Imaging Studies

In the past, roentgenograms were the basis for diagnosing fractures to the frontal sinus.^[3]Admittedly, the sensitivity of conventional plain films was not considered to be very high.^[3]Plain films are especially poor in defining the severity of damage to the posterior table and the nasofrontal duct region.^[4]

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.^{[5, 6, 4, 36, 37, 38, 39]}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.^[4]

A study by Gala et al indicated that maxillofacial CT scanning can more effectively reveal anterior table frontal sinus fractures than head CT scanning can. Out of 47 of these fractures, head CT scanning identified 32, compared with all 47 for maxillofacial CT scanning. With regard to posterior table frontal sinus fractures, the success rate for head CT scanning did not significantly differ from that for maxillofacial scanning.^[40]

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.

Treatment & Management

Metzinger SE, Guerra AB, Garcia RE. Frontal sinus fractures: management guidelines. Facial Plast Surg. 2005 Aug. 21(3):199-206. [QxMD MEDLINE Link].
Lofgren DH, McGuire D, Gotlib A. Frontal Sinus Fractures. StatPearls. 2023 Jan. [QxMD MEDLINE Link]. [Full Text].
May M, Ogura JH, Schramm V. Nasofrontal duct in frontal sinus fractures. Arch Otolaryngol. 1970 Dec. 92(6):534-8. [QxMD MEDLINE Link].
Harris L, Marano GD, McCorkle D. Nasofrontal duct: CT in frontal sinus trauma. Radiology. 1987 Oct. 165(1):195-8. [QxMD MEDLINE Link].
Johnson DH Jr. CT of maxillofacial trauma. Radiol Clin North Am. 1984 Mar. 22(1):131-44. [QxMD MEDLINE Link].
Schatz CJ, Becker TS. Normal CT anatomy of the paranasal sinuses. Radiol Clin North Am. 1984 Mar. 22(1):107-18. [QxMD MEDLINE Link].
Reidel. Schenk Inaug Dissertation. Jena. 1898.
Killian G. Handbuch Der Haus, Nasen, Oren, Heilkunde, Dender Und Kahler. 1904. 2:820.
Lynch RC. The technique of a radical frontal sinus operation which has given me the best results. Laryngoscope. 1921. 31:
Bergara AR, Itoiz OA. Present status of the surgical treatment of chronic frontal sinusitis. Arch Otolaryngol. 1955. 61:616-28.
Goodale RL, Montgomery WW. Experiences with the osteoplastic wall approach to the frontal sinus. Arch Otolaryngol. 1958. 68:271-83.
Goodale RL, Montgomery WW. Anterior osteoplastic frontal sinus operation: five-year experience. Ann Otol Rhinol Laryngol. 1961. 70:860-80.
Goodale RL, Montgomery WW. Technical advances in osteoplastic frontal sinusectomy. Arch Otolaryngol. 1964. 79:522-9.
Levine SB, Rowe LD, Keane WM, Atkins JP Jr. Evaluation and treatment of frontal sinus fractures. Otolaryngol Head Neck Surg. 1986 Jul. 95(1):19-22. [QxMD MEDLINE Link].
Donald PJ, Bernstein L. Compound frontal sinus injuries with intracranial penetration. Laryngoscope. 1978 Feb. 88(2 Pt 1):225-32. [QxMD MEDLINE Link].
Bordley JE, Bosley WR. Mucoceles of the frontal sinus: causes and treatment. Ann Otol Rhinol Laryngol. 1973 Sep-Oct. 82(5):696-702. [QxMD MEDLINE Link].
Garg RK, Afifi AM, Gassner J, et al. A novel classification of frontal bone fractures: the prognostic significance of vertical fracture trajectory and skull base extension. J Plast Reconstr Aesthet Surg. 2015 May. 68 (5):645-53. [QxMD MEDLINE Link].
