Spiros Manolidis, M.D. Larry H. Hollier, Jr., M.D. New York, N.Y.; and Houston, Texas Summary: Frontal sinus fractures are relatively uncommon maxillofacial inju- ries, making up only 5 to 12 percent of all facial fractures. Associated intracra- nial, ophthalmologic, and other maxillofacial injuries are very common because of the force of injury required to fracture the frontal bone. High-resolution computed tomography of the frontal region in multiple planes is essential for predicting the degree of frontal injury, associated injuries, and the type of proce- dure indicated. Exploration of the frontal sinus with reduction alone is reserved for a small minority of very simple fractures. Most frontal sinus fractures will require the obliteration of the sinus. This is achieved in the majority of instances with preser- vation of the posterior wall. Those with more extensive injuries and the presence of a cerebrospinal fluid leak will require frontal sinus cranialization after repair of the dural injuries. In rare instances, primary bone grafts will be required. In both cranialization and obliteration procedures, the nasofrontal ducts must be managed appropriately to avoid complications. Newer techniques involving endoscopic im- age-guidedsurgery may offer analternative for a small subset of patients withfrontal sinus injury. (Plast. Reconstr. Surg. 120 (Suppl. 2): 32S, 2007.) F rontal sinus fractures account for 5 to 15 percent of all maxillofacial fractures. 1,2 As- saults and vehicular trauma account for the majority of frontal sinus injuries. Frontal sinus frac- tures have been associated with severe maxillofacial and systemic injuries, with a high rate of morbidity and mortality. 3,4 The management of frontal sinus injury is an important topic, as inappropriate man- agement of these injuries not only leads to cosmetic deformities and functional problems but may give rise to serious complications, including the devel- opment of mucoceles, osteomyelitis, and potentially fatal central nervous system complications such as meningitis and brain abscesses. 1,5,6 Several aspects of frontal sinus injury treatment remain controversial secondary to the relatively small numbers of patients reviewed in the literature andthedifficulty inmaintaininglong-termfollow-up in these patients. 6 Areas of controversy include the roles of frontal sinus obliteration, cranialization, and nasofrontal duct stenting in the acute trauma setting. 7 BIOMECHANICS The frontal bone is the strongest component of the craniofacial skeleton. It can withstand be- tween 800 and 2200 pounds of force before fracturing. 8 In an average size adult human, these forces can be reached with a frontal collision at 30 mph for an unrestrained passenger. 9,10 Because of its projectionandthe large surface area it occupies relative to the rest of the facial skeleton, the frontal region is frequently the first site of exposure in both vehicular and assault injuries. The anterior table of the frontal sinus is the stronger component of the two bone tables of the frontal sinus because of its overall thickness, es- pecially along the supraorbital buttress. The pos- terior table is thinner and is not part of this but- tress system. The dura is densely adherent to the deep surface of the posterior table. The dura be- comes thinner and more adherent along the cau- dal edge, where it turns to cover the roof of the ethmoid air cells (fovea ethmoidalis). When sig- nificant fractures of the frontal bone occur, these propagate easily and extensively along the orbital and nasoethmoid complexes, which have signifi- cantly weaker tolerances. 9,10 Injuring forces capa- From the Department of OtolaryngologyHead and Neck Sur- gery, Beth Israel Hospital, and Baylor College of Medicine and Department of Plastic Surgery, Ben Taub General Hospital. Received for publication May 8, 2006; accepted January 18, 2007. Copyright 2007 by the American Society of Plastic Surgeons DOI: 10.1097/01.prs.0000260732.58496.1b Disclosures: Neither of the authors has received funds or support or has a financial interest in any of the products, devices, or drugs mentioned in this article. Dr. Manolidis lectures as part of the faculty for the North American AO-ASIF group and for that, in the past, has received stipends for attend- ing/lecturing at their educational conferences. www.PRSJournal.com 32S ble of disrupting the anterior table will frequently involve the posterior table and the elements of the floor of the anterior cranial fossa: the fovea eth- moidalis and cribriform plate. Injuring forces capa- ble of disrupting the anterior table will frequently involve the posterior table and the elements of the floor of the anterior cranial fossa: the fovea eth- moidalis andcribriformplate. This leads to the com- monintraoperative finding of comminutedanterior table with posterior table fractures and associated dural tears capable of producing cerebrospinal fluid leaks. The nasofrontal duct opening usually lies in the posteromedial floor of the sinus and runs cau- dally to the anterior middle meatus. Significant anatomical variations exist in the width, length, and shape of the nasofrontal duct. 7 These ana- tomical variations make it difficult to predict with accuracy the future functioning of the nasofrontal duct in the face of frontal sinus injury. In addition, forces that are capable of fractur- ing the supraorbital buttress will frequently cause comminuted, displaced fractures of the superior orbital rim that typically involve the frontonasal duct. These fractures are associated with a dispro- portionate number of ocular injuries and other orbital injuries withlong-termeffects onvision. 11,12 Occasionally, fractures of the frontal region will extend to the skull base beyond the anterior cra- nial fossa into the middle cranial fossa fractures that course throughthe foramina of the skull base. In severe injuries, attention should be given to the temporal bone, as these fractures canextendthrough the temporal bone with severe consequences for both hearing and facial nerve function, and with the potential for a cerebrospinal fluid leak through the temporal bone. 2,13 Occasionally, forces will be transmitted through the anterior table, without its fracturing, to struc- tures posterior to it. Such patterns of injury account for isolated nasofrontal duct injuries, with subse- quent frontal sinus complications if left untreated. 