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Management of Frontal Sinus Fractures: Summary
Management of Frontal Sinus Fractures: Summary
F
rontal sinus fractures account for 5 to 15 tween 800 and 2200 pounds of force before
percent of all maxillofacial fractures.1,2 As- fracturing.8 In an average size adult human, these
saults and vehicular trauma account for the forces can be reached with a frontal collision at 30
majority of frontal sinus injuries. Frontal sinus frac- mph for an unrestrained passenger.9,10 Because of
tures have been associated with severe maxillofacial its projection and the large surface area it occupies
and systemic injuries, with a high rate of morbidity relative to the rest of the facial skeleton, the frontal
and mortality.3,4 The management of frontal sinus region is frequently the first site of exposure in
injury is an important topic, as inappropriate man- both vehicular and assault injuries.
agement of these injuries not only leads to cosmetic The anterior table of the frontal sinus is the
deformities and functional problems but may give stronger component of the two bone tables of the
rise to serious complications, including the devel- frontal sinus because of its overall thickness, es-
opment of mucoceles, osteomyelitis, and potentially pecially along the supraorbital buttress. The pos-
fatal central nervous system complications such as terior table is thinner and is not part of this but-
meningitis and brain abscesses.1,5,6 tress system. The dura is densely adherent to the
Several aspects of frontal sinus injury treatment deep surface of the posterior table. The dura be-
remain controversial secondary to the relatively comes thinner and more adherent along the cau-
small numbers of patients reviewed in the literature dal edge, where it turns to cover the roof of the
and the difficulty in maintaining long-term follow-up ethmoid air cells (fovea ethmoidalis). When sig-
in these patients.6 Areas of controversy include the
nificant fractures of the frontal bone occur, these
roles of frontal sinus obliteration, cranialization, and
propagate easily and extensively along the orbital
nasofrontal duct stenting in the acute trauma setting.7
and nasoethmoid complexes, which have signifi-
cantly weaker tolerances.9,10 Injuring forces capa-
BIOMECHANICS
The frontal bone is the strongest component
of the craniofacial skeleton. It can withstand be-
Disclosures: Neither of the authors has received
From the Department of Otolaryngology–Head and Neck Sur- funds or support or has a financial interest in any
gery, Beth Israel Hospital, and Baylor College of Medicine and of the products, devices, or drugs mentioned in this
Department of Plastic Surgery, Ben Taub General Hospital. article. Dr. Manolidis lectures as part of the faculty
Received for publication May 8, 2006; accepted January 18, for the North American AO-ASIF group and for
2007. that, in the past, has received stipends for attend-
Copyright ©2007 by the American Society of Plastic Surgeons ing/lecturing at their educational conferences.
DOI: 10.1097/01.prs.0000260732.58496.1b
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Volume 120, Number 7 Suppl. 2 • Frontal Sinus Fractures
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Plastic and Reconstructive Surgery • December Supplement 2, 2007
Fig. 3. Variations in the depth (relative downward displacement of the cribriform plate) is related to the location of the
fovea ethmoidalis, that is, the pneumatization of the ethmoid air cells. In this figure, the fovea ethmoidalis is the intra-
cranial surface that overlies the ethmoid air cell labyrinth.
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Plastic and Reconstructive Surgery • December Supplement 2, 2007
Fig. 6. Classification 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, both anterior and posterior frontal sinus walls involved
by comminuted fractures; type 4, comminuted anterior and posterior wall fractures with
dural injury and potential cerebrospinal fluid leak; and type 5, comminuted anterior and
posterior wall fractures with dural injury and potential cerebrospinal fluid leak in addition to
tissue and/or bone loss. (Reprinted with permission from Semin. Plast. Surg. 16: 2002.)
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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 with frontal 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. A cerebrospinal fluid leak
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
Fig. 7. Severe cranio-orbitofrontal injury. The globe is displaced placed on a cloth surface. If it contains cerebro-
into the maxilla/oral cavity and there is extensive dural exposure spinal fluid, this will diffuse in a radial pattern
and separation of the upper nasal skeleton from the skull base. 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-
ton should be examined and scanned because of the
high incidence of associated craniomaxillofacial
injuries.
