1. IN THE NAME OF GOD

2. Frontal Sinus Fractures
Cummings Otolaryngology 2015
CHAPTER 23 – Maxillofacial Trauma
Dr .Akhtar Kavan

3. Introduction
The term maxillofacial trauma is generally used to refer to the injuries of the facial skeleton
Craniomaxillofacial trauma might be a better term because the anterior wall and floor of the anterior cranial fossa are included in these injuries
management of these injuries is sometimes thought of as “facial orthopedics.”

4. Embryology Absent at birth
Doesn’t begin development until about 2 years
Radiographically evident at about 8 years
Adults size at about 12 years ; but pneumatization continues slowly until 40 years
Consists of one or more compartments
Irregular shapes & asymmetric

5. Embryology Lined by respiratory epithelium
Intimate relation with cranial fossa
Volume approx mls
Ant. wall thickers / stronger than post. wall
Dura adheres to deep surface of post. table
Mucosal lining continous with ethmoidal air cells & Nasofrontal ducts

6. Embryology
Foramina of Breschet = venous drainage of mucosa are site of potential intracranial spread of infection
Mucosa deeply invaginates foramina

7. Anatomical Variation 10 % unilateral 5 % rudimentary 4 % absent
20 % of people “abnormal frontal sinus anatomy

8. Nasofrontal Duct Drains frontal sinus
Located posteromedial floor of sinus
Very variable course
True duct is absent in 85% people
- FS drains indirectly via ethmoidal air cells to middle meatus

10. Anatomy The face can be divided into 3 sections
the frontal bones are generally considered the upper third of the face
The maxillae, zygomas, and orbits comprise the middle third, or midface, which may include the nose
The mandible is considered the lower third

12. Physiology Upper Third
Displaced fractures of Frontal bone can create various deformities, the most common of which is a central forehead depression (Fig. 1).

14. Pathophysiology
Frontal bone fractures may involve only the anterior sinus walls, in which case the fractures are significant only for sinus function and cosmesis
or they may involve the posterior wall of the sinus or extend beyond the sinus, in which case they are true skull fractures and become neurosurgical concerns as well

15. Pathophysiology
The supraorbital rims and roofs are also part of the frontal bones, which are therefore also related to the orbits, and fractures can thus affect orbital and ocular functions.
This thick glabellar bone protects the underlying frontal outflow tracts and the cribriform plates, which house the branches of the olfactory nerves

16. Pathophysiology
The supraorbital and supratrochlear nerves pass through notches or foramina in the supraorbital rims and can be injured from trauma or, more commonly, from surgical manipulation.

18. Evaluation and Diagnosis
Physical Examination
performing a good physical examination.
the initial assessment must address the ABCs and any other potentially life-threatening injuries

19. Evaluation and Diagnosis
In the upper third of the face, the forehead is evaluated for sensation and motor function.
In some cases, fractures may be visible as depressions (see Fig.1) or palpable as step-offs, although typically these fractures are more readily seen on CT scans.

20. Radiographic Evaluation
With some exceptions, the CT scan has replaced other forms of radiographic imaging for the assessment of craniomaxillofacial injuries.
The exception here is for simple nasal fractures (simple meaning without evidence of involvement of other facial bones)

21. Radiographic Evaluation
For frontal fractures, a high-resolution axial CT gives good information about the anterior and posterior walls
When the posterior wall is displaced (regardless of the degree of displacement), and there is soft tissue density within the sinus, the inside of the sinus be visualized

24. Associated injuries Neurological Closed head injury Pneumocephalus
Cerebral contusions
Hematomas
Open brain

25. Associated injuries Ophthalmological - Up to 25 %
Full ophthalmological examination mandatory

26. Associated injuries Maxillofacial injuries - NOE - ZMC
- Le Fort fractures
- Panfacial fractures

27. Classification Schema
Many classification system
Can get very detailed classification ;
However not useful clinically
most useful classification, which predicts the likelihood of disruption of the frontal sinus drainage passages, was presented by Stanley and Becker.