McGraw-Wall B. Frontal sinus fractures. Facial Plast Surg. 1998. 14(1):59-66. [QxMD MEDLINE Link].
Wright DL, Hoffman HT, Hoyt DB. Frontal sinus fractures in the pediatric population. Laryngoscope. 1992 Nov. 102(11):1215-9. [QxMD MEDLINE Link].
Shockley WW, Stucker FJ Jr, Gage-White L, Antony SO. Frontal sinus fractures: some problems and some solutions. Laryngoscope. 1988 Jan. 98(1):18-22. [QxMD MEDLINE Link].
Gerbino G, Roccia F, Benech A, Caldarelli C. Analysis of 158 frontal sinus fractures: current surgical management and complications. J Craniomaxillofac Surg. 2000 Jun. 28(3):133-9. [QxMD MEDLINE Link].
Yavuzer R, Sari A, Kelly CP, et al. Management of frontal sinus fractures. Plast Reconstr Surg. 2005 May. 115(6):79e-93e; discussion 94e-95e. [QxMD MEDLINE Link].
Rohrich RJ, Hollier LH. Management of frontal sinus fractures. Changing concepts. Clin Plast Surg. 1992 Jan. 19(1):219-32. [QxMD MEDLINE Link].
Nahum AM. The biomechanics of maxillofacial trauma. Clin Plast Surg. 1975 Jan. 2(1):59-64. [QxMD MEDLINE Link].
Cormier J, Manoogian S, Bisplinghoff J, Rowson S, Santago A, McNally C. The tolerance of the frontal bone to blunt impact. J Biomech Eng. 2011 Feb. 133(2):021004. [QxMD MEDLINE Link].
Gonty AA, Marciani RD, Adornato DC. Management of frontal sinus fractures: a review of 33 cases. J Oral Maxillofac Surg. 1999 Apr. 57(4):372-9; discussion 380-1. [QxMD MEDLINE Link].
Lee TT, Ratzker PA, Galarza M, Villanueva PA. Early combined management of frontal sinus and orbital and facial fractures. J Trauma. 1998 Apr. 44(4):665-9. [QxMD MEDLINE Link].
Sakas DE, Beale DJ, Ameen AA, et al. Compound anterior cranial base fractures: classification using computerized tomography scanning as a basis for selection of patients for dural repair. J Neurosurg. 1998 Mar. 88(3):471-7. [QxMD MEDLINE Link].
Yoo A, Eun SC, Baek RM. Transcutaneous reduction of frontal sinus fracture using bony tapper device. J Craniofac Surg. 2012 Nov. 23(6):1835-7. [QxMD MEDLINE Link].
Molendijk J, van der Wal KG, Koudstaal MJ. Surgical treatment of frontal sinus fractures: the simple percutaneous reduction revised. Int J Oral Maxillofac Surg. 2012 Oct. 41(10):1192-4. [QxMD MEDLINE Link].
Patel SA, Berens AM, Devarajan K, Whipple ME, Moe KS. Evaluation of a Minimally Disruptive Treatment Protocol for Frontal Sinus Fractures. JAMA Facial Plast Surg. 2017 May 1. 19 (3):225-31. [QxMD MEDLINE Link].
Castro B, Walcott BP, Redjal N, Coumans JV, Nahed BV. Cerebrospinal fluid fistula prevention and treatment following frontal sinus fractures: a review of initial management and outcomes. Neurosurg Focus. 2012 Jun. 32(6):E1. [QxMD MEDLINE Link].
Choi M, Li Y, Shapiro SA, Havlik RJ, Flores RL. A 10-year review of frontal sinus fractures: clinical outcomes of conservative management of posterior table fractures. Plast Reconstr Surg. 2012 Aug. 130(2):399-406. [QxMD MEDLINE Link].
Koento T. Current advances in sinus preservation for the management of frontal sinus fractures. Curr Opin Otolaryngol Head Neck Surg. 2012 Aug. 20(4):274-9. [QxMD MEDLINE Link].
Ginsburg CM. Frontal sinus fractures. Pediatr Rev. 1997 Apr. 18(4):120-1. [QxMD MEDLINE Link].
