Abstract
Frontal sinus fractures are common fractures in high-energetic trauma. Different treatments options are available for different types of frontal sinus fractures. A fracture that consists only of the anterior wall is most commonly reduced with the coronal approach. This approach is invasive and produces a large scar on the scalp, which can result in an unfavourable situation in patients with alopecia and in balding men. To avoid this, a percutaneous reduction method can be used to treat patients with simple anterior wall fractures. This approach is less invasive and does not result in a conspicuous scar. The disadvantages of this procedure are the absence of direct vision and less control of the fracture, which can reduce the chances of complete reduction. This paper provides an overview of anterior wall fractures of the frontal sinus and elaborates on the simple percutaneous reduction technique.
A frontal sinus fracture (FSF) is a common injury in patients who suffered high-energetic trauma. Motor vehicle accidents (MVA) and personal violence account for the majority of FSFs. Other etiological factors are industrial and recreational accidents. The FSF accounts for 5–15% of all fractures of the maxillofacial area and is often associated with neurological and orbital injuries, and other facial fractures, such as naso-orbito-ethmoidal, zygomatic, and maxillary.
The frontal sinus is located in the frontal bone and lies between the naso-orbito-ethmoid region and the anterior cranial fossa. The complex anatomy of the frontal sinus consists of the anterior, posterior wall and the nasofrontal duct (NFD), and has a close relationship with the orbit, nose and the neurocranium. This intricate anatomy stresses the importance of multidisciplinary management of fractures in this area.
Patients with a frontal sinus fracture often have multiple trauma and involvement of the brain is not uncommon. It has been suggested that 86.7% of the patients with a fracture of both the anterior and the posterior wall have intracranial injuries, such as haemorrhages and cerebral contusions, which can be life-threatening and require fast and effective management. Pain is a common symptom in conscious patients with a frontal sinus fracture. Lacerations are seen in half of the patients and about 25% of patients have a visible depression of the forehead. Other possible symptoms are epistaxis, problems with vision, oedema and paresthesia of the area innervated by the supraorbital nerves. Leakage of cerebrospinal fluid, due to damage of the dura, is a common finding. Computed tomography (CT) is the gold standard in diagnosing the degree of involvement of the different anatomical structures that constitute the frontal sinus.
Several classifications of FSFs have been proposed. Most are based on the anatomical location of the fracture, in combination with intraoperative findings. The most important components of the classification system are involvement of the anterior and posterior wall, and the NFD. Often, dural involvement, leakage of cerebrospinal fluid, and the presence of brain trauma, are added to the classification.
The most common fracture is the isolated anterior wall fracture, followed by the combined fracture of both anterior and posterior wall. The true isolated fracture of the posterior wall has seldom been reported. The choice of treatment for FSFs depends on the involvement of the anterior or posterior wall of the sinus, and involvement of the NFD.
The main problem with an isolated fracture of the anterior wall, is the aesthetics of the contours of the forehead and orbital rim. The treatment for this fracture can be conservative if the natural anatomical contours are intact. In case of large dislocation, reduction is indicated. In the presence of lacerations, the reduction can be done through the skin. If there are no lacerations, the most accepted method is the coronal approach. This approach provides a wide exposure but often leaves a visible scar, especially when the hair is wet and in balding males. Fixation of the fracture is done with mini- or microplates.
The technique described in this paper, is indicated for anterior wall fractures that are not extensively communitive. It was first described in 1979 by McGrath and Smith. They placed stainless wires through the periosteum and stabilised them with an external device. A report by Kim et al. demonstrated the use of a transcutaneous transfrontal approach through a small peri-eyebrow skin incision. Piccolino and colleagues used a burr with a calibrated rotating drill to make two small holes in the bone fragments, which allowed for two pins to be placed, in order to reduce the fracture. A case-report by Mavili and Canter described a case in which three screws were placed percutaneously, surgical steel wire was tied around the head of the screws and controlled traction was applied to the screws in the preoperative planned direction. The authors have adjusted their techniques slightly and will discuss this in the next section.
If the NFD is also damaged, management should be focused on guaranteeing sufficient ventilation of the sinus, for compromised ventilation can lead to functional loss of the sinus and mucocele formation. When the posterior wall is involved, screening should be done for ruptures of the dura and cerebrospinal fluid leakage.
An upcoming technique is minimal invasive endoscopic reduction of the fracture. Disadvantages of this procedure are that only simple fractures can be reduced, lateral fractures are hard to reach and the fixation of screws is more challenging than with the open coronal approach. This procedure also takes time to master.
Simple percutaneous reduction
Of the frontal sinus fractures, only anterior wall fractures with depression can be reduced with the percutaneous reduction technique. The fracture should not be too comminuted, and consist of only 2–3 large bony fragments. If it is a complex fracture with many small fragments, it is difficult to reduce it successfully. Ideally, the procedure is performed in the acute stage or within a week. The chances of reducing it properly decrease after that time, as a result of resorption of the edges of the bony segments. A screw must be placed in the bony fragment, which is impossible with very small or thin fragments.
All patients with a simple fracture of the anterior wall of the frontal sinus are eligible for the technique, but it may be especially indicated in patients with alopecia and in balding males. What to do if the reduction is inadequate should be discussed with the patient before surgery. The patient is given the option to stop the procedure at that point or to convert to an open approach.
Surgical technique
The procedure is carried out under general anaesthesia with the patient in the supine position. General disinfection and draping should be performed, leaving the whole forehead and eye in the field of vision of the surgeon. Local anaesthesia should not be used as the extra fluid makes orientation more difficult. Using palpation and the CT scan the bony fragments are localised and marked. Stab incisions are made and burr holes are placed in the bony fragments followed by the placement of 2.0 mm screws ( Fig. 1 ). Size 1.5 mm screws can be used, but provide less fixation for traction and are at increased risk of coming loose during the traction. Forceps are placed on all screws and manual traction is administered on all screws at the same time in the appropriate direction in order to reduce the fracture ( Fig. 2 ). Following proper reduction the screws are removed and the stab incisions sutured using 5.0 ethylon.
