April 2020 HSC Section 4 - Plastic and Reconstructive Problems

Contemporary management of frontal sinus fractures Dedhia et al.

patient required a revision Draf IIb because of narrowing of the sinusotomy and another patient required intravenous antibiotics for orbital cellulitis. Woodworth and colleagues challenge surgical dogma that complex frontal sinus fractures man- date open repair and suggest an expanded role of transnasal endoscopic management of frontal sinus fractures [16 && ]. The low surgical complication rate in their series demonstrates the reduced morbidity of transnasal compared to open approaches. An added advantage of the transnasal approach is the ability to address other anterior skull base sources of CSF leak, which may explain the lower persistent CSF leak rate in comparison to patients undergoing pericranial flap repair, where failure rates range from 10–17% [24]. Select posterior table fractures pose a low risk of complication and nonoperative management of these fractures can be preferred when compared to themorbidity of cranialization. In a retrospective review, Flores and colleagues [25] observed 78% ( n ¼ 46) of their posterior table fractures, including comminuted and displaced fractures with CSF leaks. During the mean follow-up of 342 days, CSF leaks resolved within 10 days (mean 4.8 days) and no sequelae of untreated fractures were encoun- tered. The investigators acknowledge that the rate of delayed complications may be underreported because of limited follow-up. Additionally, selec- tion bias plays a role in this retrospective review, where the most severe fractures may have been preferentially treated surgically. Unfortunately, there remains a paucity of data to guide surgeons on which posterior table fractures are more appro- priate for observation versus cranialization. The senior authors (E.B.S. and T.T.T.) prefer to observe posterior table CSF leaks for approximately 1 week to assess for spontaneous resolution. Endoscopic surgical repair is preferred for persistent leaks in mild to moderately sized fractures. Severe injuries with significant intracranial injury are managed with combined neurosurgical and craniomaxillofa- cial teams. Authors’ treatment algorithm Posterior table fractures are compartmentalized based on degree of displacement/comminution and presence of CSF leak Fig. 4. Severe fractures with displacement more than 4mm, severe pneumoce- phalus, significant comminution, or significant dural disruption with CSF leak should be treated with cranialization because of the risk of meningitis and mucocele formation. Mild to moderate fractures (i.e., not meeting criteria for severe fractures) can be

treated with an endoscopic approach, reconstruct- ing the posterior table and maintaining a function- ing sinus.

CONCLUSION Advances in transnasal endoscopic surgery have altered the treatment algorithms for frontal sinus fractures. There is a growing body of literature that demonstrates the safety and efficacy of nonopera- tive and minimally invasive surgical treatment of anterior table, frontal sinus outflow tract, and pos- terior table injuries. However, there is limited evi- dence to guide optimal patient selection. The most severe injuries may still require open surgical treat- ment and cranialization.

Acknowledgements None.

Financial support and sponsorship None.

Conflicts of interest There are no conflicts of interest.

REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest 1. Strong EB. Frontal sinus fractures: current concepts. Craniomaxillofac Trau- ma Reconstr 2009; 2:161–175. 2. Nahum AM. The biomechanics of maxillofacial trauma. Clin Plast Surg 1975; 2:59–64. 3. Donald PJ, Bernstein L. Compound frontal sinus injuries with intracranial penetration. Laryngoscope 1978; 88:225–232. 4. Donald PJ. Frontal sinus ablation by cranialization. Report of 21 cases. Arch Otolaryngol 1982; 108:142–146. 5. Rodriguez ED, Stanwix MG, Nam AJ, et al. Twenty-six-year experience treating frontal sinus fractures: a novel algorithm based on anatomical fracture pattern and failure of conventional techniques. Plast Reconstr Surg 2008; 122:1850–1866. 6. Kim DW, Yoon ES, Lee BI, et al. Fracture depth and delayed contour deformity in frontal sinus anterior wall fracture. J Craniofac Surg 2012; 23:991–994. 7. & Patel SA, Berens AM, Devarajan K, et al. Evaluation of a minimally disruptive treatment protocol for frontal sinus fractures. JAMA Facial Plast Surg 2017; 19:225–231. This review of prospective data collected on a minimally disruptive treatment algorithm that supports the safety of nonoperative management of frontal sinus fractures. 8. Kinzinger M, Steele TO, Chin O, Strong EB. Degree of frontal bone exposure via upper blepharoplasty incision: considerations for frontal sinus fracture. Otolaryngol Head Neck Surg 2019; 160:468–471. 9. Alinasab B, Fridman-bengtsson O, Sunnergren O, Stja¨rne P. The supratarsal approach for correction of anterior frontal bone fractures. J Craniofac Surg 2018; 29:1906–1909. 10. Hahn HM, Lee YJ, Park MC, et al. Reduction of closed frontal sinus fractures through suprabrow approach. Arch Craniofac Surg 2017; 18:230–237. 11. Kim J, Choi H. A review of subbrow approach in the management of non- complicated anterior table frontal sinus fracture. Arch Craniofac Surg 2016; 17:186–189.

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