14,15 Rarely, suchforces canbetransmittedmoreposteriorly toinvolvetheopticcanal or thesuperior orbital fissure, causing visual loss and/or superior orbital fissure syn- drome, respectively 1618 (Fig. 1). The geometry of the impact is also a significant factor in frontal sinus fractures. Sharp objects that impart much greater force in a smaller surface area and blunt heavy objects that transfer larger amounts of energy will cause increasing amounts of trauma, such as that commonly seen in assault. Gunshot injuries, especially high velocity, and in- dustrial accidents will invariably fracture both an- terior and posterior tables of the frontal sinus and breach the anterior cranial fossa. Under these cir- cumstances, posterior table fractures are invari- ably associated with dural tears and fractures ex- tending to the anterior cranial base to involve the cribriform plate and fovea ethmoidalis. ANATOMY AND EMBRYOLOGY The frontal sinus is in critical approximation to anatomical structures, which underscores the importance of its management in injury. Posteri- orly, the cribriform plate, dura mater, and frontal lobes are in close apposition to one another and to the posterior wall of the sinus. The dura is densely adherent to the deep surface of the pos- terior table and becomes more adherent and thin- ner along the caudal edge, where it turns to cover the fovea ethmoidalis. The frontal sinus develops starting at infancy from the middle meatus, with continuous growing through early adulthood, attaining an average vol- ume of 5 cm 3 . The frontal sinuses are absent at birth and do not begin to develop until the second year of life. 19 The frontal sinus itself cannot be identified radiographically until approximately the age of 8 years, and it does not reach adult size until age 12 years or older. In 10 percent of persons, the frontal sinus develops unilaterally, in 5 percent it is a rudi- mentary structure, and in 4 percent it is absent al- together, so that almost one-fifth of individuals have aberrant sinus development. 20 The frontal sinuses develop from the ethmoid infundibular air cells by invagination of the frontal bone throughthe frontal recess or fromthe superior meatus 21 (Fig. 2). The size of the adult frontal sinus shows exceptional variability in the degree of pneu- matization. Sinus pneumatization begins from the Fig. 1. Fractures involvingthesuperior orbital ssureandopticca- nal region(left side) andthe lateral orbital wall posteriorly at the re- gionof thesuperior orbital ssure(right side). Thispatient presented with minimal frontal sinus trauma and bilateral loss of vision. Volume 120, Number 7 Suppl. 2 Frontal Sinus Fractures 33S nasal part of the frontal bone by several ethmoid air cells at once, which are termed frontal bullae. This multiplicity of pneumatization results in variability and tortuosity of the frontal sinus drainage pathway (nasofrontal duct). An intersinus septum separates the two sides. The frontal sinus may consist of one or more com- partments, depending on the source of pneuma- tization. The intersinus septum, which separates these compartments, is continuous with the crista galli inferiorly, whereas its superior attachment to the sinus walls is frequently asymmetrical. When this septum is asymmetrical, the crista galli shows varying degrees of pneumatization and protrusion within the sinus. In this situation, a surgical risk exists for entering the anterior cranial fossa at the cribriform plate (olfactory groove) if this area is mistaken for the posterior wall of the frontal sinus (Fig. 3). The lateral floor of the frontal sinus is the roof of the orbit, whereas the medial floor of the frontal sinus contains the opening of the nasofrontal duct. 7 The nasofrontal duct is the exclusive drain- age of the frontal sinus and thus of utmost clinical significance in the management of frontal sinus injury. Its course is highly variable, running cau- dally from a few millimeters to up to 2 cm. 22 A true identifiable duct may be absent inup to 85 percent of frontal sinuses. In this situation, the frontal sinus drains indirectly throughethmoid air cells to the middle meatus 7 (Fig. 4). The nasofrontal duct terminates at the unci- nate process in the nasal cavity, which is a thin bone plate that is covered on either side by mu- cosa. On computed tomographic scans, the infe- rior portion of the uncinate process is mostly vis- ible, whereas the superior portion of the uncinate Fig. 2. Development of thefrontal sinusthroughinvaginationof the frontal bone by ethmoidal air cells. Fig. 3. Variations inthedepth(relativedownwarddisplacement of thecribriformplate) is relatedtothelocationof the fovea ethmoidalis, that is, the pneumatization of the ethmoid air cells. In this gure, the fovea ethmoidalis is the intra- cranial surface that overlies the ethmoid air cell labyrinth. Plastic and Reconstructive Surgery December Supplement 2, 2007 34S process cannot be identified in up to 40 percent of cases. 23 There are twoidentifiable patterns of drainage of the frontal sinus. When the uncinate process is attached to the lamina papyracea, the drainage is medial to the uncinate process through the mid- dle meatus. This type of drainage pattern is seen in 66 to 88 percent of cases. 20,24 When the uncinate process attaches superiorly to more medial struc- tures (middle turbinate, cribriform, or skull base), the drainage of the sinus is lateral to the uncinate process. This type of drainage pattern is seen in 12 to 34 percent of cases. 24,25 A significant feature of the frontal sinus is the mucosal lining, which is contiguous with that of the ethmoid air cells and nasofrontal ducts. The mucosal lining of the frontal sinus consists of ciliated columnar epithelium. The cilia of these cells are bathed by a proteinaceous solution (mucus). Through ciliary motion, this mucous layer moves in a clockwise fashion to- ward the nasofrontal duct, from where it is ul- timately expelled into the hiatus semilunaris and then nasal cavity (Fig. 5). The frontal sinus is unique in that it is the only sinus that has a recirculation phenomenon. The mucus travels along the lateral side of the sinus and turns medially over the sinus floor and down the lateral frontal recess wall. Of the secretion, 60 percent is directed back into the sinus cavity as it reaches the frontal recess. 26 Mucus is produced by goblet cells interspersed in the ciliated mucosa of the frontal sinus. Clinically significant anatomical structures of the mucosa of the frontal sinus are the foramina of Breschet, first described over 60 years ago. 27 These foramina are sites of venous drainage of the mucosa andcanserve as the route of intracranial spread of infection. 3 The mucosais founddeeply invaginatingtheseforamina. If mucosa is not completely removed microscopi- cally from these foramina in obliteration or crani- alizationprocedures, there is a highriskof mucocele formation. 2831 CLASSIFICATION OF INJURIES Numerous classificationschemes of frontal sinus fractures have been described. The lack of unifor- mity intreatment andsmall numbers of suchinjuries have contributed to this situation. Most classifica- tions are based on anatomical location and obser- vations of intraoperativefindings incomparisonwith preoperative evaluations by high-resolution com- puted tomography. 1,32,33 Early work by Manson and others derived classification schemes of frontal and midface injuries basedonthese principles that are in wide use today. 3436 Elaborate classification schemes with multiple subdivisions do not add significantly in the manage- ment of frontal sinus injuries, as the operative op- tions are limited. 37 Most authors agree that three components related to the frontal sinus must be taken into account: the anterior table, the posterior table, and the nasofrontal duct. 1,7,15,33,38 In addition, injury to the dura, presence of cerebrospinal fluid leak, and open cerebral trauma, most frequently associated with tissue loss, must be taken into ac- count ina classificationof frontal sinus injury. Three further observations cansimplify the classificationof frontal injuries: (1) isolated posterior table fractures are rare entities of questionable significance; (2) involvement of the anterior and posterior tables in- Fig. 4. Sagittal transparency viewof thenasofrontal duct andits relation to the ethmoidal labyrinth. Drainage is through the hia- tus semilunaris underneath the middle turbinate. Fig. 5. Mucociliaryowof thefrontal sinus, invaginations of mu- cosa into the bone at the foramina of Breschet. Volume 120, Number 7 Suppl. 