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The Laryngoscope

C 2017 The American Laryngological,


V
Rhinological and Otological Society, Inc.

Does the Frontal Sinus Need to Be Obliterated Following


Fracture With Frontal Sinus Outflow Tract Injury?

Helena Wichova, MD; Alexander G. Chiu, MD; Jennifer A. Villwock, MD

BACKGROUND table comminution, displacement, or persistent cerebro-


Frontal sinus fractures account for 5% to 15% of all spinal fluid (CSF) leak, cranialization or obliteration have
facial fractures and are most commonly due to high historically been recommended.3,4 For fractures that
velocity, blunt force injuries such as motor vehicle acci- involve the FSOT, frontal sinus obliteration at the time of
dents and blunt interpersonal violence.1,2 These frac- the fracture repair has traditionally been recommended.2
tures are often associated with intracranial injury and With the advent and success of endoscopic techniques to
other facial fractures.1,2 Approximately half of frontal maintain frontal recess patency, treatment options have
sinus fractures are limited to the anterior table. The evolved, and there continues to be controversy regarding
remaining fractures involve both the anterior and poste- the need for obliteration for fractures involving the
rior table, and isolated fractures of the posterior table FSOT.2,3
are very rare.3 Patients with frontal sinus outflow tract
(FSOT) injuries have three times more concomitant LITERATURE REVIEW
facial fractures than those without.1,2 Indications of The literature regarding frontal sinus fractures is
FSOT obstruction include fracture of the floor of the largely limited to retrospective reviews. The largest of
frontal sinus, fracture of the medial aspect of the anteri- these is a 6-year, single-institution experience of 857
or table, and gross obstruction.2,4 Complications of FSOT patients.3 Particular attention was paid to fracture loca-
obstruction include mucocele formation and chronic tion, degree of displacement, comminution, and FSOT
frontal sinusitis as a result of anatomic obstruction.3,4 injury. Injuries were classified into three broad categories:
The treatment goals of frontal sinus fracture repair isolated anterior table fracture, anterior and posterior
include maintenance of normal sinus function, avoidance wall fractures, and isolated posterior wall fracture. Each
of short- and long-term complications, and preservation of category was further subdivided based on presence or
an aesthetic facial contour.3 Potential treatment of these absence of fracture displacement. Additionally, radio-
fractures has traditionally included observation, open graphic criteria of FSOT injury—FSOT obstruction,
reduction, and internal fixation, obliteration, cranializa- frontal sinus floor fracture, fracture of medial aspect of
tion, ablation/exenteration (removal of anterior wall, the anterior table—was further used to stratify injuries.
mucosa, supraorbital rims, and proximal nasal bones to Two general treatment patterns were identified: patients
allow skin retraction to posterior wall or dura), or osteo- without FSOT obstruction or frank involvement were
neogenesis (mucosal stripping, frontal outflow tract seal- observed; patients with FSOT involvement and evidence
ing, and preservation of sinus cavity with delayed healing of obstruction underwent cranialization. Of 504 patients
as scar tissue and bone fill the cavity). The latter two who underwent surgery, 94% had FSOT involvement by
options have largely been relegated to history as they are at least one criteria and 80% by two or more criteria.
associated with increased complication rates and, in Patients with radiologic FSOT obstruction and one or
the case of ablation/exenteration, significant cosmetic more other criteria had a 100% complication rate when
deformation.3 For fractures with significant posterior treated with observation or reconstruction. These were
defined as duct and mucosal preservation with anterior
From the Department of Otolaryngology, University of Kansas wall reconstruction. Overall, among patients undergoing
Medical Center, Kansas City, Kansas, U.S.A. operative repair, there was a 10.4% complication rate.
Editor’s Note: This Manuscript was accepted for publication Patients who were observed had a 3.1% complication
March 7, 2017. rate. The vast majority of complications were secondary
The authors have no funding, financial relationships, or conflicts
of interest to disclose.
to FSOT injury (98.5%). None of the 222 patients without
Send correspondence to Jennifer A. Villwock, MD, Department of FSOT injury experienced complications. Despite the lack
Otolaryngology, University of Kansas Medical Center, 3901 Rainbow Boule- of specific use of the endoscope for surgical management,
vard, Mailstop 3010, Kansas City, KS 66160. E-mail: jvillwock@kumc.edu
these results highlight the need for precise preoperative
DOI: 10.1002/lary.26601 FSOT, as it was the chief determinant of mucocele
Fig. 1. Algorithm for evaluation and management option of frontal sinus fractures. [Color figure can be viewed in the online issue, which is
available at www.laryngoscope.com.]

