JAMA Facial Plastic Surgery
Journal Club Slides:
Frontal Sinus and Naso-orbital-Ethmoid
Fractures
Pawar SS, Rhee JS. Frontal sinus and naso-orbital-ethmoid
fractures. JAMA Facial Plast Surg. Published online May 1,
2014. doi:10.1001/jamafacial.2014.14.
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Introduction
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Frontal sinus and naso-orbital-ethmoid (NOE) fractures are among the most
challenging injuries in the treatment of maxillofacial trauma.
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Goals of frontal sinus fracture treatment include minimizing early and late
complications, establishing a “safe sinus,” restoring normal frontal sinus
function, and restoring frontal contour.
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Goals of NOE fracture repair are to restore intercanthal distance, orbital
volume, dorsal support, and nasal tip projection and length.
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The primary concerns of frontal sinus and NOE fracture treatment in the
pediatric population relate to the associated intracranial injuries and
implications for growth of the facial skeleton.
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Purpose
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To summarize the current knowledge regarding frontal sinus and NOE
fractures and to present some of the recent, evidence-based literature to
support current treatment recommendations.
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Relevance to Clinical Practice
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Frontal sinus fractures account for 5% to 15% of all facial fractures and
typically result from motor vehicle crashes, assaults, and sporting injuries;
75% of patients will have serious concomitant injuries owing to the highenergy mechanisms.
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Most common complications of frontal sinus fractures include mucocele,
sinusitis, meningitis, osteomyelitis, wound infection, encephalocele,
cerebrospinal fluid (CSF) leak, chronic pain, cosmetic deformity, and death.
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Approximately 65% of patients with NOE fractures have other concomitant
facial fractures, most commonly LeFort or frontal sinus fractures.
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Description of Evidence
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A PubMed search of articles from 1990 through 2013 was performed.
Search terms included frontal sinus fracture, NOE fracture, naso-orbitoethmoid fracture, naso-ethmoid-orbital fracture, and nasoethmoid fracture.
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Description of Evidence
Treatment Algorithm for Frontal Sinus Fractures
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Description of Evidence
Classification of NOE Fractures12
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Controversies and Consensus
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Goals of frontal sinus fracture treatment include minimizing early and late
complications, establishing a “safe sinus,” restoring normal frontal sinus
function, and restoring frontal contour.
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Conservative treatment is warranted in minimally displaced or comminuted
anterior table fractures.
– Although open reduction and internal fixation (ORIF) is an option in the
acute setting, many patients go on to recover with minimal visible
deformity or concerns.
– A delayed secondary endoscopic approach can be used to camouflage
a contour defect.
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Controversies and Consensus
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Much of the controversy in treatment has to do with the posterior table and
frontal sinus outflow tract (FSOT).
– Traditional approaches have advocated for frontal sinus obliteration or
canalization for fractures of the posterior table.
– A “sinus preservation” approach should be considered for:
• Nondisplaced or minimally displaced fractures of the anterior wall.
• Nondisplaced or minimally displaced posterior wall fractures without
clinically significant intracranial injury or persistent CSF leak
(traditionally cranialized).
• Displaced anterior wall fractures with suspected FSOT involvement
(traditionally obliterated).
• Displaced anterior and minimally displaced posterior wall fractures
without significant intracranial injury or persistent CSF leak
(traditionally obliterated or cranialized).
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Controversies and Consensus
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Surgical treatment of NOE fractures is guided by the pattern of injury and
classification.
– Type I fractures: Stable fractures often do not require surgical
intervention and patients can be followed clinically. However, displaced
and/or unstable fractures will require ORIF.
– Type II or III fractures: Both patterns typically require a coronal
approach to adequately expose the NOE region. Additionally, transnasal
wiring or another canthopexy method is required to restore intercanthal
distance and position of the medial canthus.
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Comment
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There is increasing evidence supporting sinus preservation approaches in
the treatment of selected frontal sinus fractures.
– Advantages include shorter operative time with anterior table reduction,
less risk of bone fragment devitalization and resorption after the wide
exposure needed for sinus obliteration, and avoidance of removing all
sinus mucosa in extensively pneumatized frontal sinuses in the acute
setting.
– Also allows for improved surveillance on computed tomographic
imaging and endoscopic examination in the clinic.
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Conclusions
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Frontal sinus and NOE fractures present some of the most challenging
constellation of injuries within craniomaxillofacial trauma.
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Advances in imaging and minimally invasive surgical techniques are
introducing more conservative options that may provide better patient
outcomes while minimizing the risks and morbidity associated with more
traditional treatment approaches.
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Contact Information
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If you have questions, please contact the corresponding author:
– Sachin S. Pawar, MD, Division of Facial Plastic and Reconstructive
Surgery, Department of Otolaryngology and Communication Sciences,
Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI
53226 (spawar@mcw.edu).
Conflict of Interest Disclosures
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None reported.
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