2 Frontal Sinus Fractures 35S variably leads to frontonasal duct injury; and (3) involvement of the nasoethmoid complex and me- dial orbital riminthe fracture patternalsoinvariably leads to frontonasal duct injury. 32,33 A classification scheme that might include these principles would appear similar to that presented in Figure 6. ASSOCIATED INJURIES Ocular Injuries Ophthalmologic injury is seen in as many as 25 percent of those with frontal sinus injuries. The range of these ophthalmologic problems in these Fig. 6. Classication of frontal sinus injuries: type 1, linear, minimally displaced fractures of the outer wall; type 2, comminuted or depressed anterior table fractures (may or may not involve the nasofrontal duct); type 3, bothanterior andposterior frontal sinus walls involved by comminuted fractures; type 4, comminuted anterior and posterior wall fractures with dural injury and potential cerebrospinal uid leak; and type 5, comminuted anterior and posterior wall fractures withdural injury andpotential cerebrospinal uidleak inadditionto tissue and/or bone loss. (Reprinted with permission from Semin. Plast. Surg. 16: 2002.) Plastic and Reconstructive Surgery December Supplement 2, 2007 36S patients is wide. The most common abnormal finding, in up to 10 percent of those with a frontal sinus fracture, is an afferent pupillary defect sec- ondary to optic nerve involvement (Fig. 1). Such optic nerve involvement must be assessed carefully by high-resolution computed tomography. The management of optic nerve involvement by high- dose steroids versus optic nerve decompression is controversial. The treatment of optic nerve in- volvement supersedes the correction of frontal sinus fractures with the exception of central ner- vous system injury requiring acute management, severe soft-tissue loss, and/or exposure of brain parenchyma. Involvement of the superior orbital rim and/or orbital roof will increase the chance of ocular injury to 25 percent. 11,39 The most significant of these in- juries, open globe or globe rupture, though rarely seen, is usually a devastating injury that results in visual loss. In this situation, concurrent enucleation must be considered along with preparation of the anophthalmic socket for an ocular implant. Lesser degrees of injury, such as hyphema, retinal detach- ments, andcorneal lacerations, shouldbe diagnosed and treated before surgical intervention for the cor- rection of frontal sinus injuries. Particular attention should be given to factors that might result in cor- neal exposure: facial paralysis froma temporal bone injury or other injury to the facial nerve. Lid lacer- ations should be repaired primarily as early as pos- sible. A complete ophthalmologic examination should be carried out as soon as feasible and visual acuity tests should be performed as soon as the pa- tient is awake and cooperative. Neurologic Injuries Over half of the patients with frontal sinus fractures present with some form of neurologic injury, and these span a wide range. 1,7,15,33,38,40 The majority of patients who sustain a frontal sinus fracture will have experienced loss of conscious- ness. Closed head injury with evidence of cerebral contusion by computed tomography and/or mag- netic resonance imaging is very common. Sub- dural and epidural hematomas requiring imme- diate neurosurgical intervention occur in 10 percent of patients. 1 Open cerebral injuries are seen in the most severe form of frontal sinus frac- tures and are found in 2.5 to 13 percent of these patients. 1,40,41 Depressed skull fractures other than those of the frontal bone are also a common fea- ture in severe motor vehicleassociated frontal si- nus fractures. 3 A worrisome aspect of frontal sinus fractures is the presence of a cerebrospinal fluid leak on presentation or on exploration. Up to one-third of patients with frontal sinus fractures will present with a cerebrospinal fluid leak. 7,30,38,42 This may be the result of injury to the posterior wall and subsequent disruption of the attached dura and/or the result of a disruption of the an- terior cranial fossa floor at the level of the cribri- form plate or the fovea ethmoidalis. 43 Pneumo- cephalus is frequently seenoncomputedtomography in injuries of the frontal sinus. Pneumocephalus is not a reliable or consistent signfor neurologic injury or for the presence of a cerebrospinal fluid leak. Pneumo- cephalus frominjury tothefrontal sinus may becaused by involvement of the cribriform, the fovea ethmoida- lis, the orbit, or other regions of the skull and/or skull base; thus, it is not a specific or sensitive measure of a potential cerebrospinal fluid leak. In instances of se- vere frontobasilar injury with or without tissue loss, cerebrospinal fluid leaks are obvious (Fig. 7). Associated Maxillofacial Injuries One-third to one-half of patients with frontal injuries will have associated midface fractures. These fractures lie in close proximity and it is safe to assume that they will involve the nasofrontal duct region, which predisposes to early and late complications. Both medial orbital rim and naso- orbito-ethmoid fractures are associated with a very high involvement of the nasofrontal duct 15,32,33 (Fig. 8). This necessitates management of the frontal sinus by obliteration or cranialization. 7,32 Medial orbital rim fractures, seen as part of the supraorbital bar involvement in frontal sinus frac- tures, are seen in up to 20 percent of frontal sinus injuries. With increasing involvement of the na- soethmoid/midface region, progressive collapse/ telescoping of the ethmoid labyrinth is seen. In addition to the obvious implications for orbital reconstruction vis-a`-vis the medial canthal com- plex, the potential for involvement of the fovea ethmoidalis (the roof of the ethmoid labyrinth) and the cribriform plate increases. Naso-orbito- ethmoid fractures are addressed after the frontal sinus is obliterated/cranialized and its fractures reduced in the sequencing of complex craniofa- cial injuries. With orbital involvement along with frontal sinus injury, the goal is to reconstitute the pre- morbid orbital volume and achieve the centric position of the globe by proper positioning of the canthal tendons and suspensory ligaments of the globe. This is achieved easier when only one orbit is injured along with the frontal sinus, as the intact side can function as a radiographic template, by Volume 120, Number 7 Suppl. 2 Frontal Sinus Fractures 37S three-dimensional high-resolution computed to- mography or through the use of an intraoperative stereolithography template. When both orbits are injured, such reconstruction is more difficult and based solely on precise reduction of fragments. In either situation and in more extensive, panfacial fractures, correction of frontal sinus fractures as- sumes greater importance, as this region provides the central stable reduction on which the rest of the craniofacial skeleton may be referenced. EXAMINATION AND RADIOLOGIC INVESTIGATIONS Physical Examination Facial pain is experienced in the majority of conscious patients (82 percent), and over half have frontal lacerations and in a quarter of pa- tients withfrontal sinus injury there will be a visible depression. 