April 2020 HSC Section 4 - Plastic and Reconstructive Problems

Contemporary management of frontal sinus fractures Dedhia et al.

POSTERIOR TABLE Fractures of the frontal sinus posterior table can result in mucoceles, CSF leaks, and intracranial infection. Although there are no universally accepted criteria for surgical repair, most authors believe that surgical intervention should be based on the degree of fracture displacement and presence of a CSF leak. Some authors have suggested that fractures with displacement greater than one table width or 2mm should be managed surgically [23]. However, there is a lack of prospective data, and these are the opinions of experienced surgeons based on personal experience. Historically, fractures involving the posterior table were explored and treated with obliteration or cranialization (e.g., persistent CSF leak, muco- cele, or intracranial infection) [3,4]. However, open surgical approaches to the frontal sinus are

Table 1. Draf’s classification of frontal sinus procedures

Frontal sinus procedure

Definition

Draf I

Removal of uncinate process with preservation of agger nasi cell

Draf IIa Draf IIb

Removal of all frontal recess cells

Draf IIa with removal of the floor of the frontal recess Bilateral Draf IIb with removal of the intersinus septum

Draf III

patency of the FSOT. Patients with severe FSOT fractures should be treated in the acute setting because the risk of obstruction and mucocele forma- tion is high. The authors prefer an endoscopic approach when possible.

FIGURE 3. A 14-year-old girl suffered frontal sinus fractures involving the anterior table, posterior table with CSF leak, and frontal sinus outflow tract. She underwent an osteoplastic flap approach through a preexisting forehead laceration to reduce the posterior table and repair the CSF leak with a free mucosal flap and dural sealant. A Draf III frontal sinusotomy for treatment of the frontal sinus outflow tract. Preoperative axial CT scans demonstrate a (a) comminuted and displaced anterior and posterior table fracture as well as a (b) frontal sinus outflow tract fracture and soft tissue and bony debris within the tract. Postoperative axial CT scans 8 months after surgery demonstrate (c) reduced anterior and posterior table fractures and a (d) patent Draf III frontal sinusotomy. (e) Endoscopic view of healed Draf III frontal sinusotomy 8 months after surgery. CSF cerebrospinal fluid, CT, computed tomography.

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