Jc on frontal fracture

$: Jc on frontal fracture$
DEPARTMENT OF

ORAL & MAXILLOFACIAL SURGERYRUNGTA COLLEGE OF DENTAL SCIENCES & RESEARCH

KOHKA, BHILAI

PRESENTED BY –

DR. SHEETAL KAPSE

2nd YEAR, P.G. STUDENT

MODERATORS -

DR. M. SATISH

DR. MANISH PANDIT

DR. DEEPAK THAKUR

Kalavrezos N. Current trends in the management of frontal sinus fractures. Injury. 2004 Apr;35(4):340-6.

Current trends in the

management of frontal sinus

fractures

AUTHOR

• Nicholas Kalavrezos, FRCS, FFDRRCSI, MD

Consultant in Oral and Maxillofacial Surgery at University College London Hospitals (UCLH), LONDON, US.

Inclusions 1. Introduction

2. Development

3. Surgical anatomy

4. Clinical diagnosis and imaging of the injured sinus

5. Principles of treatment

6. To obliterate or not to obliterate?

7. Is there an ideal implant for the sinus obliteration?

8. Complications following treatment of frontal sinus fractures

9. Conclusions

10. References

Introduction

• Frontal sinus fractures are a rather common problem faced in the trauma units involved in the management of craniofacial injuries. The incidence of frontal sinus fractures is estimated between 6 and 12% of all craniofacial fractures.

• However, severe comminuted fractures with involvement of both anterior and posterior walls of the frontal sinus occur in only 0.7—2.1% of the cases of craniocerebral trauma.

• The frontal sinus fracture is not the most pressing immediate concern during resuscitation and stabilization.

• Ioannides C, Freihofer HP, Friens J. Fractures of the frontal sinus: a rationale of treatment. Br J Plast Surg 1993;46:208—14.

• Luce EA. Frontal sinus fractures: guidelines to management. Plast Reconstr Surg 1987;80:500—10.

• Sataloff RT, Sariego J, Myers DL, Richter HJ. Surgical management of the frontal sinus. Neurosurgery 1984;15: 593—6.

Introduction

• Nevertheless, it rapidly assumes a prominent position in the management algorithm of craniofacial trauma, because of the complications of delayed or improper management: persistent cerebrospinal fluid (CSF) leak, mucocele/ mucopyocele, encephalitis or brain abscess.

• Gerbino G, Roccia F, Benech A, Caldarelli C. Analysis of 158 frontal sinus fractures: current surgical management and complications. J Craniomaxillofac Surg 2000;28:133—9.

Fonseca oral & maxillofacial trauma vol. 2

• 5-15 % of all facial fractures.

• Isolated Anterior table fracture = 43 – 61 %

• Isolated Posterior table fracture = 0.6 -6%

• Both anterior & posterior table fracture = 19 – 51%

• Injuries involving nasofrontal duct = 2.5 – 21%

Development

• Ossification = 8 – 9 week IUL• Pneumatization = 4th months IUL• R/G – 6 yrs• Completed by =12 – 16 yrs

The two frontal sinuses are the only paranasal sinuses to be absent at birth, and they start to develop only after the second year of life.

They both fail to develop in only 4% of the population. They arise from one of several outgrowths originating in the region of the frontal recess of the nose.

Surgical anatomy of frontal sinus

• When fully developed they are situated posterior to the superciliary arches, lying between the outer and inner tables of the frontal bone.

• They are rarely symmetrical, the septum between them usually deviating from the midline sagittal plane.

• The adult average sinus dimensions are: height 3.2 cm, width 2.6 cm, depth 1.8 cm. The entire surface area is approximately 720 mm2.

• Each sinus opens into the anterior part of the corresponding nasal middle meatus by the ethmoidal infundibulum or nasofrontal duct, traversing the anterior part of the ethmoid labyrinth.

• Anatomically this duct is a funnel shaped constriction that passes between the cancellous part of the anterior wall underlying the glabella and the anterior ethmoidal cells.

• Blows of sufficient magnitude to displace the anterior sinus wall have a high probability of injuring the nasofrontal duct.

• Haug RH, Likavec MJ. Basics of stable internal fixation of cranial surgery. In: Greenberg A, editor. Craniomaxillofacial fractures: principles of internal fixation using the AO/ASIF technique. New York: Springer; 1993. p. 179—83.

• Som PM, Brandwein M. Sinosanal cavities: anatomy, physiology and plain film normal anatomy. In: Som PM, Curtin HD, editors. Head and neck imaging. St. Louis: Mosby; 1996. p. 61—96.

• Improper functioning or obstruction of the nasofrontal duct after frontal sinus fractures increases the risk of development of late infectious complications because of the potential cystic degeneration of the sinus mucosa.