formation, not posterior table comminution of displace- and complications. At the 12-month recall, a total of 34
ment, making it a key predictor for future complications. complications was reported in the surgical group includ-
Preoperative imaging plays a key role in determining ing headaches (13), hypoesthesia (nine), scar formation
frontal sinus functionality, which is crucial in surgical (six), forehead asymmetry (four), and sinusitis (two). The
planning. Yakirevitch et al. attempted to correlate imag- two sinusitis patients were treated endoscopically, and at
ing with operative findings.4 Radiographic criteria investi- the 24-month recall there were no cases of sinusitis
gated were fracture of the sinus floor, medial aspect of reported. Taken together, these data reiterate the impor-
the anterior table, or obstruction of the sinus. In their tance of detailed radiographic evaluation of outflow tract
series of 39 patients, they found that operative findings of patency as a component of management decision making.
obstructed FSOT had at least two preoperative imaging The findings of the above studies—namely that reflex
findings consistent with obstruction. The presence of all cranialization or obliteration is not warranted, along with
three of these findings was significantly associated with increased utilization of CT imaging for operative plan-
FSOT obstruction. Of the patients with obstructed FSOT, ning—are represented in Carter et al.’s systematic review
none were amenable to sinus reconstruction. These find- of fontal sinus fractures, which focused on sinus preserva-
ings highlight the continued need for aggressive treat- tion.2 With seven articles meeting inclusion criteria for
ment in appropriate selected groups who are at high risk sinus preservation, there were 515 total patients. Three
for unsalvageable FSOT obstruction. hundred fifty patients were managed with frontal sinus
Further components of computed tomography (CT) preservation, 77 patients were obliterated, and 75 were
analysis were investigated by Torre et al. by determining cranialized. Taken in aggregate, these reviews indicate an
the impact dislocation distance of a fractured frontal sinus alternative to cranialization or obliteration in the majority
along with presence of FSOT obstruction and CSF rhinor- of fractures that do not grossly derange the FSOT
rhea.1 Fractures were defined as minimally displaced (<2 anatomy (Fig. 1).
mm), moderately displaced (2–5 mm), or severely Three articles specifically addressed the role of
displaced (>5 mm). In this series of 164 patients, FSOT endoscopic operative management. Recommended treat-
injury was found in 29.2% of patients. Of these, 43 were ment of suspected FSOT obstruction included 1) open
treated surgically, and five were observed (P < .001). Over- reduction and internal fixation of the anterior table and
all, moderately and severely displaced fractures repre- a 4-week course of antibiotics, subsequent serial CT
sented a relative indication for surgical treatment. Other scans with endoscopic unilateral extended frontal
treatment consideration included concomitant injuries sinusotomy (Draf type III) in persistent frontal sinusitis;
2) initial frontal sinusotomy or endoscopic-assisted frontal sinus fractures that involve the FSOT, which is
trephination to gain access to the frontal sinus fracture supported by the limited literature available. As such,
and FSOT; and 3) using a balloon catheter to reduce obliteration is not always indicated in frontal sinus frac-
FSOT fractures.2 tures involving the FSOT. Specifically, sequential
One of the articles reviewed above, Smith et al., increases in the number of patients managed conserva-
presented the only prospective study for management tively have not led to a concomitant increase in compli-
based on involvement of FSOT in patients with anterior cations. This suggests that conservative management is
wall frontal sinus fractures.5 Of 14 patients, seven were a reasonable treatment modality in appropriately select-