28. Classification Schema
They separated frontal sinus fractures into linear horizontal and linear vertical and comminuted anterior and posterior walls, with and without NEC or supraorbital rim fractures

30. Clincal Classification
Anterior Table
- Displassed
- un -displaced
Posterior Table
- Displaced
- Un- displaced

31. Clincal Classification
Anterior & Posterior Table
- Displaced
- Un - displaced
Nasofrontal duct
- Involved
- Un involved

32. Simplified Clinical Classification
1- Fracture of anterior table
2- Fracture with disruption of posterior wall
3- Fracture involving floor of sinus

33. Management
General
Antibiotic treatment should be initiated at the time the patient initially presents
Typically, antibiotics that cover oral organisms such as penicillins, cephalosporins, or clindamycin are selected

34. Management
Many surgeons have suggested that surgery should be delayed until swelling resolves
Certainly, logic seems to suggest that early intervention to restore the hard and soft tissues to their normal anatomic positions would be beneficial

35. Surgical Access
There is also an additional challenge in craniomaxillofacial surgery, which is the inability to make incisions directly over most fractures,
because unacceptable scars and facial nerve injuries would result

36. Surgical Access Coronal flap preferable
Generally avoid using laceration or local incisions
Avoid “ Gull Wing “ & “ Open Sky “ approaches
In the patient with hair, irregularizing the incision with a running W or a wavy line

42. Surgical Access Shaving the hair is not required
When full exposure of the zygomas is required, the incision begins in the preauricular crease
When zygomatic exposure is not needed, the incision starts above the auricle
When a long pericranial flap is needed , the incision should not violate the pericranium

46. Surgical Access
As the flap is elevated anteriorly, care must be used to avoid injury to the temporal (frontalis) branches of the facial nerve
The supraorbital and supratrochlear nerves are encountered as the flap is elevated to the supraorbital rims.

47. Biomechanics of the Facial Skeleton
In the upper third, the anterior wall of the frontal sinus is thin and there are no significant forces acting on this area.
The supraorbital rims and the frontal bones lateral and superior to the frontal sinuses are thicker , It requires more force to fracture these bones

48. Surgical Management
Cranialization Vs
Oblitration

49. Oblitration Frontonasal ducts oblitrated ,
Mucosal lining removed And sinus “ packed “
Various materials advocated :
-Fat
-Muscle
-Bone
-Hydroxyapatite

50. Fracture Repair
Most repairs are performed using titanium plates and screws
a variety of absorbable plates and screws are used as well
there is no contraindication to the use of stainless steel wires when needed

51. Fracture Repair A number of algorithms have been published
The key issues in frontal sinus trauma relate to two fundamental questions:
(1) Is exploration necessary?
(2) Is obliteration necessary?

52. Fracture Repair Keep in mind the purposes of the bone being repaired
The sinus outflow tracts must function to drain the sinuses
Thus pure anterior wall fractures that do not extend into the nasofrontal ducts are repaired for cosmetic purposes only.

53. Fracture Repair
These should be explored if they are significantly depressed, because even in the absence of acute deformity, they are likely to lead to deformities when the swelling resolves.
The smallest plates available are generally used, because there are little or no force
Use of the endoscope may allow repair of selected anterior wall fractures with minimal incisions

54. Fracture Repair
When the ducts are involved but the posterior wall is intact, judgment allows more than one option
1- Frontal sinus obliteration is always acceptable
2-Allow the sinus to function to see what happens

55. Fracture Repair A nondisplaced posterior wall fracture can be observed
if the posterior wall is displaced, it is difficult to determine the status of the dura and underlying brain
In the absence of apparent ductal injury, it is still wise to consider trephination and transcutaneous endoscopy

56. Fracture Repair
In the absence of posterior wall displacement and with no soft tissue abnormalities associated with such a nondisplaced fracture, it is unclear that obliteration is mandatory
Careful follow-up including interval CT scans will demonstrate whether or not aeration of the sinus ensues

57. Fracture Repair
Numerous complications have been encountered using hydroxyapatite cements
but in one series using it in combination with live pericranial flaps, no complications were seen
they can be used to repair the frontal contour in the presence of severe comminution and/or bone loss of the anterior wall

59. Cranialization Frontal craniotomy Dural repair
Removal of posterior wall
Removal of mucosal lining
Plugging of nasofrontal ducts
Galeal flap placed

60. CSF Rhinorrhea
CSF rhinorrhea is not rare and may occur via the frontal sinuses, or through the cribriform plate, ethmoid sinuses, and/or sphenoid sinuses
Large defects should be repaired at the time of facial fracture repair.
Small defects should be identified endoscopically and can usually be repaired using this approach

61. Skull Base Disruption Prophylactic Antibiotics
Incidence of meningitis between 3-50%
Mortality about 10%
Usually pneumococcus spp.
Prophylactic Antibiotics not recommended

62. CSF leak Fracture reduction often stops leak
Most traumatic leaks close spontaneously
Leak more than 72 h.= lumbar drain
Surgical repair
-Endoscopic
-Intracranial

63. Skull Base Disruption
The use of the Transglabellar Subcranial Approach may allow for earlier intervention
It also allows direct visualization of the cribriform area without disarticulating it completely