Fig. 8. View after reduction of the naso-orbito-ethmoid and
frontal region. For the displacement of the bicoronal flap, the Radiographic Evaluation
superior orbital nerves were downfractured and the bicoronal Plain skull radiographs were used in the past
incision was extended to the tragal/helical junction. to screen and evaluate for fractures of the frontal
sinus, with the Caldwell and lateral views being the
three-dimensional high-resolution computed to- most useful. When plain films are available, evi-
mography or through the use of an intraoperative dence of air-fluid levels and clouding of the frontal
stereolithography template. When both orbits are sinus should be investigated further. In most cir-
injured, such reconstruction is more difficult and cumstances, plain radiographs should be avoided,
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Volume 120, Number 7 Suppl. 2 • Frontal Sinus Fractures
because their sensitivity and specificity is very low dergo this operation, even under the threat of
and are time consuming to obtain, especially in a complications with high mortality.46 Killian intro-
critically ill patient. However, if a frontal sinus duced a variation of this procedure by preserving
obliteration/cranialization is planned, it is helpful the supraorbital bar but still removing the anterior
to obtain a 1:1 ratio frontal projection plain ra- table and contents of the frontal sinus and then
diograph to use as an intraoperative template for collapsing the skin to the posterior table of the
entering the frontal sinus. frontal sinus. The Killian procedure produced less
All patients with forehead lacerations and/or disfigurement but had significant rates of failure
palpable deformities in which the magnitude of because of persistent disease at the nasofrontal
the injury raises suspicion for a fracture should ducts and incomplete removal of all frontal sinus
undergo computed tomographic scanning of the mucosa.47 After Skillern published a review of the
craniofacial skeleton. In those with altered mental morbidity and mortality on the Killian procedure,
status or other evidence of neurologic injury, the
it was abandoned as a treatment option.48 The
evaluation should include a non– contrast-enhanced
next significant advance in dealing with frontal
brain computed tomographic scan to assess for he-
matomas, contusions, and other brain injuries. In sinus infection was the Lynch operation, which
patients with evidence of decrease in visual acuity or relied on exenteration of the anterior ethmoid air
loss of color vision, the computed tomographic scan cells to create a wide communication from the
should include the optic foramina, orbital apex, and frontal sinus to the nasal cavity through a medial
sella region. periorbital incision.49 Disappointing results with
Pneumocephalus can be seen on computed this procedure were soon realized because of re-
tomography with a number of injuries that may or stenosis of the nasofrontal duct, either by scarring
may not involve the frontal sinus. These may in- or by herniation of the orbital tissues into the
volve the cribriform, the fovea ethmoidalis, and created communication with the nasal cavity.50 –52
the orbit, and thus it is not a specific or sensitive Several modifications of this approach using stents
measure of a potential cerebrospinal fluid leak. In of silicone and mucoperiosteal flap were devised
the absence of intracranial injury, and with min- in an attempt to maintain this artificial conduit
imal frontal injury that does not merit operative patent. These met with various degrees of success.
intervention, cerebrospinal fluid leaks are best in- The osteoplastic flap procedure, as reported by Ber-
vestigated with high-resolution computed tomo- gara and Itoiz in 1955, hinged the anterior frontal
graphic cisternography and/or nasal endoscopy sinus wall on an inferior pedicle of pericranium.53
after the administration of intrathecal fluorescein. This procedure allowed easy visualization of the
damaged sinus, replacement of the bone on com-
MANAGEMENT OF FRONTAL pletion of the surgery, and improved forehead cos-
SINUS FRACTURES mesis. Goodale and Montgomery carried this pro-
cedure one step further, as they recognized the
Historical Perspective
importance of nasofrontal duct injury and often re-
The need to surgically address the frontal si- moved the sinus contents and obliterated the sinus
nus arose from infection and the related compli- with autologous fat.51–53 The osteoplastic flap oper-
cations of frontal sinusitis. Complications of fron- ation has been subsequently modified for use in
tal sinusitis in the preantibiotic era were fearsome,
trauma of the frontal sinus by elevating the pericra-
with high morbidity and mortality secondary to
nium with the scalp flap and exploring the frontal
