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Unformatted text preview: Frontal Sinus Frontal Sinus Fractures University of Texas Medical Branch Department of Otolaryngology January 17, 2006 Jeffrey Buyten, MD Matthew Ryan, MD Outline Outline Etiology Associated injuries Management Fixation methods Sinus obliteration Cranialization Frontal Sinus Anatomy Facts Frontal Sinus Anatomy Facts Absent @ birth Radiographically evident @ 8 years Adult size by 15 yrs 15% with unilateral sinus 4% with no sinus Anterior table 2­12 mm thick Posterior table 0.1 to 4.8 mm thick Strong, EB et al. Frontal sinus fractures: A 28­year retrospective review. Otolaryngology–Head and Neck Surgery (2006) 135, 774­ 779 Demographics/Etiology Demographics/Etiology 5 ­ 12% of facial fractures 30 year old males 800 – 1600 ft lb to fracture Strong, EB et al. Frontal sinus fractures: A 28­year retrospective review. Otolaryngology–Head and Neck Surgery (2006) 135, 774­ 779 Demographics/Etiology Demographics/Etiology High velocity impacts MVA 71% to 52% 1974­86 to 1987­02 Demographics/Etiology Demographics/Etiology 9% 5% MVA 52% 26% Assault Recreational Accidents I ndustrial Accidents Strong, EB et al. Frontal sinus fractures: A 28­year retrospective review. Otolaryngology–Head and Neck Surgery (2006) 135, 774­ 779 Sports Injuries 20% 25 % 6% 15% 34% Soccer Rugby Extreme sports Martial Arts Other Maladiere et al. Aetiology and Incidence of Facial Fractures Sustained During Sports: A Prospective Study of 140 Patients. Int J Oral Maxillofac Surg, 2001: 30; 291­295. Fracture Distribution Fracture Distribution Wallis et al Strong et al 1974­1986 1987­2002 Gossman et al 1990­2003 Chen et al 1994­2002 Anterio r 13 (18 %) 35 (28 %) 48 (50 %) 22 (28 %) Posterio r Ant/Post Frontal recess Total 2 (3%) 55 (79%) 2 70 4 (3%) 88 (69%) 3 127 0 48 (50%) n/a 96 0 56 (72%) n/a 78 Associated injuries Associated injuries Loss of consciousness 72% Obtunded/intubated 21% Intracranial injuries Pneumocephalus 26% Cerebral contusion 18% Dural tear 14% CSF leak 11% 5% with persistent CSF leaks Epidural hematoma 8% Strong, EB et al. Frontal sinus fractures: A 28­year retrospective review. Otolaryngology–Head and Neck Surgery (2006) 135, 774­ 779 Other Facial Fractures Multiple facial fractures in 75% of pts. Pediatric frontal sinus fractures 100% with concomitant orbital fractures Taiwan data California data Taiwan data Complications Complications Major complications 5% Meningitis Mucocele Minor complications 8% Wound infections, frontal paresthesias, temporal nerve paresis, frontal bone irregularities, diplopia on upward gaze Strong, EB et al. Frontal sinus fractures: A 28­year retrospective review. Otolaryngology–Head and Neck Surgery (2006) 135, 774­ 779 CSF leak CSF leak 12­30% basilar skull fx Spontaneous resolution 24­48 hrs Temporal bone > Ant cranial fossa Sx’s Postural headache Bacterial meningitis 7­30% Friedman, JA et al. Persistent Posttraumatic Cerebrospinal Fluid Leakage. Neurosurg Focus. 2000 (9), 1­5. Management Management Weigh intervention risks in critical patients PE, CT scan Primary goal Protect brain from further injury Secondary goals +/­ Sinus function Cosmetic Anterior, Posterior, Nasofrontal duct, CSF leak Anterior Table Management Anterior Table Management Non­displaced Observation Displaced ORIF (coronal, mid­brow approach) Endoscopic vs open Comminuted fractures ORIF (mesh vs miniplates) Ensure no mucosa trapped between fragments Rice, DH. Management of Frontal Sinus Fractures. Curr Opin Otolaryngol Head Neck Surg. Curr Opin Otolaryngol Head Neck Surg 12:46–48. © 2004 Lippincott Williams & Wilkins. Posterior Table Management Separate nasal cavity/sinus from intracranial cavity CSF leak No spontaneous resolution explore Repair dural tears Sinus obliteration Severely comminuted Cranialization Rice, DH. Management of Frontal Sinus Fractures. Curr Opin Otolaryngol Head Neck Surg. Curr Opin Otolaryngol Head Neck Surg 12:46–48. © 2004 Lippincott Williams & Wilkins. Nasofrontal Duct Management Obliteration