18 Cerebrospinal fluid rhinorrhea or cerebrospinal fluid in the wound is present in up to one-third of these patients. 3 The finding of cerebrospinal fluid in conjunction with extensive injury places the patient in a priority for operative intervention. When cerebrospinal fluid leak is present with minimal injury, this presents a diag- nostic dilemma. In this circumstance, operative intervention of the frontal sinus is not indicated in the absence of fractures. Acerebrospinal fluidleak under these circumstances should then be inves- tigated radiographically. Suspicion of a cerebro- spinal fluid leak can be heightened with a positive halo test. In this test, a drop of the bloody fluid is placed on a cloth surface. If it contains cerebro- spinal fluid, this will diffuse in a radial pattern along with the blood. However, the fluid will mi- grate farther than the blood, forming a halo effect. A definite confirmation can be made by sending a specimen for 2-transferrin analysis. 44,45 A complete ophthalmologic examination should be carried out as soon as feasible and visual acuity tests should be performed as soon as the patient is awake and cooperative. Any evidence in the drop of visual acuity and/or limitation of extraocular movement should be further inves- tigated by appropriate computed tomographic scanning. The remainder of the craniofacial skele- tonshouldbe examinedandscannedbecause of the high incidence of associated craniomaxillofacial injuries. Radiographic Evaluation Plain skull radiographs were used in the past to screen and evaluate for fractures of the frontal sinus, with the Caldwell and lateral views being the most useful. When plain films are available, evi- dence of air-fluidlevels andclouding of the frontal sinus should be investigated further. In most cir- cumstances, plain radiographs should be avoided, Fig. 7. Severe cranio-orbitofrontal injury. The globe is displaced intothe maxilla/oral cavity andthere is extensive dural exposure and separation of the upper nasal skeleton from the skull base. Fig. 8. View after reduction of the naso-orbito-ethmoid and frontal region. For the displacement of the bicoronal ap, the superior orbital nerves were downfractured and the bicoronal incision was extended to the tragal/helical junction. Plastic and Reconstructive Surgery December Supplement 2, 2007 38S because their sensitivity and specificity is very low and are time consuming to obtain, especially in a critically ill patient. However, if a frontal sinus obliteration/cranialization is planned, it is helpful to obtain a 1:1 ratio frontal projection plain ra- diograph to use as an intraoperative template for entering the frontal sinus. All patients with forehead lacerations and/or palpable deformities in which the magnitude of the injury raises suspicion for a fracture should undergo computed tomographic scanning of the craniofacial skeleton. In those with altered mental status or other evidence of neurologic injury, the evaluationshouldincludea noncontrast-enhanced brain computed tomographic scan to assess for he- matomas, contusions, and other brain injuries. In patients with evidence of decrease in visual acuity or loss of color vision, the computed tomographic scan shouldinclude the optic foramina, orbital apex, and sella region. Pneumocephalus can be seen on computed tomography with a number of injuries that may or may not involve the frontal sinus. These may in- volve the cribriform, the fovea ethmoidalis, and the orbit, and thus it is not a specific or sensitive measure of a potential cerebrospinal fluid leak. In the absence of intracranial injury, and with min- imal frontal injury that does not merit operative intervention, cerebrospinal fluid leaks are best in- vestigated with high-resolution computed tomo- graphic cisternography and/or nasal endoscopy after the administration of intrathecal fluorescein. MANAGEMENT OF FRONTAL SINUS FRACTURES Historical Perspective The need to surgically address the frontal si- nus arose from infection and the related compli- cations of frontal sinusitis. Complications of fron- tal sinusitis in the preantibiotic era were fearsome, with high morbidity and mortality secondary to intracranial spread. The first reported procedure on the frontal sinus for a mucopyocele was per- formed by Wells in 1870. 46 Numerous operations of limited extent that involved puncturing the an- terior table of the frontal bone were subsequently introduced, some with limited removal of the mu- cosa and others with packing of the sinus or cre- ation of an external draining sinus tract. 46 Reidel first described ablation of the anterior sinus wall in 1898. This was a radical, disfiguring operation that involved removal of the frontal bone and supraorbital bar to the posterior table of the fron- tal sinus. Few patients could be convinced to un- dergo this operation, even under the threat of complications with high mortality. 46 Killian intro- duced a variation of this procedure by preserving the supraorbital bar but still removing the anterior table and contents of the frontal sinus and then collapsing the skin to the posterior table of the frontal sinus. The Killian procedure produced less disfigurement but had significant rates of failure because of persistent disease at the nasofrontal ducts and incomplete removal of all frontal sinus mucosa. 47 After Skillern published a review of the morbidity and mortality on the Killian procedure, it was abandoned as a treatment option. 48 The next significant advance in dealing with frontal sinus infection was the Lynch operation, which relied on exenteration of the anterior ethmoid air cells to create a wide communication from the frontal sinus to the nasal cavity through a medial periorbital incision. 49 Disappointing results with this procedure were soon realized because of re- stenosis of the nasofrontal duct, either by scarring or by herniation of the orbital tissues into the created communication with the nasal cavity. 5052 Several modifications of this approachusing stents of silicone and mucoperiosteal flap were devised in an attempt to maintain this artificial conduit patent. These met with various degrees of success. The osteoplastic flap procedure, as reported by Ber- gara and Itoiz in 1955, hinged the anterior frontal sinus wall on an inferior pedicle of pericranium. 53 This procedure allowed easy visualization of the damaged sinus, replacement of the bone on com- pletion of the surgery, and improved forehead cos- mesis. Goodale and Montgomery carried this pro- cedure one step further, as they recognized the importance of nasofrontal duct injury and often re- moved the sinus contents and obliterated the sinus with autologous fat. 5153 The osteoplastic flap oper- ation has been subsequently modified for use in trauma of the frontal sinus by elevating the pericra- nium with the scalp flap and exploring the frontal sinus by removal of the free bone fragments. Con- sistently excellent results withminimal complication rates and a less than 1 percent incidence of infec- tious complications after mucosal exenteration and fat graft obliteration of sinuses with injured naso- frontal ducts have been reported. 