intracranial spread. The first reported procedure
on the frontal sinus for a mucopyocele was per- sinus by removal of the free bone fragments. Con-
formed by Wells in 1870.46 Numerous operations sistently excellent results with minimal complication
of limited extent that involved puncturing the an- rates and a less than 1 percent incidence of infec-
terior table of the frontal bone were subsequently tious complications after mucosal exenteration and
introduced, some with limited removal of the mu- fat graft obliteration of sinuses with injured naso-
cosa and others with packing of the sinus or cre- frontal ducts have been reported.15,32,33,43,54,55 A vari-
ation of an external draining sinus tract.46 Reidel ety of materials such as bone, muscle, fascia, and
first described ablation of the anterior sinus wall hydroxyapatite have been successfully used to oblit-
in 1898. This was a radical, disfiguring operation erate the sinus cavity.29,56 –59 Cranialization of the
that involved removal of the frontal bone and frontal sinus was specifically developed to address
supraorbital bar to the posterior table of the fron- severe frontal sinus fractures when the posterior wall
tal sinus. Few patients could be convinced to un- is damaged.3,30
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Plastic and Reconstructive Surgery • December Supplement 2, 2007
changes as the dura is approached. This is done extensive comminution of the posterior wall,
under the operating microscope or with magni- bone fragments must be removed and the dura
fying loupes. In well-pneumatized sinuses, the explored for injury. Dural injuries should be
bone exposure may need to be increased with the primarily repaired in this instance and the si-
use of additional osteotomies through the ante- nus obliterated with fat (Fig. 11). The areas of
rior frontal table. Rarely, a very-well-pneumatized the nasofrontal ducts (i.e., the floor of the
frontal sinus that extends to the sphenoid wing frontal sinus) should be addressed next. The
will require removal of the posterior sinus wall to management principle of this area is the cre-
access the farther recesses by gentle retraction on ation of scar tissue to the exclusion of mucosal
the frontal lobes. This maneuver converts the elements in such a fashion that mucosal migra-
obliteration into a cranialization. tion into the obliterated sinus will be pre-
Nasofrontal duct obliteration: This is necessary for vented. This is done by opening the frontona-
isolation of the frontal sinus from the sinonasal sal ducts with punch forceps and creating a
tract to prevent contamination and to avoid zone of injury in the superior ethmoid air cells.
regrowth of mucosa from the ethmoids into the Care should be taken to avoid injury to the
frontal sinus. Muscle, fascia, or bone chips can cribriform plate and fovea ethmoidalis. Be-
be used to obliterate the nasofrontal ducts bi- cause the fovea and cribriform are very fragile,
laterally (Fig. 10). the technique of bone removal in the adjacent
Frontal sinus obliteration: The frontal sinus can be region should be achieved with a sharp tool or
left alone for osteogenesis to occur or obliter- a high-speed drill; avoiding a rocking motion
ated with fat, hydroxyapatite, fascia, or bone and/or a levering against these structures is
chips.56,64 – 67 No significant advantage of one critical. The ducts are then tightly packed with
technique over another has been demon- muscle or fascia that will provide the nidus for
strated. In contaminated fractures, consider- scar formation in this area.
ation should be given to the use of biomateri- Fracture reduction: Frontal sinus fractures are re-
als. For example, use of bone substitutes with duced according to standard techniques using
incomplete removal of mucosa will result in the microplates. If the comminution is extensive,
formation of mucoceles, infection of the mate- titanium mesh can be used.8 This technique is
rial used, and dissolution of the underlying particularly useful with the concurrent reduc-
dura.5,68 –70 This can lead to intracranial compli- tion of orbital rim fractures. The fragments can
cations and the loss of tissue of the forehead. be reduced in situ or removed and reduced to
Therefore, it is best to avoid nonautogenous plates or mesh outside the fracture confines
materials in the setting of acute injury to avoid and subsequently positioned to the fracture.
serious complications. If there is evidence of 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. The next step in this sequence will be
to plug the ducts with fascia/muscle and/or bone chips. Arrows Fig. 11. Dural injury repair with a patch of cadaveric dura and
point to the enlarged region of the frontonasal ducts. nonabsorbable sutures. The arrow points to the dural repair.