Jain SA, Manchio JV, Weinzweig J. Role of the sagittal view of computed tomography in evaluation of the nasofrontal ducts in frontal sinus fractures. J Craniofac Surg. 2010 Nov. 21(6):1670-3. [QxMD MEDLINE Link].
Stanwix MG, Nam AJ, Manson PN, Mirvis S, Rodriguez ED. Critical computed tomographic diagnostic criteria for frontal sinus fractures. J Oral Maxillofac Surg. 2010 Nov. 68(11):2714-22. [QxMD MEDLINE Link].
Jarrahy R, Vo V, Goenjian HA, et al. Diagnostic accuracy of maxillofacial trauma two-dimensional and three-dimensional computed tomographic scans: comparison of oral surgeons, head and neck surgeons, plastic surgeons, and neuroradiologists. Plast Reconstr Surg. 2011 Jun. 127(6):2432-40. [QxMD MEDLINE Link].
Donald PJ. Neurosurgery: Skull Base Craniofacial Trauma. J Neurol Surg B Skull Base. 2016 Oct. 77 (5):412-8. [QxMD MEDLINE Link]. [Full Text].
Gala Z, Bai D, Halsey J, et al. Head Computed Tomography Versus Maxillofacial Computed Tomography: An Evaluation of the Efficacy of Facial Imaging in the Detection of Facial Fractures. Eplasty. 2022. 22:e22. [QxMD MEDLINE Link]. [Full Text].
Lee JC, Andrews BT, Abdollahi H, Lambi AG, Pereira CT, Bradley JP. Computed tomography image guidance for more accurate repair of anterior table frontal sinus fractures. J Craniofac Surg. 2015 Jan. 26 (1):e64-7. [QxMD MEDLINE Link].
Kim YJ, Kim HR, Jun YJ, Seo BC. Usefulness of vascularized galeal frontalis myofascial flap as treatment for postoperative infection in frontal sinus fracture. J Craniofac Surg. 2011 Sep. 22(5):1968-71. [QxMD MEDLINE Link].
Kim YH, Youn SK, Kim JT, Kim SW, Yi HJ, Kim CY. Treatment of the severely infected frontal sinus with latissimus dorsi myocutaneous free flaps. J Craniofac Surg. 2011 May. 22(3):962-6. [QxMD MEDLINE Link].
Noury M, Dunn RM, Lalikos JF, Fudem GM, Rothkopf DM. Frontal sinus repair through a frontalis rhytid approach. Ann Plast Surg. 2011 May. 66(5):457-9. [QxMD MEDLINE Link].
Massarelli O, Gobbi R, Soma D, Raho MT, Tullio A. An aesthetically possible alternative approach for craniomaxillofacial trauma: the "pretrichial incision". Craniomaxillofac Trauma Reconstr. 2011 Sep. 4(3):161-70. [QxMD MEDLINE Link].
Chen DJ, Chen CT, Chen YR, Feng GM. Endoscopically assisted repair of frontal sinus fracture. J Trauma. 2003 Aug. 55(2):378-82. [QxMD MEDLINE Link].
Strong EB, Buchalter GM, Moulthrop TH. Endoscopic repair of isolated anterior table frontal sinus fractures. Arch Facial Plast Surg. 2003 Nov-Dec. 5(6):514-21. [QxMD MEDLINE Link].
Chaaban MR, Conger B, Riley KO, Woodworth BA. Transnasal endoscopic repair of posterior table fractures. Otolaryngol Head Neck Surg. 2012 Dec. 147(6):1142-7. [QxMD MEDLINE Link].
Broer PN, Levine SM, Tanna N, Weichman KE, Hershman G, Caldroney SJ. A novel approach to frontal sinus surgery: treatment algorithm revisited. J Craniofac Surg. 2013 May. 24(3):992-5. [QxMD MEDLINE Link].
Kim DW, Yoon ES, Lee BI, Dhong ES, Park SH. Fracture depth and delayed contour deformity in frontal sinus anterior wall fracture. J Craniofac Surg. 2012 Jul. 23(4):991-4. [QxMD MEDLINE Link].
