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Chapter 23 PARANASAL SINUS FRACTURES Paranasal Sinus Fractures Chapter 23 PARANASAL SINUS FRACTURES † MARK GIBBONS, MD, FACS,* AND NATHAN SALINAS, MD INTRODUCTION ANATOMY DIAGNOSIS: CLINICAL AND IMAGING STUDIES MANAGEMENT ISSUES AND ALGORITHM SUMMARY CASE PRESENTATIONS Case Study 23-1 Case Study 23-2 *Lieutenant Colonel (Retired), Medical Corps, US Army; formerly, Chief, Department of Otolaryngology, Carl R. Darnall Army Medical Center, 36000 Darnall Loop, Fort Hood, Texas 76544 †Major, Medical Corps, US Army; Chief, Department of Otolaryngology, Fort Wainwright, 4076 Neely Road, Fort Wainwright, Alaska 99703 281 Otolaryngology/Head and Neck Combat Casualty Care INTRODUCTION Frontal sinus trauma may be blunt or penetrating, combat injuries, nearly half of all patients with both with frontal sinus fractures representing 6% to 12% of cranial and ocular combat injuries requiring surgical craniofacial fractures.1,2 Two-thirds of patients with intervention also underwent frontal sinus repair, frontal sinus trauma may have sustained concomitant obliteration, or cranialization.8 Another contempo- injuries to other facial structures.3 Contemporary al- rary review of facial trauma following improvised gorithms for classification and management of frontal explosive device blasts identified trauma to the sinus trauma are largely based on civilian injury pat- forehead aesthetic subunit as a “danger zone” in terns, which carry a trend toward high-velocity blunt massive facial trauma, which was defined as injury trauma.1,2,4,5 to three or more facial units.9 Because massive facial War trauma yields a higher incidence of pen- trauma is associated with elevated Injury Severity etrating injuries due to the preponderance of blast Scores and an increased rate for blood transfusions and missile trauma.6–8 Open craniomaxillofacial in war trauma, early assessment of these patients fractures may comprise up to 75% of injuries to the may help identify patients who require rapid trans- craniomaxillofacial skeleton.6 Additionally, given port to higher levels of care.9 Prompt evaluation by the proximity of the frontal bone to the cranium and neurosurgery and ophthalmology is important to orbits, concomitant brain and/or eye injury is not optimize the care of patients with significant frontal uncommon with penetrating or blunt frontal trauma. sinus and skull base trauma with potential or associ- In a recent review of concomitant cranial and ocular ated cranial or orbital injuries. ANATOMY Comprehensive knowledge of the surgical anatomy of the anterior cranial fossa, separating the frontal sinus of the frontal sinus is important for appropriately from the anterior cranial fossa. The medial portion of managing frontal sinus fractures resulting from ei- the orbital roof creates the floor of the frontal sinus. The ther blunt or penetrating injuries. Absent at birth, the frontal sinus outflow tract (FSOT), also known as the frontal sinuses begin developing after age 2. Most frontal recess, is the funnel-shaped space that connects patients develop a pair of frontal sinuses, which are the frontal sinus to the anterior ethmoid sinuses.11 The not fully formed until ages 15 to 20.10 However, 8% to frontal ostium is the apex of the FSOT. The frontal si- 15% of patients may only develop one frontal sinus, nus is lined with mucosa, which provides mucociliary and 5% have complete aplasia.10,11 The frontal sinus is clearance from the frontal sinus via the FSOT. a three-dimensional structure composed of an anterior Frontal sinus fractures may be classified as nondis- table, a posterior table, and a floor. The anterior table placed or displaced fractures involving the anterior provides the skeletal contour of the forehead, brow, table, the posterior table, or both. Accurate classifica- and glabella. The posterior table is the anterior portion tion also requires identification of FSOT involvement. DIAGNOSIS: CLINICAL AND IMAGING STUDIES Clinical diagnosis of a frontal sinus injury is based the complex three-dimensional anatomy, frontal sinus on physical examination findings. In the presence of fractures are best diagnosed with a thin-cut (1.0–1.5 blunt trauma, significant forehead edema may make mm) CT scan in axial, coronal, and sagittal planes if clinical diagnosis difficult. Penetrating trauma is often available and if time allows. The axial images allow more conspicuous. Pertinent clinical findings include clear assessment of the anterior and posterior tables, supraorbital distribution anesthesia or paresthesia, whereas the coronal images define the sinus floor forehead laceration, contour irregularity, and hema- and anterior skull base. The sagittal images add toma. Frontal sinus fractures may be suspected with the necessary dimension to fully assess the FSOT. bone fragments present in a laceration, cerebrospinal Three-dimensional CT reconstructions are valuable fluid (CSF) rhinorrhea, supraorbital/frontal bone ste- in visualizing any external contour deformity that poffs, or crepitus. may not be appreciated on physical examination or on Radiographic assessment with computed tomog- two-dimensional CT images. A radiographic finding raphy (CT) scan in patients with head injuries is of pneumocephalus suggests posterior table and/or required to evaluate their intracranial status. Given skull base fracture. 