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Plastic Surgery for Frontal Sinus Fractures Workup

  • Author: Arjun S Joshi, MD; Chief Editor: Jorge I de la Torre, MD, FACS  more...
 
Updated: Jul 17, 2015
 

Imaging Studies

In the past, roentgenograms were the basis for diagnosing fractures to the frontal sinus.[2] Admittedly, the sensitivity of conventional plain films was not considered to be very high.[2] Plain films are especially poor in defining the severity of damage to the posterior table and the nasofrontal duct region.[3]

The use of high-resolution, 1.5-mm thin-cut CT scanning provides improved diagnostic power for assessing injuries to the frontal sinus and midface.[4, 5, 3, 34, 35, 36] Unfortunately, involvement of the nasofrontal duct is not clearly definable even with CT imaging; therefore, decisions regarding management of the duct and sinus are frequently made during surgical exploration. Certain findings on a CT scan image strongly suggest injury to the nasofrontal duct. A CT image that demonstrates a fracture through the base of the frontal sinus and/or the anterior ethmoid complex strongly suggests trauma to the nasofrontal duct.[3]

Some authors have proposed obtaining a 6-foot Caldwell view plain film prior to surgical intervention. The goal is to obtain an image that depicts the exact dimensions of the patient's frontal sinuses. This film is then sterilized and used as a template to mark the exact location of the frontal sinuses intraoperatively when the frontal bone is exposed. The film assists in designing a precise osteoplastic flap. Take care to ensure that the dimensions of the skull correspond exactly to the patient.

 
 
Contributor Information and Disclosures
Author

Arjun S Joshi, MD Assistant Professor of Surgery, Division of Otolaryngology–Head and Neck Surgery, George Washington University School of Medicine and Health Sciences

Arjun S Joshi, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Head and Neck Society, American Medical Association, American Thyroid Association

Disclosure: Nothing to disclose.

Coauthor(s)

Patrick Byrne, MD Associate Professor, Department of Head and Neck Surgery, Division of Facial Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine

Patrick Byrne, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Cleft Palate-Craniofacial Association, American College of Surgeons

Disclosure: Nothing to disclose.

Diego A Preciado, MD, PhD, FAAP Assistant Professor, Department of Otolaryngology, Division of Pediatric Otolaryngology, George Washington University School of Medicine, Children's National Medical Center

Diego A Preciado, MD, PhD, FAAP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, Association for Research in Otolaryngology, American Society of Pediatric Otolaryngology, American Academy of Otolaryngology-Head and Neck Surgery

Disclosure: Nothing to disclose.

Neil S Nayak George Washington University School of Medicine and Health Sciences

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Jaime R Garza, MD, DDS, FACS Consulting Staff, Private Practice

Jaime R Garza, MD, DDS, FACS is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Society for Aesthetic Plastic Surgery, American Society of Maxillofacial Surgeons, Texas Medical Association, Texas Society of Plastic Surgeons

Disclosure: Received none from Allergan for speaking and teaching; Received none from LifeCell for consulting; Received grant/research funds from GID, Inc. for other.

Chief Editor

Jorge I de la Torre, MD, FACS Professor of Surgery and Physical Medicine and Rehabilitation, Chief, Division of Plastic Surgery, Residency Program Director, University of Alabama at Birmingham School of Medicine; Director, Center for Advanced Surgical Aesthetics

Jorge I de la Torre, MD, FACS is a member of the following medical societies: American Burn Association, American College of Surgeons, American Medical Association, American Society for Laser Medicine and Surgery, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, American Society for Reconstructive Microsurgery, Association for Academic Surgery, Medical Association of the State of Alabama

Disclosure: Nothing to disclose.

Additional Contributors

James F Thornton, MD Associate Professor, Department of Plastic Surgery, University of Texas Southwestern Medical Center

Disclosure: Nothing to disclose.

Acknowledgements

Adel R Tawfilis, DDS Assistant Clinical Professor, Department of Surgery, Division of Plastic Surgery, University of California at San Diego Medical Center

Adel R Tawfilis, DDS is a member of the following medical societies: American Association of Oral and Maxillofacial Surgeons, American Dental Association, and American Society of Maxillofacial Surgeons

Disclosure: Nothing to disclose.

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CT scan showing frontal sinus fracture with comminution injury to the anterior table and supraorbital rim. However, the posterior table appears to be intact.
More superior cut of CT scan showing frontal sinus fracture with comminution injury to the anterior table and supraorbital rim. The degree of anterior table displacement was sufficient to cause significant aesthetic deformity. Although the fracture spares the base of the frontal sinus and the posterior wall, the sinuses were explored for nasofrontal duct injury. The ducts were found to be intact. The anterior table was repaired, and no obliteration was performed.
Fracture of the frontal sinus involving the anterior table and both supraorbital rims, medial to the supraorbital notch.
Lower cut of CT scan in a patient with fracture of the frontal sinus involving the anterior table and both supraorbital rims, medial to the supraorbital notch. Note the fracture extension through the base of the frontal sinus and involvement of the anterior ethmoid complex. Even though the fracture spares the posterior table, damage to the nasofrontal ducts is highly likely.
Coronal views of a CT scan in a patient with fracture of the frontal sinus involving the anterior table and both supraorbital rims, medial to the supraorbital notch. Note the injuries to the frontal recesses. Injury to the nasofrontal ducts is expected.
More anterior view of a coronal CT scan in a patient with fracture of the frontal sinus involving the anterior table and both supraorbital rims, medial to the supraorbital notch. Note associated orbital blowout fracture.
A proposed algorithm for the management of anterior table fractures. Note that in the case of a displaced anterior table fracture with involvement of the nasolacrimal duct, some have also proposed recannulation of the duct.
A proposed algorithm for the management of frontal sinus posterior table fractures. In patients with cerebrospinal fluid leak and displacement, obliteration or cranialization is usually indicated. If no cerebrospinal fluid leak is present, the fracture can be reduced and the algorithm for anterior table fractures can be followed. See Image 7.
 
 
 
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