• Invasive mucoceles as a result of a traumatically obstructed nasofrontal duct may extend into the orbits and the anterior cranial fossa causing gradual destruction of the osseous confines of the frontal sinus.

• Bordley JE, Bosley WR. Mucoceles of the frontal sinus: causes and treatment. Ann Otol 1973;82:696—702.

• Constantinidis J, Steinhart H, Schwerdtfeger K, Zenk J, Iro H. Therapy of invasive mucoceles of the frontal sinus.

Nasofrontal duct

20 mm long15 % true duct

Clinical diagnosis and imaging of the injured sinus

• Blunt and penetrating trauma to the frontal sinus encompasses a wide spectrum of injury which may range from mucosal contusion to severe disruption of the sinus, dura and brain.

• Clinical diagnosis of a frontal sinus fracture is often difficult because of the presence of oedema.

• Clinical signs may include anaesthesia of the supraorbital nerves, cerebrospinal rhinorrhoea, subconjuctival ecchymosis, air in the orbit, depression over the frontal sinus, or bony fragments showing through lacerations.

Adkins WY, Cassone RD, Putney FJ. Solitary frontal sinusfracture. Laryngoscope 1979;89:1099—104.

• The initial evaluation of the injury includes the basic general rules of emergency care. Airway management and control of bleeding have to be attended to first.

• Frontal sinus fractures are assessed as part of the general head injury evaluation.

• Injury to the posterior wall with possible penetration and/or dural tear or concomitant intracerebral injury should be considered in any case of rhinorrhoea with suspected cerebrospinal fluid leak. Dural tears may also be present without CSF rhinorrhoea if the sinus outflow is obstructed.

Newman MH, Travis NL. Frontal sinus fracture. Laryngoscope1973;83:1281—92.

• Abnormal vision and restriction of the movements of the extraocular muscles have to be considered as potential signs of an associated neurological or ophthalmic injury and must be ascertained by appropriate neurological and ophthalmological evaluation.

• Virtually, all patients with severe head injury require computed tomography (CT) scan for assessment of their intracranial status, and the frontal sinuses can be included in the examination with little modification.

• Plain films are of little value• 1-1.5 mm thin cut CT• Contrast medium : hemorrhage

• Axial view : location, severity &

degree of comminution

• Coronal view : floor fracture• Sagittal view : nasofrontal duct

IMAGING

• CT scans are useful in the assessment of the sinus and the presence of pneumocranium indicates posterior frontal sinus wall and/or base of skull fracture which most of the time is associated with significant intracranial haemorrhage.

• The level of fracture and the degree of disruption of the floor of the sinus may also be predictive of nasofrontal duct obstruction.

8

Frontal sinus fracture with involvement of both anterior and posterior walls. White arrow on the left indicates bony spicule causing dural tear. Double black arrow on the right indicates extensive intracranial haemorrhage in the same patient.

Classification

• Ioannides & Freihofer : Type I, Type II, Type III, Type IV

• Stanley’s modification of Gonty’s classification :

Type I : anterior table fractureType II : anterior & posterior table fracturesType III :posterior table fractureType IV : through & though frontal sinus fracture

Principles of treatment

Treatment of frontal sinus fractures is aiming at:

1. Isolation of the neurocranium and cessation of any CSF leak.

2. Prevention of early and avoidance of delayed postoperative complications from the central nervous system.

3. Restoration of the preoperative facial aesthetics.

Ioannides C, Freihofer HP, Friens J. Fractures of the frontal sinus: a rationale of treatment. Br J Plast Surg 1993;46:208—14.

• In order to achieve these goals it is necessary to classify the sinus fractures so that an algorithm of management can be applied.

• The key factors influencing any proposed system of classification and the subsequent treatment are:

a) Integrity of the posterior wall - The decisive factor for the separation of the intracranial contents from the outer environment.

b) Involvement of the nasofrontal duct – The decisive factor for the potential dysfunction of the respiratory type epithelium of the sinus mucosa.

• Most authors agree to a classification scheme including:

1. anterior wall fractures;

2. posterior wall fractures;

3. anterior and posterior wall fractures;

4. ‘‘through and through’’ fractures;

5. fractures involving the nasofrontal duct.


• Gonty AA, Marciani RD, Adornato DC. Management of frontal sinus fractures: a review of 33 cases. J Oral Maxillofac Surg 1999;57:372—9.

• Rohrich RJ, Mickel TJ. Frontal sinus obliteration: in search of the ideal autogenous material. Plast Reconstr Surg 1995;95:580—5.

• Sailer HF, Gratz KW, Kalavrezos ND. Frontal sinus fractures: principles of treatment and long term results after sinus obliteration with the use of lyophilized cartilage. J Craniomaxillofac Surg 1998;26:235—42.