Endoscopic Lothrup procedure Observation Minor injury in a reliable patient Reimage the patient in 1 to 3 months Rice, DH. Management of Frontal Sinus Fractures. Curr Opin Otolaryngol Head Neck Surg. Curr Opin Otolaryngol Head Neck Surg 12:46–48. © 2004 Lippincott Williams & Wilkins. Chen et al. Frontal Sinus Fractures: A Treatment Algorithm and Assessment of Outcomes Based on 78 Clinical Cases. Plast. Chen et al. Frontal Sinus Fractures: A Treatment Algorithm and Assessment of Outcomes Based on 78 Clinical Cases. Plast. Reconstr. Surg. 118: 457, 2006. Gossman et al Anterio Anterio r 48 (50%) 1990­2003 Posterior Ant/Post Frontal recess 0 48 (50%) ?? 8% 11% 3% 47% 30% Observation ORIF Stent Cranialization Obliteration Gossman et Laryngoscope al. Management of Frontal Sinus Fractures: A Review of 96 Cases., 116: 1357­136, 2006. Total 96 Anterior Chen et al 94­2002 Posterior Ant/Post 22 0 56 Chen et al. Frontal Sinus Fractures: A Treatment Algorithm and Assessment of Outcomes Based on 78 Clinical Cases. Plast. Reconstr. Surg. 118: 457, 2006. Wallis et al Strong et al 1974­1986 1987­2002 Anterio r 13 (18%) 35 (28%) Posterior Ant/Post Frontal recess Total 2 (3%) 55 (79%) 2 70 4 (3%) 88 (69%) 3 127 Strong, EB et al. Frontal sinus fractures: A 28­year retrospective review. Otolaryngology–Head and Neck Surgery (2006) 135, 774­ Strong, EB et al. Frontal sinus fractures: A 28­year retrospective review. Otolaryngology–Head and Neck Surgery (2006) 135, 774­ 779 Endoscopic Repair Endoscopic Repair Allows fixation of favorable ant table fxs Opportunity for nasofrontal aperture procedures at same setting. Endoscopic Repair Endoscopic Repair Fracture reduction Endoscopic browlift (subperiosteal) 30 degree scope w/endosheath Central stab incision Lateral incision to assist with the reduction Fracture camouflage Old fractures Alloplastic implant hides defect Pham, A and Strong, EB. Endoscopic management of facial fractures. Curr Opin Otolaryngol Head Neck Surg 14:234–241. 2006 Pham, A and Strong, EB. Endoscopic management of facial fractures. Curr Opin Otolaryngol Head Neck Surg 14:234–241. 2006 Lippincott Williams & Wilkins. Frontal Depressions Frontal Depressions Alloplastic fillers Acrylic implants Commonly used Hydroxyapatite cement Osseointegration Good biocompatibility Friedman, C et al. Reconstruction of the Frontal Sinus and Frontofacial Skeleton With Hydroxyapatite Cement. Arch Facial Plast Surg.2000;2:124­129 Friedman, C et al. Reconstruction of the Frontal Sinus and Frontofacial Skeleton With Hydroxyapatite Cement. Arch Facial Plast Friedman, C et al. Reconstruction of the Frontal Sinus and Frontofacial Skeleton With Hydroxyapatite Cement. Arch Facial Plast Surg.2000;2:124­129 Titanium Mesh Titanium Mesh Severely Comminuted fxs Lakhani, Raam S. MD et al. Titanium Mesh Repair of the Severely Comminuted Frontal Sinus Fracture. Arch Otolaryngol Head Neck Surg.2001;127:665­669 Closed Reduction Closed Reduction Case report Lost tip of probe in sinus Hwang et al. Closed Reduction of Fractured Anterior Wall of the Frontal bone. Journal of Craniofacial Surgery. 2005 (16); 120­ 122. Obliteration History Obliteration History Dates back to 1950’s (Bergara) Hypothesis Transplanted fat would remain vascularized Non­viable fat would fibrose •Weber, R, Draf, W et al. Osteoplastic Frontal Sinus Surgery With Fat Obliteration: Technique and Long­Term Results Using Magnetic Resonance Imaging in 82 Operations. Laryngoscope. 2000. 1037­44. •Fattahi et al. Comparison of 2 Preferred Methods Used for Frontal Sinus Obliteration. J Oral Maxillofac Surg 63; 487­91, 2005. Obliteration History Obliteration History Goodale and Montgomery (late 50’s and 60’s) Fat obliteration standard of care for difficult frontal sinus disease No sx recurrence or radiographic recurrence after 5 years Hardy and Montgomery (1976) 250 patients; median follow­up 8 years Complication rate 18% Abdominal wound ­ 5.2% Acute postoperative infections (necrosis of implanted fat) ­ 3% Recurrent chronic sinusitis ­ 3% 4% of cases had to be revised No report on the occurrence of mucoceles •Weber, R, Draf, W et al. Osteoplastic Frontal Sinus Surgery With Fat Obliteration: Technique and Long­Term Results Using Magnetic Resonance Imaging in 82 Operations. Laryngoscope. 