2017-18 HSC Section 4 Green Book

Treatment strategies for frontal sinus anterior table fractures and contour deformities

Treatment algorithm for the management of acute frontal sinus fractures.

Figure 5

Figure 6 Surgical approaches to the frontal sinus. A) Coronal incision. B) Modified coronal incision for male-pattern baldness, where incision traverses the upper occiput. C) Endoscope-assisted brow-lift approach. D) Direct brow approach. E) Medial peri- brow stab incision to facilitate reduction and/or fixation.

Endoscopic reduction of anterior table frontal sinus fractures evolved as a natural extension of endoscopic surgery in the same region, namely endoscopic brow lift and endoscopic sinus surgery. The endoscopic brow lift approach is best suited for mild to moderately depressed simple fractures above the orbital rim. Severely comminuted fractures and fractures inferior to the orbital rim are better repaired via an open approach. 19,21,22 Sharing the same approach as an endo- scopic brow lift, two or three longitudinal incisions are placed behind the hairline in the frontal or temporoparietal scalp for introduction of a 4-mm 30 endoscope and peri- osteal elevator to expose the anterior table fracture in a subperiosteal dissection plane. Alternatively, the dissection can be transitioned from a subperiosteal plane to a supra- periosteal plane when the fragments are encountered, to keep the fragments together, thus avoiding the need to manipulate multiple loose fragments. 1 Care is taken to avoid injury to the supraorbital neurovasculature during dissection. A stab incision is then made over the fracture to allow for introduction of an elevator to assist with reduc- tion of the depressed fragment. When possible, the bony

of percutaneous screws via stab incisions, which were reduced by pulling on steel wires wrapped around the screws. Of the 15 patients, three (20%) required conversion to an open coronal approach due to the inability to achieve satisfactory closed reduction. In the appropriate candidate, close reduction of a depressed frontal sinus fracture can be fast and simple, with low risk of complication and disfigurement. This technique is best suited for simple depressed fractures of the anterior table with few fragments. The major drawback of closed reduction, however, is the inability to confidently assess for adequate reduction. Furthermore, rigid fixation is not possible through small peri-brow incisions, and if rigid fixation becomes necessary, the peri-brow incision has to be extended or another approach to the frontal sinus used. Closed reduction is not appropriate for comminuted frac- tures. When selected for the appropriate candidate, a closed reduction may greatly decrease operative time, blood loss, risk of scarring and hypoesthesia, and recovery time. With that said, patients undergoing a closed reduc- tion should always be counseled on the possibility of con- version to an open approach, should the need arise.

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