4 key question to be addressed -

1. Penetrating or concurrent intracranial injury

2. Patency of nasofrontal duct

3. Comminution or displacement of anterior table

4. Concurrent craniomaxillofacial injuries

Management

Preoperative management

• Goal :

1. Protect intracranial structures

2. Control CSF

3. Prevent post traumatic inflammatory complications

4. Restore contour & symmetry

• Antibiotics :

1. Extended spectrum penicillins, cephalosporins, clindamycin (for open frontal sinus injuries)

2. Nafcillin & gentamycin for injuries communicating with neurocranium

3. Cefazolin, Nafcillin & gentamycin : debalable in CSF leak (to prevent meningitis)

Operative management• Approaches

• Closed, undisplaced fractures of the anterior wall do not require surgical treatment. The treatment of depressed fractures of the anterior wall depends upon the involvement of the nasofrontal duct.

• If the duct is intact simple elevation of the fracture and plate fixation is all that is required. However, if the duct is involved in the fracture the treatment should include the obliteration of the sinus cavity after the hermetic sealing of the injured duct.

• Frontal sinus obliteration is defined as the obliteration of the frontal sinus cavity when maintaining or restoring the bony sinus walls.

• The essential principles of successful obliteration include the meticulous removal of all visible mucosa, the removal of the inner cortex of the sinus wall and the permanent occlusion of the nasofrontal duct. In this way the frontal sinus is treated as an isolated cavity precluding any potential mucosal regrowth from the nasal epithelium.

• The frontal sinus is accessed using a coronal approach dissecting in a supraperiosteal plane and preserving the pericranium which remains pedicled on its caudal border.

• Loose and displaced fragments of bone along the supraorbital margins and orbital roofs are removed and kept.

• The mucosal lining of the frontal sinus and the intersinus septum is removed with, preferably, the use of a rotating cutting burr.

• The nasofrontal duct is occluded with the use of bone and the pedicled pericranium flap is rotated into the sinus.

• The rest of the sinus cavity is packed, usually with autologous cancellous bone. The use of fat or muscle along with the technique of spontaneous osteogenesis are also well documented.

• The anterior wall then is reduced, the supraorbital bony bar is repositioned and stabilized with micro- or bioresorbable plates.

‘‘Through and Through’’ fracture (F) associated with bone loss and concomitant dural tear.

• Rohrich RJ, Mickel TJ. Frontal sinus obliteration: in search of the ideal autogenous material. Plast Reconstr Surg 1995;95:580—5.

• If the posterior wall is involved the determinant of the successful management of the frontal sinus fracture is the restoration of the dural integrity and the complete isolation of the brain from the potential communication with the nose through the injured frontal sinus.

• The access is the same as previously described. Formal removal of an intact supraorbital margin is often of help in exposing basal dural tears extending posteriorly.

• Before the dural repair is undertaken the displaced bony fragments of the posterior sinus wall have to be removed, ‘‘cranialization’’ the frontal sinus and aiding the access to the anterior cranial fossa.


• Afterwards, the dura can be sutured under the microscope. It is expected that the swollen brain will partially cover the space provided by the discarded posterior wall.

• The mucous lining of the frontal sinus is removed and the pedicled pericranium flap is rotated into the sinus to seal off the frontal basis and the nasofrontal duct.

Reconstruction of the posterior wall of the sinus with split thickness calvarial bone (B). Surgicel (S) on top of the pericranium flap covering the exposed dura.

• An additional layer of separation can be provided by the use of split thickness calvarial bone or sheets of lyophilized cartilage. In order to avoid any dead space the residual cavity can be obliterated with an autologous material.

Postoperative axial CT scan: white arrow indicating the reconstructed bony layer of separation between dura and frontal sinus.

Obliteration of the sinus cavity and the ‘‘burr holes’’ with cancellous bone (C) and ‘‘bony dust’’. Fixation of the bony segments with bio-resorbable plates (P).

To obliterate or not to obliterate?

• Spontaneous postoperative obliteration of the frontal sinus was reported initially by Samoilenko MacBeth, whereas Bosley provided radiographic evidence that sinus obliteration was by new bone formation in 93 out of 100 patients treated with the method.

• Improved results by spontaneous osteogenesis have been reported after occlusion of the nasofrontal duct with bone - a modification which was not included in the original MacBeth procedure.

Bosley WR. Osteoplastic obliteration of the frontal sinuses: a review of 100 patients. Laryngoscope 1972;82:1463—76.

• Mickel TJ, Rohrich RJ, Robinson Jr JB. Frontal sinus obliteration: a comparison of fat, muscle, bone, and spontaneous osteogenesis in the cat model. Plast Reconstr Surg 1995;95:586—92.

• Owens M, Klotch DW. Use of bone for obliteration of the nasofrontal duct with the osteoplastic flap: a cat model. Laryngoscope 1993;103:883—9.