found to have CT findings of probable FSOT obstruction ed patients. Frank FSOT obstruction is a key indicator
including inferior frontal sinus fracture (n 5 6), superior for more aggressive surgical management. Even in these
orbital rim fracture (n 5 5), and anterior ethmoid or cases, postfracture repair surveillance with subsequent
naso-orbito-ethmoid (NOE) fracture (n 5 6). The anteri- endoscopic treatment of persistent disease is still an
or table was restored immediately, whereas conservative option. In all cases, individual patient characteristics,
management with 4 weeks of broad-spectrum antibiotics ability to follow-up postoperatively, and comorbidities
was implemented for treatment of suspected FSOT must be considered. Complications including meningitis
obstruction. Persistent frontal sinus disease was identi- and mucocele formation have an insidious course and
fied in two patients despite a further course of antibiot- usually result from the regrowth of sinus mucosa in
ics, and topical and systemic steroids. Both ultimately poorly managed frontal sinus fractures. Presented stud-
underwent endoscopic sinus surgery (extended endoscop- ies range from a follow-up of days to 66 months, thus
ic frontal sinusotomy and endoscopic modified Lothrop not always capturing all potential complications. Addi-
procedure). With the mean follow-up of 17.8 months and tional studies are needed to strengthen the current body
no cases of persistent frontal sinus disease, this article of knowledge; radiologic assessment of the FSOT,
indicates that with the use of endoscopic sinus surgery, type, and extent of frontal sinus fractures along with
more conservative measures and serial evaluation of treatment evolution with the use of endoscopes are key
FSOT are a possible treatment option.5 predictors of outcomes.
Other considerations that may lead to favoring
sinus preservation include the extent of concomitant
intracranial or other injuries, patient ability to tolerate LEVEL OF EVIDENCE
prolonged operative times typically needed with open The studies included one prospective cohort and
approaches, degree of pneumatization of the frontal four retrospective, randomized, controlled studies with
sinus, and risk of bone fragment devitalization and level of evidence ranging from 2a to 2b.
resorption with manipulation and mucosal stripping.
Additionally, complications in the setting of the pre- BIBLIOGRAPHY
served sinus may be more apparent on subsequent imag- 1. Torre DD, Burtscher D, Kloss-Brandstatter A, Rasse M, Kloss F. Manage-
ing or based on endoscopic exam. Taken together, these ment of frontal sinus fractures—treatment decision based on metric dislo-
cation extent. J Craniomaxillofac Surg 2014;42:1515–1519.
results highlight techniques and possible advantages of 2. Carter K, Poetker D, Rhee J. Sinus preservation management for frontal
trial of conservative or minimally invasive endoscopic sinus fractures in the endoscopic sinus era: a systematic review.
approaches to frontal sinus fracture management prior Craniomaxillofac Trauma Reconstr 2010;3:141–149.
3. Rodriguez ED, Stanwix MG, Nam AJ. Twenty-six-year experience treating
to commitment to maximal surgical intervention such as frontal sinus fractures: a novel algorithm based on anatomical fracture
an obliteration or cranialization. pattern and failure of conventional techniques. Plast Reconstr Surg
2008;122:1850–1866.
4. Yakirevitch A, Bedrin L, Alon EE, Yoffe T, Wolf M, Yahalom R. Relation
between preoperative computed tomographic criteria of injury to the
BEST PRACTICE nasofrontal outflow tract and operative findings in fractures of the frontal
Although there is no clear consensus in the litera- sinus. Br J Oral Maxillofac Surg 2013;51:799–802.
5. Smith T, Han JK, Loehrl TA, Rhee JS. Endoscopic management of the
ture regarding optimal treatment, there has been a par- frontal recess in frontal sinus fractures: a shift in the paradigm?
adigm shift toward more conservative management of Laryngoscope 2002:112:784–790.

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