15,32,33,43,54,55 A vari- ety of materials such as bone, muscle, fascia, and hydroxyapatite have been successfully used to oblit- erate the sinus cavity. 29,5659 Cranialization of the frontal sinus was specifically developed to address severe frontal sinus fractures whenthe posterior wall is damaged. 3,30 Volume 120, Number 7 Suppl. 2 Frontal Sinus Fractures 39S Classification of Frontal Sinus Procedures and Their Indications Observation The variables that determine which patients canbe safely observed, rather thantreatedby open surgery, are as follows: degree of injury, ability/will to follow-up, availability of expertise in functional endoscopic sinus surgery, and evolution of mini- mally invasive techniques. Minimally displaced frontal sinus anterior table fractures can be clearly observed. Minimally displaced fractures in the re- gion of the frontonasal duct would traditionally require exploration and management. If there is expertise available to endoscopically open the na- sofrontal duct at a later time and the patient is willing and reliable in terms of follow-up, it may be reasonable to observe these patients. These pa- tients will have to be followed on a frequent basis with serial radiographic investigations. Symptoms or findings suggestive of obstruction and/or de- velopment of a complication such as a mucocele would be indications for intervention at a later date. The frequency and length of radiographic and clinical follow-up required in these instances has not been defined. Other factors to consider are the need for operative intervention of associ- ated injuries. The following general indications should be considered for frontal sinus surgery in the face of frontal sinus fractures: 1. To avoid immediate and short-term compli- cations such as cerebrospinal fluid leak, meningitis, and spreading infection. 2. To avoid long-term complications such as frontal bone osteomyelitis, chronic frontal sinusitis, mucocele, mucopyocele, and brain abscess. 3. To provide adequate exposure for anatomi- cal reduction of naso-orbito-ethmoid frac- tures. 4. To restore proper aesthetic contour of the forehead. Applying these indications to the classification system of frontal sinus injury presented in Figure 2 leads to a simplified management algorithm. There are four basic choices for managing the frontal sinus when it is injured: observation, ex- ploration and fracture reduction without obliter- ation/cranialization, obliteration, and cranializa- tion. Variations in these approaches are related to the methods of soft-tissue access, the type of ma- terial used for obliteration, the requirement for bone grafting, whether dural repairs are required, and variations of surgical technique. Soft-Tissue Access There are three ways to access the frontal si- nus. In limited outer table frontal sinus injuries without involvement of the nasofrontal duct and/or the medial orbital rim, in the absence of other associated regional craniofacial injuries, the fractures can be reduced and fixed through the laceration. In this instance, the sinus mucosa is left intact. Very rarely, in a hypopneumatized frontal sinus with outer table fractures, one can adequately remove the mucosa throughanextensive laceration. As a general rule, this should be avoided if possible. Endoscopic repair of frontal sinus fractures has been performed satisfactorily with the use of bone substitutes to recreate the frontal contour. 60,61 The approachis similar tothat of anendoscopic browlift. However, the indication for this minimally invasive approach is limited at the present time to nondis- placed outer table fractures that do not involve the medial orbital rim and/or frontonasal duct. This wouldbe a subset of type 1 fractures according tothe classificationscheme providedhere. Inaddition, the use of bone substitute in the face of acute injury is associated with the risk of secondary infection and should be monitored closely. However, as tech- niques of endoscopy improve and as the instrumen- tation for endoscopic surgery becomes increasingly sophisticated, more involved frontal sinus fractures will surely become amenable to treatment with min- imally invasive approaches. The accepted method for soft-tissue access to the frontal, nasofrontal, and orbital craniofacial skeletal structures is the bicoronal incision. Though a large incision, the panoramic access it provides is unparalleledandthe placement inthe hairline com- pletely conceals the incision. Cosmetic problems may arise in the following situations: visibility of in- cision in subjects with alopecia; injury to the frontal branches of the facial nerve, which will give both a cosmetic and functional problem; and devascular- ization of the temporal fat pad, with subsequent hollowing of the temporal fossa. Specific sharp dis- section under the superficial temporal fascia later- ally and under the pericranium medially/centrally will avoid injury to the facial nerve and maximize exposure. In the region of the temporal fat pad, a combination of blunt and sharp dissection to the zygomatic arch is performed, with the goal of min- imizing injury to the blood supply of the fat pad. If access to the lateral orbit is required, the bicoronal incisionshouldbe extendedtothe preauricular area to the junction of the tragus and helix of the auricle; this allows better downward displacement of the bi- coronal flap(Fig. 8). However, it must be notedthat, for isolated access to the zygomatic arch/temporal Plastic and Reconstructive Surgery December Supplement 2, 2007 40S region, a full bicoronal incision is not required, and this can be achieved through a limited hemicoronal access without extension to the nonhair-bearing skin inferiorly. Meticulous technique with hemosta- sis andthe avoidance of clips at the edges of the flaps will prevent hair loss around the incision. 18 It is also important to make the incision of the scalp parallel to the hair follicles. Avoiding the transection of hair follicles further avoids alopecia at the edges of the wound. 62,63 At the orbital rim, the superior orbital nerve foramina are outfractured to further facilitate exposure at the nasion and orbits. Exploration and Fracture Reduction Alone without Obliteration or Cranialization Type 1 and some type 2 fractures can be man- aged with a simple exploration and fracture re- duction without the requirement for frontal sinus obliteration. A contraindication for exploration alone is a type 2 fracture that involves the naso- ethmoid complex and/or the medial superior or- bital rim or orbital floor. These associated injuries will invariably involve the nasofrontal duct, neces- sitating an obliteration procedure. With obliteration of the frontal sinus, the an- terior bone fragments are removed and debrided of mucosal elements and the sinus is irrigated with saline. If there is no evidence of posterior wall injury and nasofrontal duct involvement, reduc- tion in anatomical position with low-profile mi- croplates completes the procedure. If there is ev- idence of injury to the nasofrontal ducts, the procedure is converted to an obliteration. Frontal Sinus Obliteration Most type 2 fractures that are associated with naso-orbito-ethmoid and superior orbital rimfrac- tures and all type 3 fractures require a frontal sinus obliteration. A bicoronal incision access is re- quired in almost all of these frontal sinus fractures (Fig. 9). Sinus