April 2020 HSC Section 4 - Plastic and Reconstructive Problems

Reprinted by permission of Curr Opin Otolaryngol Head Neck Surg. 2019; 27(4):253-260.

C URRENT O PINION

Contemporary management of frontal sinus fractures

Raj D. Dedhia, Megan V. Morisada, Travis T. Tollefson, and E. Bradley Strong

Purpose of review Frontal sinus fracture management is evolving. This article will highlight recent literature and provide an evidence-based algorithm in the contemporary management of frontal sinus fractures. Recent findings The role of transnasal endoscopic treatment of frontal sinus fractures has expanded to include fracture reduction and posterior table reconstruction. Evidence continues to support the safety of nonoperative management in select frontal sinus outflow tract fractures. Summary The management of frontal sinus fractures with frontal sinus outflow tract injury continues to evolve with a trend toward observation and minimally invasive approaches. Restoration of the frontal sinus outflow tracts with transnasal endoscopic techniques is being used increasingly in the acute and delayed setting. For severe fractures, the role of conservative treatment paradigms requires further research. Keywords anterior table, cerebral spinal fluid leak, endoscopic sinus surgery, facial fractures, frontal sinus fracture, frontal sinus outflow tract, maxillofacial trauma, treatment algorithm

INTRODUCTION Frontal sinus fractures account for 5–15% of facial fractures, among which approximately 1/3 is iso- lated to the anterior table and 2/3 are a combination of anterior table, frontal recess, and posterior table [1]. Isolated posterior table fractures are rare. The thick cortical bone of the anterior table of the frontal sinus is more resistant to fracture than any other facial bone [2]. Fractures of the frontal sinus, there- fore, require significant force and are associated with high-energy trauma. The goals in management of frontal sinus frac- ture include restoration of forehead contour, reestab- lishment of a safe and functional sinuswhenpossible, protection of intracranial contents, and prevention of associated sequelae. Improperly treated fractures can result in chronic sinusitis, forehead deformity, mucocele, mucopyocele, meningitis, cerebrospinal fluid (CSF) leak, meningitis, and brain abscess [3,4]. The ideal management strategy for frontal sinus fractures is controversial [5]. Complications and adverse sequelae of treated and untreated frontal sinus fractures can present in a delayed fashion, adding uncertainty to the best management. We will review the recent frontal sinus fracture literature including management of anterior and posterior

table fractures, nasofrontal outflow tract obstruc- tion, and CSF leaks. We will also present the senior author’s evidence-based treatment algorithm.

ANTERIOR TABLE FRACTURES The risk of mucocele formation with isolated ante- rior table fractures is low; however, esthetic defor- mities can occur if larger fractures are left untreated. The decision for surgical management must weigh the risk of an esthetic deformity (if left untreated), with the potential for iatrogenic deformity during surgery. We present the evidence for conservative management of these injuries, reserving surgical reduction for more severe cases. Department of Otolaryngology – Head and Neck Surgery, University of California, Davis, Sacramento, California, USA Correspondence to E. Bradley Strong, MD, Department of Otolaryngol- ogy – Head and Neck Surgery, University of California Davis, 2521 Stockton Blvd., Suite 7200, Sacramento, CA 95817, USA. Tel: +1916 734 2801; fax: +1916 703 5011; e-mail: ebstrong@ucdavis.edu Curr Opin Otolaryngol Head Neck Surg 2019, 27:253–260 DOI:10.1097/MOO.0000000000000546

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