• Since the frontal sinus after removal of all of its mucosa and occluding the nasofrontal duct is nothing more than an isolated bone cavity, it is not irrational to expect the gradual ossification of the whole cavity.

• It is supposed, though, that the use of an osteoconductive material such as Cancellous bone may accelerate this process and therefore obliteration of the sinus is still advisable.

Is there an ideal implant for the sinus obliteration?

• Autogenous materials such as fat, muscle and bone have been used for the obliteration of the frontal sinuses.

• Cancellous bone used as frank osteoconductive material enhances bony consolidation when the fractured sinus is obliterated. However, it has not become widely used–—possibly because of the associated donor site morbidity.

• In order to overcome the problem of donor site, allografts such as lyophilized cartilage have been successfully used.

Hardy JM, Montgomery WW. Osteoplastic frontal sinusotomy: an analysis of 250 operations. Ann Otol Rhinol Laryngol 1976;85:523—32.

Kalavrezos ND, Gratz KW, Warnke T, Sailer H. Frontal sinus fractures: computed tomography evaluation of sinus obliteration with lyophilized cartilage. J Craniomaxillofac Surg 1999;27:20—4.

Sailer HF, Gratz KW, Kalavrezos ND. Frontal sinus fractures: principles of treatment and long term results after sinus obliteration with the use of lyophilized cartilage. J Craniomaxillofac Surg 1998;26:235—42.

• Nevertheless, the possibility of infectious complications following allogeneic cartilage grafting, although remote, cannot be ignored.

• Lately, the use of alloplastic materials such as micropore hydroxyapatite cement or ionomer cement has gained increasing popularity. Obliteration with alloplastic materials may be considered as a formidable alternative especially when the integrity of the posterior wall is not breached.

Kalavrezos ND, Holmes SB. Treatment of an invasive frontal mucocele: long term results after sinus obliteration with hydroxyapatite cement. J R Coll Surg Edin, in press.

Weber A, May A, von Ilberg C. Bone replacement by ionomer cement in osteoplastic frontal sinus operations. Eur Arch Otorhinolaryngol 1997;254(Suppl 1):162—4.

Complications following treatment of frontal sinus fractures

EARLY COMPLICATIONS : within 6 months

• Inflammatory & aesthetic

• Sinus opacification

• Oedematous painful forehead & eye

• Meningitis

• Concomitant neurological injuries / death

• CSF leak & fistulae

• Displacement of frontal bone into orbit and ocular injury

(diplopia/blindnes)

• Injury to supratrochlear nerve

decongestants & antibiotics

Surgical interventions

LATE COMPLICATIONS : AFTER 6 months

postoperative contour deformity, acute and chronic sinusitis, delayed mucocele/mucopyocele formation, osteomyelitis, meningitis or even brain abscess. Pain & headache without identifiable cause may also be noted.

Deformity of the contour of the frontal bone requiring surgical correction is the most common cause of surgical ‘‘second look’’.

The use of hydroxyapatite cement for remodeling of the contour during the initial operation may reduce this need.

Gerbino G, Roccia F, Benech A, Caldarelli C. Analysis of 158 frontal sinus fractures: current surgical management and complications. J Craniomaxillofac Surg 2000;28:133—9.

Ioannides C, Freihofer HP, Friens J. Fractures of the frontal sinus: a rationale of treatment. Br J Plast Surg 1993;46: 208—14.

Late appearance of mucoceles remains always a possibility and therefore long-term clinical and CT follow-up of 10 years has been suggested.

This should be the case when the treatment includes ‘‘through and through’’ or compound posterior and anterior wall fractures.

Smoot EC, Bowen DG, Lappert P, Ruiz JA. Delayeddevelopment of an ectopic frontal sinus mucocele afterpediatric cranial trauma. J Craniofac Surg 1995;4:327—31.

Conclusion

It is evident from the preceding review that the treatment of frontal sinus fractures is of paramount importance because of the close relationship of the sinus to the brain and the anatomically complex naso-orbito-ethmoidal (NOE) region.

The potential of devastating complications many years after the treatment emphasizes the need for the formulation of a clear therapeutic plan at the initial assessment.

The main factors influencing the decision-making process and the final outcome are disruption of the posterior wall of the sinus with concomitant breach of the dural integrity and involvement of the nasofrontal duct.

There is no consensus with regard to the surgical treatment of fractures of the frontal sinus, mainly because of the lack of randomized studies and because of the short-term follow-up in most of the published reviews.

Nevertheless, most authors would agree that, with the exception of the isolated undisplaced anterior (or posterior linear) wall fracture, an early surgical intervention using a coronal flap and preserving the pericranium as potential sinus lining following the removal of the traumatized mucosa are mandatory prerequisites for a favorable outcome.

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Jc on frontal fracture

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