2000. 1037­44. •Fattahi et al. Comparison of 2 Preferred Methods Used for Frontal Sinus Obliteration. J Oral Maxillofac Surg 63; 487­91, 2005. Obliteration Indications Obliteration Indications Mucopyocele, or recurrent acute sinusitis Severe fractures Chronic sinusitis Tumor Obliteration Principles Obliteration Principles Meticulous removal of all visible mucosa Removal of the inner cortex Cutting burr for thick bone and a diamond burr for the dura and orbital roof–periorbita Results do not depend on the choice of microscope or Loupe magnification Permanent occlusion of the nasofrontal duct Material that forms a fibrous barrier between the obliterated sinus and the nasal cavity. Prevents the implanted material from sliding downward and impairs the ingrowth of nasal mucosa. Weber, R, Draf, W et al. Osteoplastic Frontal Sinus Surgery With Fat Obliteration: Technique and Long­Term Results Using Magnetic Resonance Imaging in 82 Operations. Laryngoscope. 2000. 1037­44. Obliteration Materials Obliteration Materials Adipose tissue Pericranium Hydroxyapatite Temporalis fascia Bone chips Bio glass Polytetrafluoroethylene carbon fiber Calcium sulfate methylmethacrylate Oxidized cellulose Gelfoam Lyophilized cartilage Fattahi et al. Comparison of 2 Preferred Methods Used for Frontal Sinus Obliteration. J Oral Maxillofac Surg 63; 487­91, 2005. Hydroxyapatite Obliteration Hydroxyapatite Obliteration Friedman and Costantino (1991) HAC obliteration feline frontal sinuses. 30% replacement of the HAC with bone at 12 months 63% at 18 months. There was no evidence of mucosal membrane ingrowth or mucocele formation No complications in recent report in humans Fattahi et al. Comparison of 2 Preferred Methods Used for Frontal Sinus Obliteration. J Oral Maxillofac Surg 63; 487­91, 2005. Pericranial Flap Obliteration Pericranial Flap Obliteration Vascularized flap Does not rely on sinus walls for blood supply Low post op infection rate Bulky enough to obliterate frontal sinus Axial or random flap Axial flaps Anterior – supraorbital / supratrochlear arteries Lateral ­ anterior division of superficial temporal artery •Parhiscar et al. Frontal Sinus Obliteration with the Pericranial Flap. Otolaryngol Head Neck Surg 2001; 124: 304­7. •Ducic, Y et al. Frontal Sinus Obliteration Using a Laterally Based Pedicled Pericranial Flap. Laryngoscope 1999; 109 (4), p 541­55. Ducic, Y et al. Frontal Sinus Obliteration Using a Laterally Based Pedicled Pericranial Flap. Laryngoscope 1999; 109 (4), p 541­55. Ducic, Y et al. Frontal Sinus Obliteration Using a Laterally Based Pedicled Pericranial Flap. Laryngoscope 1999; 109 (4), p 541­55. Fat Obliteration Fat Obliteration Outcome not influenced by degree of surviving fat. Post op fat distribution < 20% 53% of cases > 60% 18% of cases Statistical tests and modeling Significant decrease of adipose tissue with time Median half­life 15.4 mo Weber, R, Draf, W et al. Osteoplastic Frontal Sinus Surgery With Fat Obliteration: Technique and Long­Term Results Using Magnetic Resonance Imaging in 82 Operations. Laryngoscope. 2000. 1037­44. Post op scans Post op scans CT Soft tissue windows Low attenuation of fat may be confused with air Range of normal appearances stages of partial fibrosis of the obliterating fat. Weber, R, Draf, W et al. Osteoplastic Frontal Sinus Surgery With Fat Obliteration: Technique and Long­Term Results Using Magnetic Resonance Imaging in 82 Operations. Laryngoscope. 2000. 