April 2020 HSC Section 4 - Plastic and Reconstructive Problems

Facial plastic surgery

and colleagues [16 && ] performed Draf IIa, IIb, or III frontal sinusotomies in 46 patients to treat anterior and posterior table fractures. Only one patient (2%) required a revision Draf IIB frontal sinusotomy to maintain normal sinus function and drainage. Because of the success rate for maintaining a patent frontal sinus outflow tract after Draft IIb and III techniques, the risk of frontal sinus obstruction is lower than mucocele rates after obliteration or cra- nialization. The authors thereby challenge the notion that obliteration and cranialization reduce infectious complications in frontal sinus fractures with FSOT obstruction [16 && ]. As these conservative and minimally invasive approaches continue to gain traction, additional studies with long-term follow-up are required to determine fracture characteristics suitable for endo- scopic approaches and their true complication rates. In severe fractures with significant disruption of the FSOT, obliteration and cranializationmay be the only viable treatment. Rodriguez and colleagues’ [5] land- mark study of 857 patientswith frontal sinus fractures demonstrated a higher percentage of complications secondary to sinus obstruction in patients with FSOT obstruction managed with observation (63% of all complications in the observation group) versus those managedwithobliteration or cranialization (9%of all complications in the surgery group). It should be noted that the overall complication rate under each treatment was comparable (observation 8.4%, oblit- eration 8.9%, and cranialization 8.4%), underscoring the importance of balancing complications from untreated fractures with surgical complications when determining the best treatment. Cranialization has a limited, but necessary role in treatment of the most severe frontal sinus fractures that include posterior table and FSOT obstruction. Chegini and colleagues [22] report a lower complica- tion rate in patients treated with cranialization (4%, n ¼ 4) compared to patients who met criteria for cranialization but were observed because of comor- bid injuries or medical conditions (37.5%, n ¼ 3). Although their study demonstrated that cranializa- tion is a safe procedure and reduces complications in patients with FSOT obstruction or displaced posterior table fractures, it was subject to selection bias as the severity of fracture and comorbid conditions in the observation group may have contributed to the higher complication rate. The management of frontal sinus fractures with FSOT involvement continues to evolve with a trend toward observation and minimally invasive approaches. The senior authors (EBS and TTT) prefer to observe an increasing number of patients, while relying on transnasal endoscopic techniques to address the FSOT in the acute and delayed setting.

For the most severe fractures with posterior table involvement and CSF leak, cranialization remains the preferred option, but is an active area of research. Author’s treatment algorithm Fractures involving the FSOT are divided into mild- to-moderate displacement/comminution where the FSOT lumen may be narrowed but remains patent and severe displacement/comminution where there is complete obstruction of the FSOT Fig. 2. Mild to moderate FSOT fractures can be managed with observation and serial computed tomography scans. If the patient is asymptomatic with spontaneous ventilation of the sinus, then continued observation is appropriate. If patients become symptomatic or has sinus opacification, then transnasal endoscopic frontal sinusotomy is performed to reestablish

FIGURE 2. Algorithm for management of frontal sinus outflow tract fractures.

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Volume 27 Number 4 August 2019

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