAnatomy & Embryology• Absent at birth• Doesn’t begin development until about 2 years
of age• Radiographically evident at about 8 years• Radiographically evident at about 8 years• Adult size at about 12 years, but pneumatization
continues slowly until about 40 yearsy y• Consists of one or more compartments• Irregular shape & asymmetric
Li d b i i h li• Lined by respiratory epithelium• Intimate relation with cranial cavity and orbits
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AnatomyAnatomy • Volume approx 5 mlsVolume approx 5 mls• Anterior wall thicker/stronger than posterior wall• Dura adheres to deep surface of posterior tableDura adheres to deep surface of posterior table• Mucosal lining contiguous with ethmoidal air
cells & nasofrontal ductscells & nasofrontal ducts• Foramina of Breschet venous drainage of
mucosa are site of potential intracaranial spread ucosa a e s te o pote t a t aca a a sp eadof infection
• Mucosa deeply invaginates foraminap y g
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Anatomical VariationAnatomical Variation
• 10% unilateral10% unilateral• 5% rudimentary
4% b t• 4% absent• 20% of people “abnormal” frontal sinus
anatomy
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Nasofrontal DuctNasofrontal Duct
• Drains frontal sinusDrains frontal sinus• Located posteromedial floor of sinus
V i bl• Very variable course• True duct is absent in 85% people
– FS drains indirectly via ethmoidal air cells to middle meatus
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ExaminationExamination
• Full assement as per ATLSFull assement as per ATLS• Lacerations
D i• Depression• CSF leak
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Dr. Peter Aquilina©q
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InvestigationsInvestigations
• CT imaging modality of choiceCT imaging modality of choice– Request axial and coronal slices
Beta Transferrin CSF• Beta Transferrin CSF• Other investigations as requireds as
medically indicated
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Dr. Peter Aquilina© Dr. Peter Aquilina©
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Dr. Peter Aquilina©
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Associated injuriesAssociated injuries
• NeurologicalNeurological– Closed head injury
Pneumocephalus– Pneumocephalus– Cerebral contusions
Haematomas– Haematomas– Open brain
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Associated injuriesAssociated injuries
• OpthalmologicalOpthalmological– Up to 25%
Full opthalmological examination mandatory– Full opthalmological examination mandatory
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Associated injuriesAssociated injuries• Maxillofacial injuriesMaxillofacial injuries
– NOEZMC– ZMC
– Le Fort fracturesPanfacial fractures– Panfacial fractures
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Classification of Frontal Sinus FFractures
• Many classification systemsMany classification systems• Can get very detailed classification,
however not useful clinicallyhowever not useful clinically
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Clinical ClassificationClinical Classification• Anterior Table
– Displaced– Un-displaced
• Posterior TablePosterior Table– Displaced– Un-displaced
• Anterior & Posterior Table• Anterior & Posterior Table– Displaced– Un-displaced
• Nasofrontal Duct– Involved– uninvolved
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Simplified Clinical ClassificationSimplified Clinical Classification
1. Fracture of anterior table
2. Fracture with disruption of posterior wall
3. Fracture involving floor of sinus
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Surgical Management
G l “S f Si ”Goal = “Safe Sinus”
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Anterior Table FracturesAnterior Table Fractures
• Non surgicalNon surgical– Undisplaced
Minimal displacement with no cosmetic defect– Minimal displacement with no cosmetic defect• Surgical Intervention
f– Displaced fractures
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Anterior Table FracturesSurgical Access
• Coronal flap preferableG ll id i l ti l l• Generally avoid using lacerations or local incisions
• Avoid “Gull Wing” & “Open Sky” approaches
• Anatomically reduce fragments & hold in place with 1.3mm hardwarep
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Dr. Peter Aquilina©
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Dr. Peter Aquilina©
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Dr. Peter Aquilina©
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Dr. Peter Aquilina©
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Dr. Peter Aquilina©
Dr. Peter Aquilina©
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Anterior Table with Bone LossAnterior Table with Bone Loss
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D P t A iliDr. Peter Aquilina©
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Dr. Peter Aquilina©
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Frontal Sinus with Orbital RoofFrontal Sinus with Orbital Roof
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Dr. Peter Aquilina©
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Dr. Peter Aquilina©
Dr. Peter Aquilina©
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Dr. Peter Aquilina©
Dr. Peter Aquilina©
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Dr. Peter Aquilina©
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Dr. Peter Aquilina©
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Fractures with Disruption of the P i T blPosterior Table
• Non-Surgical managementNon Surgical management– Undisplaced fractures
• Surgical ManagementSurgical Management– Displaced fractures
• Displacement more than thickness of posterior p ptable
– Clinical findings suggestive of significant dural teartear
• Encephalocoele• Persistent CSF leakPersistent CSF leak
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Surgical Management of Posterior T bl FTable Fractures
CranializationVs
ObliterationObliteration
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ObliterationObliteration
• Frontonasal ducts obliterated mucosalFrontonasal ducts obliterated, mucosal lining removed and sinus “packed”
• Various materials advocated• Various materials advocated– Fat
M l– Muscle– Bone– Hydroxyapatite
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CranializationCranialization
• Frontal craniotomyFrontal craniotomy• Dural repair
R l f t i ll• Removal of posterior wall• Removal of mucosal lining• Plugging of nasofrontal ducts• Galeal flap placedGaleal flap placed
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Dr. Peter Aquilina©
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Dr. Peter Aquilina©
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Dr Peter Aquilina©Dr. Peter Aquilina©
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Dr. Peter Aquilina©
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Dr. Peter Aquilina©
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Dr. Peter Aquilina©
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Dr. Peter Aquilina©
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Dr. Peter Aquilina©
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Dr. Peter Aquilina©
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Fracture of the Floor of the Frontal SiSinus
• Unusual in isolationUnusual in isolation• Usually associated with NOE fractures• ? Treat isolated floor fracture to prevent• ? Treat isolated floor fracture to prevent
mucocoele formation• If isolated floor fracture & sinus clinically• If isolated floor fracture & sinus clinically
draining satisfactorily may opt to leave alonealone
• Accurate reduction of fractures can expect NFD function to resume (Gruss)expect NFD function to resume (Gruss)
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Management of the Nasofrontal DDuct
• Role of drainage via nasofrontal duct may beRole of drainage via nasofrontal duct may be overstated in trauma compared to infective sinusitis (Evans)
• Avoid trying to restablish a frontonasal duct prone to failure
• If radiological evidence of NFD disruption, explore and treat on merits
• NFD function most likely to return to normal with accurate anatomical fracture reduction.
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CSF LEAKCSF LEAK
• Management controversialManagement controversial• Surgical or non-surgical
P h l ti tibi ti ?• Prophylactic antibiotics?
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Prophylactic AntibioticsProphylactic Antibiotics
• incidence of meningitis between 3-50%incidence of meningitis between 3 50%• Mortality about 10%
U ll• Usually pnuemococcus spp.
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Prophylactic AntibioticsProphylactic Antibiotics
• EBMEBM– Prophylactic antibiotics not recommended
Prophylactic antibiotics may increase– Prophylactic antibiotics may increase incidence of menigitis by changing the pathogenicity of the nasopharygeal florapathogenicity of the nasopharygeal flora
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Managing CSF leakManaging CSF leak
• Fracture reduction often stops leakFracture reduction often stops leak• Most traumatic leaks close spontaneously
L k 72 h l b d i• Leak > 72 hrs lumbar drain• Surgical repair
– Endoscopic– intracranial