Muderris T, Bercin S, Sevil E, Kiris M. Management of frontal sinus fracture: reconstruction of the sinus with iliac bone graft. J Craniofac Surg. 2013 Mar. 24(2):e194-5. [QxMD MEDLINE Link].
Luce EA. Frontal sinus fractures: guidelines to management. Plast Reconstr Surg. 1987 Oct. 80(4):500-10. [QxMD MEDLINE Link].
Koento T. Current advances in sinus preservation for the management of frontal sinus fractures. Curr Opin Otolaryngol Head Neck Surg. 2012 Aug. 20(4):274-9. [QxMD MEDLINE Link].
Phang SY, Whitehouse K, Lee L, Khalil H, McArdle P, Whitfield PC. Management of CSF leak in base of skull fractures in adults. Br J Neurosurg. 2016 Dec. 30 (6):596-604. [QxMD MEDLINE Link].
de Melo WM, Colete JZ, Mariano RC, Shinohara EH, Souza FA, Garcia IR Jr. Anterior pericranial flap for frontal sinus duct obliteration: is it a valuable resource?. J Craniofac Surg. 2013 Mar. 24(2):e147-9. [QxMD MEDLINE Link].
Morais de Melo W, Koogi Sonoda C, Garcia IR Jr. Vascular pericranial graft: a viable resource for frontal sinus obliteration. J Craniofac Surg. 2013 Jan. 24(1):e5-7. [QxMD MEDLINE Link].
Kim YH, Youn SK, Kim JT, Kim SW, Yi HJ, Kim CY. Treatment of the severely infected frontal sinus with latissimus dorsi myocutaneous free flaps. J Craniofac Surg. 2011 May. 22(3):962-6. [QxMD MEDLINE Link].
Heckler FR. Discussion of frontal sinus fractures. Guidelines to Management of Plastic Reconstructive Surgery. 1987. 80:509-20.
Pollock RA, Hill JL Jr, Davenport DL, Snow DC, Vasconez HC. Cranialization in a cohort of 154 consecutive patients with frontal sinus fractures (1987-2007) review and update of a compelling procedure in the selected patient. Ann Plast Surg. 2013 Jul. 71(1):54-9. [QxMD MEDLINE Link].
Stanley RB Jr. Fractures of the frontal sinus. Clin Plast Surg. 1989 Jan. 16(1):115-23. [QxMD MEDLINE Link].
Ioannides C, Freihofer HP, Vrieus J, Friens J. Fractures of the frontal sinus: a rationale of treatment. Br J Plast Surg. 1993 Apr. 46(3):208-14. [QxMD MEDLINE Link].
Thaller SR, Donald P. The use of pericranial flaps in frontal sinus fractures. Ann Plast Surg. 1994 Mar. 32(3):284-7. [QxMD MEDLINE Link].
Donald PJ. The tenacity of the frontal sinus mucosa. Otolaryngol Head Neck Surg. 1979 Sep-Oct. 87(5):557-66. [QxMD MEDLINE Link].
Bui TG, Bell RB, Dierks EJ. Technological advances in the treatment of facial trauma. Atlas Oral Maxillofac Surg Clin North Am. 2012 Mar. 20(1):81-94. [QxMD MEDLINE Link].
Hwang K, Song YB. Closed reduction of fractured anterior wall of the frontal bone. J Craniofac Surg. 2005 Jan. 16(1):120-2. [QxMD MEDLINE Link].
Tiwari P, Higuera S, Thornton J, Hollier LH. The management of frontal sinus fractures. J Oral Maxillofac Surg. 2005 Sep. 63(9):1354-60. [QxMD MEDLINE Link].
Whatley WS, Allison DW, Chandra RK, Thompson JW, Boop FA. Frontal sinus fractures in children. Laryngoscope. 2005 Oct. 115(10):1741-5. [QxMD MEDLINE Link].

Media Gallery

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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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)

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

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.

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.

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.