exploration: Frontal bone fragments are re- moved and debrided of mucosal elements with a high-speed drill and continuous suction irri- gation. Mucosal exenteration: All mucosal elements of the frontal sinus must be removed diligently. Atten- tion should be given to the recesses of the frontal sinus. Removal of a layer of bone throughout the sinus will ensure that no mucosal elements are left behind. A high-speed drill with a coarse dia- mond burr is essential for removal of mucosa, both from the anterior table bone fragments and from the posterior wall. At the edges of the fron- tal sinus, this becomes technically challenging because of the narrow angle formed where the outer table meets the inner table. It is helpful to use a variety of drill bits with ever-decreasing sizes as this part of the sinus is approached. The direc- tion of drilling in these recesses should be paral- lel to the posterior wall to avoid injury to the dura. Suction irrigation is essential for this part of the procedure also. The irrigation should be used in a steady flow over where the drill is passed; in this way, the thin film of water flowing over the bone does two important things: it avoids thermal injury to the bone and, most im- portantly, provides the surgeon with a degree of transparency of the bone. As the bony dissection proceeds in this way, the color of the bone Fig. 9. Type 2, simple anterior table displaced fracture. Volume 120, Number 7 Suppl. 2 Frontal Sinus Fractures 41S changes as the dura is approached. This is done under the operating microscope or with magni- fying loupes. In well-pneumatized sinuses, the bone exposure may need to be increased with the use of additional osteotomies through the ante- rior frontal table. Rarely, a very-well-pneumatized frontal sinus that extends to the sphenoid wing will require removal of the posterior sinus wall to access the farther recesses by gentle retraction on the frontal lobes. This maneuver converts the obliteration into a cranialization. Nasofrontal duct obliteration: This is necessary for isolation of the frontal sinus from the sinonasal tract to prevent contamination and to avoid regrowth of mucosa from the ethmoids into the frontal sinus. Muscle, fascia, or bone chips can be used to obliterate the nasofrontal ducts bi- laterally (Fig. 10). Frontal sinus obliteration: The frontal sinus can be left alone for osteogenesis to occur or obliter- ated with fat, hydroxyapatite, fascia, or bone chips. 56,6467 No significant advantage of one technique over another has been demon- strated. In contaminated fractures, consider- ation should be given to the use of biomateri- als. For example, use of bone substitutes with incomplete removal of mucosa will result in the formation of mucoceles, infection of the mate- rial used, and dissolution of the underlying dura. 5,6870 This can lead to intracranial compli- cations and the loss of tissue of the forehead. Therefore, it is best to avoid nonautogenous materials in the setting of acute injury to avoid serious complications. If there is evidence of extensive comminution of the posterior wall, bone fragments must be removed and the dura explored for injury. Dural injuries should be primarily repaired in this instance and the si- nus obliterated with fat (Fig. 11). The areas of the nasofrontal ducts (i.e., the floor of the frontal sinus) should be addressed next. The management principle of this area is the cre- ation of scar tissue to the exclusion of mucosal elements in such a fashion that mucosal migra- tion into the obliterated sinus will be pre- vented. This is done by opening the frontona- sal ducts with punch forceps and creating a zone of injury in the superior ethmoid air cells. Care should be taken to avoid injury to the cribriform plate and fovea ethmoidalis. Be- cause the fovea and cribriform are very fragile, the technique of bone removal in the adjacent region should be achieved with a sharp tool or a high-speed drill; avoiding a rocking motion and/or a levering against these structures is critical. The ducts are then tightly packed with muscle or fascia that will provide the nidus for scar formation in this area. Fracture reduction: Frontal sinus fractures are re- duced according to standard techniques using microplates. If the comminution is extensive, titanium mesh can be used. 8 This technique is particularly useful with the concurrent reduc- tion of orbital rim fractures. The fragments can be reduced in situ or removed and reduced to plates or mesh outside the fracture confines and subsequently positioned to the fracture. Nasoethmoid and orbital fractures must be ad- dressed at this point by fixation onto stable bone in the frontal region. With the dissection Fig. 10. Superior view of the frontonasal ducts from within the frontal sinus. The superior ethmoid cells have been removed from above to create a zone of injury for scar formation and to prevent mucosal ingrowth. Thenext stepinthis sequencewill be to plug the ducts with fascia/muscle and/or bone chips. Arrows point to the enlarged region of the frontonasal ducts. Fig. 11. Dural injury repair with a patch of cadaveric dura and nonabsorbable sutures. The arrow points to the dural repair. Plastic and Reconstructive Surgery December Supplement 2, 2007 42S proceeding inferiorly, care should be taken to avoid injury to the lacrimal sac. The perios- teum is densely adherent to the nasal bones and especially the suture lines. It is important to elevate the soft tissues, including the perios- teum, using a sharp elevator. Frontal Sinus Cranialization This procedure was developed specifically for extensive injuries of the frontal sinus that involve cerebrospinal fluid leak on exploration and/or soft-tissue and bone loss such as those seen in type 4 and 5 injuries. The procedure is identical to that of a frontal sinus obliteration, with the exception of complete removal of the posterior sinus wall. It is important in a cranialization procedure to ad- dress the recesses of the sinus before removing the posterior wall extensively. This is accomplished with a high-speed diamond drill under continu- ous-suction irrigation in a pattern similar to that of obliteration. However, the depth of bone removal of the posterior wall is much more extensive. It helps to remove as much bone as possible with the high-speed drill under continuous suction irriga- tion so as to eggshell the posterior table. The dura is thendissectedfromthe overlying bone first in the areas where the posterior table has been fractured. Subsequently, bone fragments are re- moved with further drilling and/or a rongeur. Care should be taken at the level of the sagittal sinus where the bone invaginates on either side of the sinus. Inferiorly, the crista galli should be drilled carefully with a diamond burr, taking care to avoidentering the cribriformplate. Inextensive fractures that involve the cribriform plate and/or the fovea ethmoidalis, fragments of thin bone along with the ethmoid mucosa need to be de- brided meticulously. The region of the nasofron- tal ducts needs to be managed as in a frontal sinus obliteration. With a cranialization, the correct management of this region is even more critical. Failure to do so will result in mucosal ingrowth directly over dura, potentially exposing the nasal cavity to the splanchnocranium. These principles apply equally to cranializa- tion of the sinus after a bifrontal craniotomy. The residual elements of mucosa, especially those at- tached to the posterior table, must be removed along with the bone. A pericranial flap can be used to manage ex- tensive injuries of the floor and/or the posterior wall of the frontal sinus. It is frequently a good option for a cerebrospinal fluid leak identified during surgery. 