1037­44. Post op scans Post op scans MRI Fat Fibrotic areas High signal intensity (T1) Intermediate signal (T2) Low to intermediate signal (T1 and T2) Patients with persistent symptoms had no distinguishing MRI features when compared with asymptomatic patients. Appearance of mucoceles. Varies according to the protein concentration of the secretions T1 ­ low, intermediate, or high signal T2 ­ high signal intensity Fat Obliteration Fat Obliteration Catalano 59 patients (1 to 9 years post op) 8.5% needed revision of osteoplastic flap 6.7% required correction of frontal bossing Loevner 13 patients (1 to 12 years post op) 3 mucoceles Weber, Draf 59 patients (1 to 12 post op) Mucoceles 5 of 51 cases 1, 3, 4, 8 and 10 years Weber, R, Draf, W et al. Osteoplastic Frontal Sinus Surgery With Fat Obliteration: Technique and Long­Term Results Using Magnetic Resonance Imaging in 82 Operations. Laryngoscope. 2000. 1037­44. Weber, R, Draf, W et al. Osteoplastic Frontal Sinus Surgery With Fat Obliteration: Technique and Long­Term Results Using Weber, R, Draf, W et al. Osteoplastic Frontal Sinus Surgery With Fat Obliteration: Technique and Long­Term Results Using Magnetic Resonance Imaging in 82 Operations. Laryngoscope. 2000. 1037­44. Pericranial Flap Cranialization Pericranial Flap Cranialization Donald and Bernstein (1978) First report of cranialization By convention; frontal sinus left as dead space or filled with free adipose tissue. Consider with displacement > one table width Severely comminuted fx Donath et al (2006) 19 patients, no reported complications One sphenoid CSF leak post op No post op infections Donath, A. Frontal Sinus Cranialization Using the Pericranial Flap: An Added Layer of Protection. Laryngoscope, 116:1585–1588, 2006 Donath, A. Frontal Sinus Cranialization Using the Pericranial Flap: An Added Layer of Protection. Laryngoscope, 116:1585–1588, 2006 Donath, A. Frontal Sinus Cranialization Using the Pericranial Flap: An Added Layer of Protection. Laryngoscope, 116:1585–1588, 2006 Donath, A. Frontal Sinus Cranialization Using the Pericranial Flap: An Added Layer of Protection. Laryngoscope, 116:1585–1588, 2006 What would you do? What would you do? References References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. Strong, EB et al. Frontal sinus fractures: A 28­year retrospective review. Otolaryngology–Head and Neck Surgery (2006) 135, 774­779. Maladiere et al. Aetiology and Incidence of Facial Fractures Sustained During Sports: A Prospective Study of 140 Patients. Int J Oral Maxillofac Surg, 2001: 30; 291­295. Friedman, JA et al. Persistent Posttraumatic Cerebrospinal Fluid Leakage. Neurosurg Focus. 2000 (9), 1­5. Weber, R, Draf, W et al. Osteoplastic Frontal Sinus Surgery With Fat Obliteration: Technique and Long­Term Results Using Magnetic Resonance Imaging in 82 Operations. Laryngoscope. 2000. 1037­ 44. Fattahi et al. Comparison of 2 Preferred Methods Used for Frontal Sinus Obliteration. J Oral Maxillofac Surg 63; 487­91, 2005. Gossman et Laryngoscope al. Management of Frontal Sinus Fractures: A Review of 96 Cases., 116: 1357­136, 2006. Hwang et al. Closed Reduction of Fractured Anterior Wall of the Frontal bone. Journal of Craniofacial Surgery. 2005 (16); 120­122. Pham, A and Strong, EB. Endoscopic management of facial fractures. Curr Opin Otolaryngol Head Neck Surg 14:234–241. 2006 Lippincott Williams & Wilkins. Friedman, C et al. Reconstruction of the Frontal Sinus and Frontofacial Skeleton With Hydroxyapatite Cement. Arch Facial Plast Surg.2000;2:124­129 Lakhani, Raam S. MD et al. Titanium Mesh Repair of the Severely Comminuted Frontal Sinus Fracture. Arch Otolaryngol Head Neck Surg.2001;127:665­669 Rice, DH. Management of Frontal Sinus Fractures. Curr Opin Otolaryngol Head Neck Surg. Curr Opin Otolaryngol Head Neck Surg 12:46–48. © 2004 Lippincott Williams & Wilkins. Parhiscar et al. Frontal Sinus Obliteration with the Pericranial Flap. Otolaryngol Head Neck Surg 2001; 124: 304­7. Ducic, Y et al. Frontal Sinus Obliteration Using a Laterally Based Pedicled Pericranial Flap. Laryngoscope 1999; 109 (4), p 541­55. Donath, A. Frontal Sinus Cranialization Using the Pericranial Flap: An Added Layer of Protection. Laryngoscope, 116:1585–1588, 2006 Chen et al. Frontal Sinus Fractures: A Treatment Algorithm and Assessment of Outcomes Based on 78 ...
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