April 2020 HSC Section 4 - Plastic and Reconstructive Problems

Contemporary management of frontal sinus fractures Dedhia et al.

approaches to safely perform transnasal repairs. The senior authors (E.B.S. and T.T.T.) prefer to use the more conservative approach by offering close fol- low-up to determine if the patient desires any type of surgical intervention after all soft tissue swelling has resolved. If necessary, a camouflage technique is used as described above. Authors’ treatment algorithm For mild fractures ( 4mm), observation is recom- mended because of the low incidence of contour deformities Fig. 1. Patients are candidates for sec- ondary camouflage in the rare case where residual deformity is present after edema resolves. The risk of

esthetic deformity rises with the degree of displace- ment and is greater in moderate fractures (4–6mm). The sequelae of surgical access must be balanced with the risk of frontal contour deformity. Second- ary camouflage should be considered for moderate fractures if primary repair is not pursued. Severe fractures ( 6mm) convey a high risk of deformity and are repaired in the primary setting. FRACTURES INVOLVING THE FRONTAL SINUS OUTFLOW TRACT Frontal sinus outflow tract obstruction can lead to mucocele formation and remains a key factor in treatment strategies. Traditional management has been centered around osteoplastic flap and sinus obliteration or cranialization. Open surgeries, how- ever, have a 10–17% complication rate and do not eliminate the risk of mucocele formation because of the difficulty of removing all mucosa within the sinus [18]. Furthermore, it is difficult to identify which patients have significant FSOT obstruction as fracture patterns, radiographic findings at time of fracture, and severity of obstruction do not predict long-term outflow obstruction [5]. Therefore, there has been a shift toward observation and repeat imaging, reserving endoscopic sinus surgery for those patients with long-term obstruction [19 & ]. Advances in endoscopic frontal sinus surgery techniques, used in both the acute and delayed setting, have reduced the need for frontal sinus obliteration and cranialization [16 && ,20,21]. Smith and colleagues [20] performed a prospective study evaluating patients with combined anterior table and FSOT fractures who underwent open reduction and internal fixation of the anterior table and obser- vation of their FSOT fracture. Five of seven (71%) patients developed spontaneous ventilation of their frontal sinus on serial computed tomography and two patients, both with concomitant naso–orbito– ethmoid fractures, required endoscopic frontal sinus surgery for persistent sinus obstruction despite med- ical therapy. DeConde and colleagues [21] similarly demonstrated spontaneous ventilation of seven of eight patients (88%) with frontal sinus fractures and FSOT involvement. One patient who had persistent obstruction had concomitant naso–orbito–eth- moid fractures with prolapse of orbital soft tissue into the frontal recess. The authors suggest that sinus preservation and nonoperative management can be safe in patients without medial orbital wall fractures causing FSOT obstruction. For more severe injuries that cannot be observed, acute transnasal endoscopic repair of fron- tal sinus fractures involving the FSOT can obviate the need for large open approaches. Woodworth

FIGURE 1. Algorithm for management of anterior table frontal sinus fractures.

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