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Volume 120, Number 7 Suppl. 2 • Frontal Sinus Fractures
proceeding inferiorly, care should be taken to need to isolate the anterior cranial fossa from the
avoid injury to the lacrimal sac. The perios- nasal cavity and/or associated paranasal sinuses.
teum is densely adherent to the nasal bones The robust blood supply to this flap, when based
and especially the suture lines. It is important anteriorly, is from the supratrochlear and supraor-
to elevate the soft tissues, including the perios- bital arteries. The layers included are those of the
teum, using a sharp elevator. pericranium and the galea. It can be extended to
include a portion of the pericranium and galea
Frontal Sinus Cranialization distal to the bicoronal incision. In this condition,
This procedure was developed specifically for care is taken when designing the bicoronal inci-
extensive injuries of the frontal sinus that involve sion to preserve the galea at the vertex.
cerebrospinal fluid leak on exploration and/or Dural repair under these circumstances is
soft-tissue and bone loss such as those seen in type achieved with primary closure, a fascial patch, or
4 and 5 injuries. The procedure is identical to that an artificial dural patch (Fig. 6). A pericranial
of a frontal sinus obliteration, with the exception vascularized flap that can provide blood supply to
of complete removal of the posterior sinus wall. It free calvarial grafts used to reconstruct the fron-
is important in a cranialization procedure to ad- tobasal skeleton should not substitute for primary
dress the recesses of the sinus before removing the dural closure. Approximately one in five patients
posterior wall extensively. This is accomplished with frontal injuries will require a cranialization.18
with a high-speed diamond drill under continu- The majority of these patients with extensive pos-
ous-suction irrigation in a pattern similar to that of terior wall fractures will also have a cerebrospinal
obliteration. However, the depth of bone removal fluid leak at exploration.
of the posterior wall is much more extensive. It A frontal sinus cranialization is significantly
helps to remove as much bone as possible with the easier when a bicoronal bone flap has been per-
high-speed drill under continuous suction irriga- formed for the management of intracranial injury.
tion so as to “eggshell” the posterior table. The In this situation, the drilling of the posterior wall
dura is then dissected from the overlying bone first can take place ex vivo on the back table, using a
in the areas where the posterior table has been high-speed drill. However, in this instance, again
fractured. Subsequently, bone fragments are re- the nasofrontal ducts need to be managed in a
moved with further drilling and/or a rongeur. fashion that will prevent mucosal ingrowth into
Care should be taken at the level of the sagittal the splanchnocranium.
sinus where the bone invaginates on either side of Frequently, frontal sinus procedures are com-
the sinus. Inferiorly, the crista galli should be bined with the repair of additional craniofacial
drilled carefully with a diamond burr, taking care injuries, the most common being orbital and mid-
to avoid entering the cribriform plate. In extensive face fractures.18,62 In the presence of bone loss and
fractures that involve the cribriform plate and/or in the presence of secondary complications (mu-
the fovea ethmoidalis, fragments of thin bone coceles with orbital problems), reconstruction
along with the ethmoid mucosa need to be de- with bone grafts will be required. It is preferable
brided meticulously. The region of the nasofron- to use split-thickness calvarial bone grafts because
tal ducts needs to be managed as in a frontal sinus they are readily accessible through the bicoronal
obliteration. With a cranialization, the correct incision (Figs. 12 and 13).
management of this region is even more critical. Indications to use split-thickness calvarial
Failure to do so will result in mucosal ingrowth bone grafts are as follows63:
directly over dura, potentially exposing the nasal
cavity to the splanchnocranium. 1. Extensive loss of support at the skull base
These principles apply equally to cranializa- over the fovea ethmoidalis and cribriform
tion of the sinus after a bifrontal craniotomy. The plate, in combination with a pericranial flap.
residual elements of mucosa, especially those at- 2. In superior orbital roof fractures, avoidance of
tached to the posterior table, must be removed pulsatile exophthalmos and orbital deformity.
along with the bone. 3. Extensive bone loss of the anterior table that
A pericranial flap can be used to manage ex- cannot be replaced with elements of the
tensive injuries of the floor and/or the posterior posterior table.
wall of the frontal sinus. It is frequently a good 4. In combination with naso-orbito-ethmoid
option for a cerebrospinal fluid leak identified and orbital reconstruction as layered bone
during surgery.13,71–73 This versatile axial pattern grafts to obliterate the ethmoids and recon-
fascial flap is an excellent choice when there is a struct the medial orbital wall.
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Volume 120, Number 7 Suppl. 2 • Frontal Sinus Fractures
type of patients will have to have a limited, isolated minimize the morbidity and potential mortality
injury of the frontal sinus outflow without exten- from meningitis, this condition needs to be diag-
sive frontal bone fractures and other maxillofacial nosed without delay. Change in mental status, fe-
fractures. In this instance, the goal is to restore the ver, or neck rigidity should prompt an immediate
frontal sinus outflow, an indication for which en- lumbar puncture after a brain computed tomo-
doscopic techniques are ideally suited. Further- graphic scan without any delay. Use of broad-spec-
more, in such an instance, patient follow-up is trum antibiotics with good cerebrospinal fluid
essential to avoid early and late complications. It penetration is an essential first step with culture-
is also possible to combine the two endoscopic directed antibiotics following the results of cere-
approaches for restoration of frontal sinus physi- brospinal fluid cultures. The antibiotics should be
ologic outflow and contouring of type 1 nondis- readjusted appropriately to cerebrospinal fluid
placed fractures. cultures. Operative intervention should be post-
poned in the face of active meningitis.