282 Paranasal Sinus Fractures MANAGEMENT ISSUES AND ALGORITHM Frontal sinus fracture management strategies de- ited time and resources at a Role 3 medical treatment pend on clinical and radiographic assessments of the facility, all necessary treatment is provided during anterior table, the posterior table, the FSOT, and the one operation, if possible. These patients often have dura. Assessment of these anatomical structures guides one operation and hospitalization for very complex, the head and neck surgeon in establishing the three life-threatening injuries. Thoracic, abdominal, and key functions of the frontal sinus: orthopaedic injuries are treated based on priorities established by the trauma surgeon. The treatment 1. restoring the preoperative facial aesthetics; priority for head and facial injuries is usually the 2. avoiding long-term sinus complications (eg, brain, the globes, and then the maxillofacial region. mucocele), chronic rhinosinusitis, or osteo- Concurrent surgeries by different specialties occur myelitis; and when space allows and within the parameters of the 3. isolating the neurocranium and preventing a patient’s overall medical condition. CSF leak. Skull base reconstruction has significantly improved over the past 20 years, driven largely by advances in Although these three elements are paramount, surgical treatment of skull base neoplasms. Large skull managing frontal sinus and skull base fractures in a base defects following tumor extirpation are usually deployed environment also requires an assessment treated with microvascular free-tissue transfer that of political factors and the military situation outside is the safest, most economical procedure.12 However, of the treatment facility. The head and neck surgeon this procedure has not been widely adopted in combat must understand the nature and stage of the conflict, settings because of inadequate resources and time con- the general capabilities and limitations of the host straints. Regional flaps (eg, the pectoralis major flap) nation medical system, and the patient’s military oc- are an option, but are often impractical because of a cupation and primary duties. For example, a Marine concurrent chest or thoracic injury. Local flaps are usu- who works in administration and sustains an anterior ally the best option in a deployed environment. When table frontal sinus fracture playing basketball during available, a pericranial flap is an excellent means of the nation-building phase of a conflict is treated dif- isolating the intracranial contents. Unfortunately, pen- ferently than a soldier in an infantry unit who sustains etrating head injuries often disrupt the pericranium, the same injury during a firefight in the combat phase thus an alternative method (eg, temporalis fascia, of a conflict. The former would benefit from an open tensor fasciae latae, or a dura substitute) is required.12 reduction and external fixation and convalescence in For bone reconstruction, titanium mesh is malleable, is theater, whereas the latter is best served by evacuation biocompatible with soft tissue and mucosa, undergoes to a higher level of care for treatment. osseointegration, and is readily available in the oper- Wounded American and coalition service members ating room.13 A calvarial bone graft is also an option, often require different care than host nation patients but volume loss due to resorption is a potential long- and enemy combatants. American and coalition patients term complication. Regardless of the materials used, are often the most straightforward to manage in a de- a multilayer closure is essential. Definitive cranial ployed environment. In a fluid tactical setting, damage reconstruction for decompressive craniectomy patients control surgery is performed. Neurosurgical and oph- or patients with large frontoorbital bar defects may be thalmological injuries are addressed; facial wounds are delayed and surgically addressed at a later time using copiously irrigated, judiciously debrided, and closed free flaps and bone grafts.14 primarily; and the patient is then transferred to a higher The algorithmic approach to frontal sinus fracture level treatment facility. In a more protracted conflict, repair that is used in civilian trauma
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