13,7173 This versatile axial pattern fascial flap is an excellent choice when there is a need to isolate the anterior cranial fossa from the nasal cavity and/or associated paranasal sinuses. The robust blood supply to this flap, when based anteriorly, is fromthe supratrochlear and supraor- bital arteries. The layers included are those of the pericranium and the galea. It can be extended to include a portion of the pericranium and galea distal to the bicoronal incision. In this condition, care is taken when designing the bicoronal inci- sion to preserve the galea at the vertex. Dural repair under these circumstances is achieved with primary closure, a fascial patch, or an artificial dural patch (Fig. 6). A pericranial vascularized flap that can provide blood supply to free calvarial grafts used to reconstruct the fron- tobasal skeleton should not substitute for primary dural closure. Approximately one in five patients with frontal injuries will require a cranialization. 18 The majority of these patients with extensive pos- terior wall fractures will also have a cerebrospinal fluid leak at exploration. A frontal sinus cranialization is significantly easier when a bicoronal bone flap has been per- formed for the management of intracranial injury. In this situation, the drilling of the posterior wall can take place ex vivo on the back table, using a high-speed drill. However, in this instance, again the nasofrontal ducts need to be managed in a fashion that will prevent mucosal ingrowth into the splanchnocranium. Frequently, frontal sinus procedures are com- bined with the repair of additional craniofacial injuries, the most common being orbital and mid- face fractures. 18,62 In the presence of bone loss and in the presence of secondary complications (mu- coceles with orbital problems), reconstruction with bone grafts will be required. It is preferable to use split-thickness calvarial bone grafts because they are readily accessible through the bicoronal incision (Figs. 12 and 13). Indications to use split-thickness calvarial bone grafts are as follows 63 : 1. Extensive loss of support at the skull base over the fovea ethmoidalis and cribriform plate, in combination with a pericranial flap. 2. In superior orbital roof fractures, avoidance of pulsatile exophthalmos and orbital deformity. 3. Extensive bone loss of the anterior table that cannot be replaced with elements of the posterior table. 4. In combination with naso-orbito-ethmoid and orbital reconstruction as layered bone grafts to obliterate the ethmoids and recon- struct the medial orbital wall. Volume 120, Number 7 Suppl. 2 Frontal Sinus Fractures 43S Management of Associated Neurosurgical Issues Several issues of importance arise as to the timing of surgical management of neurologic in- jury in relation to the management of frontal sinus injury. Life-threatening injuries and injuries with the potential for neurologic impairment take pre- cedence over the management of frontal sinus. Evacuation of an intracranial hematoma, whether it is intraparenchymal, subdural, and/or epidural, is performed without delay; the frontal and/or craniofacial injuries may be addressed at a later stage unless they contribute to the neurologic morbidity. It is best in this situation for the patient to declare the course of neurologic progress after neurosurgical intervention before correction of these problems. In the presence of closed head injury, the estimation of intracranial pressure and its impact on neurologic function dictates the tim- ing of surgical repair of frontal injuries. An ex- ception to this may be a frontobasilar injury in the presence of markedly raised intracranial pressure that presents withherniationof brainparenchyma into the nasal cavity. In this situation, the splanch- nocranium must be isolated from the upper aero- digestive tract through surgical intervention that will most likely concurrently manage the frontal sinus. Severe frontobasilar injuries involving tissue loss, typically seen in industrial accidents, will re- quire correction of dural defects and soft-tissue coverage along with management of the frontal sinus to avoid mucocele formation and ongoing contamination of the cranial cavity by the sinus contents. Bone reconstruction of calvarial defects can be managed at a second stage when the pa- tient is stable neurologically (Fig. 7). If surgical intervention is required emergently for the evacuation of an epidural or subdural he- matoma, the frontal sinus could be managed con- currently with the neurologic injury, depending on how stable the patient is and whether further general anesthesia can be tolerated. The easiest method for frontal sinus management in the sit- uation where a bifrontal craniotomy flap has been raised is to cranialize the sinus and obliterate the frontonasal ducts. The presence of radiographic evidence of closed head injury such as multiple small intraparenchymal hematomas may require a period of observation and serial neurologic exam- inations before surgical intervention for the facial skeletal injuries. CONTROVERSIAL ISSUE: ENDOSCOPIC MANAGEMENT In recent years, great strides have been made in the endoscopic management of frontal sinus infectious disease. 69,70 Advances in instrumenta- tion, including power tools capable of removing the thin bone of the sinuses and endoscopic drills for the removal of more compact bone, have en- abled sufficient surgical access of the frontal sinus to deal with most forms of frontal sinusitis. 24,70 Furthermore, the use of intraoperative navigation systems has enabled these approaches with an un- precedented degree of safety. 70,7476 Recently, en- doscopic obliteration of the frontal sinus with fat has become possible for infectious disease of the frontal sinus. 77 Nevertheless, the management of fractures of the frontal sinus with endoscopic techniques has been limited to contouring of the frontal bone in the simplest of fractures. 60 It is possible that in the near future the endoscopic repair of a small sub- type of these fractures may be possible. This sub- Fig. 12. Layered calvarial grafts both superiorly and medially in the orbit after resection of a mucocele. Fig. 13. Extensive skull fractures associated with both frontal and orbital injuries. The sinus was cranialized both for manage- ment and for access for an epidural hematoma evacuation. Plastic and Reconstructive Surgery December Supplement 2, 2007 44S type of patients will have to have a limited, isolated injury of the frontal sinus outflow without exten- sive frontal bone fractures and other maxillofacial fractures. In this instance, the goal is to restore the frontal sinus outflow, an indication for which en- doscopic techniques are ideally suited. Further- more, in such an instance, patient follow-up is essential to avoid early and late complications. It is also possible to combine the two endoscopic approaches for restoration of frontal sinus physi- ologic outflow and contouring of type 1 nondis- placed fractures. COMPLICATIONS OF FRONTAL SINUS FRACTURES Early Complications A complication is characterized as early if it occurs within the first few weeks of surgical inter- vention. A number of transient problems can oc- cur after bicoronal access and frontal sinus frac- ture surgery. Forehead pain, transient anesthesia of the forehead, and transient diplopia should all resolve within 2 to 3 weeks. 