Frontal Sinus Fractures

Question 1

3.1 Description

Answer 1

3.1 Large, (oblique) forehead laceration extending down to bone
On imaging, (left) frontal sinus fracture involving the anterior and posterior tables

Question 2

3.2.1 On history, the MOI would be important to

Answer 2

determine severity and type of injury

Question 3

Explore change in vision, loss of vision, or double vision, as

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orbital injuries must be ruled out prior to considering operative intervention

Question 4

Numbness of the forehead would suggest

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injury to cranial nerve V1 distribution

Question 5

Presence of rhinorrhea would suggest

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concerns for dural injury and CSF leak

Question 6

On PE, I would start by

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identifying any potentially life-threatening conditions

Question 7

I would identify lacerations over the forehead, glabella, or supraorbital ridge

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which may be used for direct assess for repair

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I would also evaluate for

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palpable step-offs and/or depressions in the frontal area

Question 9

I would evaluate for sensibility changes in

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supraorbital/supratrochlear nerve distribution

Question 10

I would examine for CSF rhinorrhea

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• at the bedside, with a ring test

- testing for b-transferrin in nasal discharge

Question 11

I would also test for function of

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frontalis and corrugator muscles

Question 12

3.2.3 On imaging I would obtain a high-resolution maxillofacial CT

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and assess in both axial and coronal planes

Question 13

On CT I would evaluate the

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involvement of the anterior and posterior tables, determining the degree of comminution and displacement

Question 14

I would evaluate the nasofrontal outflow tract for ability to

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drain the frontal sinus

Question 15

On CT I would also evaluate for

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intracranial injuries (pneumocephalus) and other facial fractures

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Intracranial injury is suspected if there is

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• significant displacement of the posterior table
• pneumocephalus
• CSF rhinorrhea

Question 17

3.2.4 If intracranial injury is suspected, I would

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obtain a neurosurgical consultation

Question 18

3.3 Management is guided by the injury pattern as

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nondisplaced fractures of the frontal sinus may not need operative repair

Question 19

3.2.1 Isolated, displaced anterior table fractures are managed with

Answer 19

• initially with irrigation and debridement

- followed by ORIF through a pre-existing laceration or coronal incision, with preservation of the sinus

Question 20

If the anterior table fracture is associated with nasofrontal duct injury

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the frontal sinus must be obliterated and the nasofrontal ducts permanently blocked

Question 21

The frontal sinus mucosa is completely removed with

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a high speed drill and diamond burr

Question 22

The frontal sinus is obliterated with

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a pericranial flap, fat, fascia, bone chips, or spontaneous osteogenesis

Question 23

Isolation of the frontal sinus from the sinonasal tract is required to

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prevent contamination and mucosal regrowth from the ethmoids into the frontal sinus

Question 24

After the frontal sinus mucosa is removed and frontal sinus obliterated

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the anterior table is replaced, reduced, and plated

Question 25

ORIF of the anterior table is performed only is there is

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minimal or no posterior table displacement and no CSF leak

Question 26

3.3.2. If the posterior table is involved there is concern for

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dural injury, which must be addressed by a neurosurgeon before fracture repair

Question 27

Posterior table injuries with displacement of less than one table width may be observed if there is

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no clear evidence of dural tear

Question 28

If the posterior table is minimally involved but the nasofrontal ducts are injured

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frontal sinus obliteration is indicated

Question 29

If the posterior table is significantly displaced or comminuted

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cranialization of the frontal sinus with obliteration of the nasofrontal outflow tract (duct) is necessary

Question 30

In combined anterior/posterior table fractures where there is significant displacement/comminution of the posterior table

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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

Question 31

In cranialization, a pericranial flap is placed along the floor of the anterior cranial fossa to

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separate the nasal and intracranial cavities

Question 32

3.4 Complications: meningitis/encephalitis, brain/epidural abscess

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-prevented by obliterating the nasofrontal outflow tract to prevent bacterial contamination of intracranial contents

Question 33

3.4 Complications: mucocele/mucopyocele

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- due to inadequate removal of sinus mucosa | - may present years after trauma

Question 34

3.4 Complications: cavernous sinus thrombosis

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-which requires management high-dose antibiotics, and possibly steroids and anticoagulation. I would ensure neurosurgery was involved in the care of the patient.