Introduction



Treatment of frontal sinus fractures is complex and sometimes controversial. Appropriate treatment decisions can be made by assessing 5 anatomic parameters, these include the presence of:

  • An anterior table fracture (A)
  • A posterior table fracture (B)
  • A nasofrontal recess fracture (C)
  • A dural tear (CSF leak) (D)
  • Fracture comminution

Treatment options would include:

  • Observation
  • Open reduction internal fixation (ORIF)
  • Obliteration
  • Cranialization
  • Ablation


Posterior table fractures



The treatment algorithm for posterior table fractures is complex due to the risk of CSF leak, meningitis, encephalitis, abscess, and mucocele formation.
The first step in the decision tree is based upon fracture displacement. The presence of significant displacement is indicative of the severity of the injury and warrants exploration. However, the absence of displacement does not assure that a significant injury to the dura or brain has not occurred. The presence of a soft-tissue density inside the sinus, even in the absence of displacement, requires further workup.
If a CSF leak is present, the risk of meningitis is high. The threshold for exploration therefore should be low. Some surgeons suggest a period of observation to see if the leak will stop spontaneously. It should be emphasized that the patient remains at risk during the period of observation and in fact may still be at risk if the leak stops spontaneously. Great care must be exercised in determining which patients require further investigation and/or exploration.
If no CSF leak is present there is still the risk of communication and the development of meningitis. An absence of actual CSF leaks does not necessarily imply an absence of an dural defect. Here again, great care must be exercised in determining which patients require further investigation and/or exploration.



This CT scan shows a minimal posterior table fracture with intracranial air and density (blood, CSF, interrupted brain, etc.) within the frontal sinus. This case requires further investigation to determine the nature of the density (blood, CSF, interrupted brain, etc.).



Whether a CSF leak is present or absent, fracture comminution must be addressed. The presence of posterior wall comminution is an indication for exploration and possible sinus obliteration and/or cranialization.
In this CT scan, the right posterior wall is comminuted and depressed. This case will require at least obliteration but most likely cranialization.



Moderate to severe comminution (such as seen in the two CT scans) ...



 

... is an indication for cranialization.