COMPLICATIONS OF FRONTAL
SINUS FRACTURES Late Complications
Early Complications Late complications are unusual but insidious
A complication is characterized as early if it and can have significant consequences. A mu-
occurs within the first few weeks of surgical inter- cocele and/or a mucopyocele can develop as
vention. A number of transient problems can oc- early as a few months or as late as several years
cur after bicoronal access and frontal sinus frac- after the initial operation.83 Mucoceles cause
ture surgery. Forehead pain, transient anesthesia bone erosion and are capable of involving the
of the forehead, and transient diplopia should all sinuses, the orbit, and the splanchnocranium
resolve within 2 to 3 weeks.3,58,78,79 The most fre- (Fig. 14). Because they are slow growing and
quent significant early complication is a cerebro- produce few symptoms, they are usually discov-
spinal fluid leak. Depending on the severity of the ered late. Reoperation with complete removal of
injuries in the population of patients studied, in the mucocele and reconstruction to isolate the
some series this is as high as 10 percent.3,40 Cere- splanchnocranium from the orbit and nasal
brospinal fluid leaks are problematic in the face of cavity is the method of choice for management
intracranial injury. The standard management of mucoceles.84 – 86 Endoscopic marsupialization
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.80 – 82 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 compromised from
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 Fig. 14. Orbital mucocele as a complication from previous fron-
infection such as high fever or hypotension. To tal sinus injury.
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Plastic and Reconstructive Surgery • December Supplement 2, 2007
of mucoceles has been attempted after infec- ment of frontal sinus fractures is based on ana-
tious complication of frontal sinusitis, with lim- tomical and physiologic principles of mucosal
ited success rates and frequent follow-up require- function and frontal sinus drainage. Classification
ments87,88 (Fig. 7). schemes based on the severity of frontal sinus in-
Brain abscesses are rare but potentially fatal jury dictate the type of operative management
complications of frontal sinus disease. Spread of required.
low-grade infection from the frontal sinus through Three general types of operations for frontal
the foramina of Breschet by thrombophlebitis sinus fractures have evolved: exploration and frac-
brings the infection intracranially.3,28 Brain ab- ture reduction alone, frontal sinus obliteration,
scesses develop by spread of infection along the and frontal sinus cranialization. Evolution of sur-
periarteriolar spaces of Virchow, along the arterial gical techniques has given these interventions a
supply of the brain parenchyma.89 The symptoms substantial degree of safety, with minimal compli-
associated with a frontal brain abscess are insidi- cations attributed to the operations themselves.
ous: loss of appetite, fatigue, lethargy, and subtle Because of the profile of patients with frontal
changes in personality rather than a fulminant sinus fractures (i.e., they are unlikely to comply
infection. Appropriate neurosurgical intervention with follow-up), it is prudent to maintain an ag-
without delay is essential in preventing the mor- gressive approach toward frontal sinus oblitera-
bidity and potential mortality, which is high even tion in the majority of instances. In more extensive
in the modern antibiotic era. injuries, a frontal sinus cranialization is indicated
Frontal bone osteomyelitis is a very rare com- if there is presence of a cerebrospinal fluid leak,
plication. In the preantibiotic era, this was com- tissue, and/or bone loss and extensive associated
monly known as Pott’s puffy tumor. Today, this naso-orbito-ethmoid fractures.
complication is encountered when the frontal si-
Spiros Manolidis, M.D.
nus has been surgically manipulated on multiple Department of Otolaryngology–
occasions, especially when synthetic material has Head and Neck Surgery
been used that became infected. This condition Columbia University
requires complete removal of the frontal bone, 180 Fort Washington, HP813
treatment with antibiotics, and subsequent recon- New York, N.Y. 10032
sm2397@columbia.edu
struction at a later stage.
In the past, frontal contour defects were fairly
common late complications. This was primarily REFERENCES
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