3,58,78,79 The most fre- quent significant early complication is a cerebro- spinal fluid leak. Depending on the severity of the injuries in the population of patients studied, in some series this is as high as 10 percent. 3,40 Cere- brospinal fluid leaks are problematic in the face of intracranial injury. The standard management with a lumbar drain will be contraindicated in the face of intracranial injuries and/or suspected in- crease in intracranial pressure. Therefore, care must be taken before such a decision is made. The administration of antibiotics for the cerebrospinal fluid leak per se is a controversial subject. 8082 An- tibiotics should be administered prophylactically for the lumbar drain and if there are independent reasons for their administration. The majority of immediate postoperative cerebrospinal fluid leaks will disappear spontaneously. Reexploration should be considered if a leak persists or it there is a con- traindication to conservative management with a lumbar drain. The incidence of meningitis can be as high as 6 percent postoperatively. 3 Fatal episodes of men- ingitis after cranialization procedures has been reported. 1 Meningitis is not necessarily associated with an active cerebrospinal fluid leak. As these patients may be neurologically compromisedfrom a head injury, they are uniquely susceptible to the consequences of meningitis. In this situation, the early signs of meningitis such as altered mental status will not become apparent before signs of an infection such as high fever or hypotension. To minimize the morbidity and potential mortality from meningitis, this condition needs to be diag- nosed without delay. Change in mental status, fe- ver, or neck rigidity should prompt an immediate lumbar puncture after a brain computed tomo- graphic scan without any delay. Use of broad-spec- trum antibiotics with good cerebrospinal fluid penetration is an essential first step with culture- directed antibiotics following the results of cere- brospinal fluid cultures. The antibiotics should be readjusted appropriately to cerebrospinal fluid cultures. Operative intervention should be post- poned in the face of active meningitis. Late Complications Late complications are unusual but insidious and can have significant consequences. A mu- cocele and/or a mucopyocele can develop as early as a few months or as late as several years after the initial operation. 83 Mucoceles cause bone erosion and are capable of involving the sinuses, the orbit, and the splanchnocranium (Fig. 14). Because they are slow growing and produce few symptoms, they are usually discov- ered late. Reoperation with complete removal of the mucocele and reconstruction to isolate the splanchnocranium from the orbit and nasal cavity is the method of choice for management of mucoceles. 8486 Endoscopic marsupialization Fig. 14. Orbital mucocele as a complication fromprevious fron- tal sinus injury. Volume 120, Number 7 Suppl. 2 Frontal Sinus Fractures 45S of mucoceles has been attempted after infec- tious complication of frontal sinusitis, with lim- ited success rates and frequent follow-up require- ments 87,88 (Fig. 7). Brain abscesses are rare but potentially fatal complications of frontal sinus disease. Spread of low-grade infectionfromthe frontal sinus through the foramina of Breschet by thrombophlebitis brings the infection intracranially. 3,28 Brain ab- scesses develop by spread of infection along the periarteriolar spaces of Virchow, along the arterial supply of the brain parenchyma. 89 The symptoms associated with a frontal brain abscess are insidi- ous: loss of appetite, fatigue, lethargy, and subtle changes in personality rather than a fulminant infection. Appropriate neurosurgical intervention without delay is essential in preventing the mor- bidity and potential mortality, which is high even in the modern antibiotic era. Frontal bone osteomyelitis is a very rare com- plication. In the preantibiotic era, this was com- monly known as Potts puffy tumor. Today, this complication is encountered when the frontal si- nus has been surgically manipulated on multiple occasions, especially when synthetic material has been used that became infected. This condition requires complete removal of the frontal bone, treatment with antibiotics, and subsequent recon- struction at a later stage. In the past, frontal contour defects were fairly common late complications. This was primarily because of the lack of rigid fixation and subse- quent frontal bone loss. However, with the advent of miniplate and microplate fixation and the use of primary bone grafts, this is seen far less fre- quently. Issues arising from late complications with contouring can be resolved at a later stage with cranial remodeling using mesh and bone sub- stitutes or alloplastic materials. However, the cli- nician must be absolutely sure that all issues with the frontal sinus are quiescent. It is in this setting that endoscopic repair of contour defects using bone substitutes is effective. It is important to recognize that all patients who have had complications associated with fron- tal sinus management should be followed long term both clinically and with serial imaging in the early postoperative years. If the frontal sinus was obliterated with fat, magnetic resonance imaging is an excellent modality for follow-up. SUMMARY Frontal sinus surgery has evolved through the need to address infectious disease of the frontal sinus and its complications. The current manage- ment of frontal sinus fractures is based on ana- tomical and physiologic principles of mucosal function and frontal sinus drainage. Classification schemes based on the severity of frontal sinus in- jury dictate the type of operative management required. Three general types of operations for frontal sinus fractures have evolved: exploration and frac- ture reduction alone, frontal sinus obliteration, and frontal sinus cranialization. Evolution of sur- gical techniques has given these interventions a substantial degree of safety, with minimal compli- cations attributed to the operations themselves. Because of the profile of patients with frontal sinus fractures (i.e., they are unlikely to comply with follow-up), it is prudent to maintain an ag- gressive approach toward frontal sinus oblitera- tioninthe majority of instances. Inmore extensive injuries, a frontal sinus cranialization is indicated if there is presence of a cerebrospinal fluid leak, tissue, and/or bone loss and extensive associated naso-orbito-ethmoid fractures. Spiros Manolidis, M.D. Department of Otolaryngology Head and Neck Surgery Columbia University 180 Fort Washington, HP813 New York, N.Y. 10032 sm2397@columbia.edu REFERENCES 1. Gerbino, G., Roccia, F., Benech, A., and Caldarelli, C. Anal- ysis of 158 frontal sinus fractures: Current surgical manage- ment and complications. J. Craniomaxillofac. Surg. 28: 133, 2000. 2. 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