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Fracture, Frontal Sinus

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Ovid: 5-Minute Sports Medicine Consult, The


Fracture, Frontal Sinus
Martha A. Dodson
Basics
Pediatric Considerations
  • Frontal sinuses are not present at birth and begin to develop around 7 yrs of age, continuing to develop until puberty.
  • Ethmoid and maxillary sinuses are present at birth.
  • Sphenoid sinuses develop around 5 yrs of age.
  • Airway control takes precedence.
    • Associated facial injuries may preclude the use of oral intubation.
    • Nasotracheal intubation is contraindicated in massive facial or nasal trauma.
    • Cricothyrotomy is the airway of choice if intubation using rapid sequence intubation cannot be performed.
  • Many patients with frontal sinus fractures have associated facial and/or neurologic injuries owing to the amount of force needed to create the injury.
  • Consider the need for cervical spine immobilization, especially in the presence of multitraumatic fractures and/or high-velocity trauma.
  • The presence of rhinorrhea and/or otorrhea should suggest the possibility of frontal sinus fracture.
  • Frontal sinus fracture is not the immediate concern in a multitrauma victim.
Description
  • Typically owing to high-velocity blunt trauma localized to the face/head/frontal sinus area
  • The most common mechanisms of injury are motor vehicle collisions, assaults, falls, and other accidents.
  • Because the anterior table is thick, it requires 800–2,200 lb of force to cause frontal sinus fracture (twice the force required to fracture other facial bones).
  • Most common classification identifies involved frontal sinus anatomy:
    • Anterior wall/table
    • Posterior wall/table
    • Anterior and posterior walls/table
    • Nasofrontal duct (NFD) involvement
Epidemiology
  • Frontal sinus fractures account for 5–12% of all facial fractures.
  • 35% have concomitant orbital fractures.
  • 17% have zygomatic fractures.
  • 15% have naso-orbitoethmoid fractures.
  • 0.7–2.1% have involvement of both anterior and posterior walls of the frontal sinus.
Risk Factors
  • High-velocity trauma to the face, especially in presence of other facial bone fractures
  • Acromegaly: Size and extension of frontal sinuses enlarged
General Prevention
  • Avoidance of motor vehicle collisions
  • Proper use of vehicle safety restraints
Commonly Associated Conditions
  • Laceration of the supraorbital ridge, glabella, or lower forehead
  • Frontal ecchymosis
  • Disruption of the NFD
  • Intracranial injuries in 12–17% of patients with frontal sinus fractures
  • Associated cerebrospinal fluid (CSF) leak in ∼15% of patients with frontal sinus fractures
  • Ocular injuries are present in up to 59%.
  • Periorbital fractures
  • Traumatic subcutaneous emphysema (TSE)
  • Concussion
  • Potential sequelae:
    • Brain abscess
    • Contour deformity
    • Osteomyelitis
    • Hematoma
    • Meningitis
    • Mucocele
Diagnosis
  • Look for and treat life-threatening injuries first.
  • Carefully palpate the frontal area for crepitus or depression.
  • Lacerations over the frontal sinus area should raise suspicion of frontal sinus fracture and mandate digital palpation for a fracture.
  • Perform a nasal speculum examination looking for blood, septal hematoma, or CSF high in the nasal cavity.
  • Perform otoscopic exam looking for otorrhea and/or hemotympanum.
  • Perform a careful neurologic examination to look for CNS injury, including concussion.
  • Perform a careful ophthalmologic exam.
Pre Hospital
  • Cervical spine immobilization considerations
  • Identify concomitant life-threatening injuries.
History
  • Victim of motor vehicle collision, assault to head/face, fall, or other high-velocity trauma
  • May or may not have loss of consciousness
Physical Exam
The physical examination is the most important aspect of the evaluation. Failure to diagnose a frontal sinus fracture can lead to abscess formation, meningitis, mucocele formation, osteomyelitis of the calvarium, or permanent cosmetic deformity.
  • Laceration on the supraorbital ridge, glabella, or lower forehead
  • Ecchymosis of periorbital region
  • Periorbital edema
  • Depression or step-off identified on palpation of frontal sinus area
  • Crepitus over the frontal sinus area
  • Subcutaneous emphysema of periorbital region
  • Associated facial trauma with supraorbital, orbital, nasal, frontonasoethmoid, or maxillary fractures
  • Associated ocular trauma may be present.
  • Bloody discharge from the nose without visible nasal source
  • Clear rhinorrhea or otorrhea indicative of CSF leak
  • Absent tearing that may be indicative of nasofrontal duct injury
  • Diplopia with upward or downward gaze
  • Supraorbital ridge anesthesia
  • Loss of consciousness or altered mental status secondary to associated brain injury or posterior table fracture
  • May complain of double vision, anesthesia to skin surrounding eye, “postnasal drip” sensation (owing to CSF leak)
  • May present with facial subcutaneous emphysema following Valsalva maneuver owing to previously undiagnosed paranasal fracture following facial trauma.
Diagnostic Tests & Interpretation
  • CT scanning is the imaging modality of choice.
    • Serial 1.5-mm cuts in both the axial and coronal planes
    • Identification of frontal sinus fractures and concomitant paranasal and facial fractures
    • Anterior table fracture, displaced or nondisplaced; displacement is defined as bony displacement more than or equal to the width of the outer table.
    • Posterior table fracture identification: Associated intracranial injuries on CT scan may include subdural hemorrhage or pneumocephalus.
    • Frontonasal duct integrity
  • Caldwell and lateral radiographic views are good for preliminary evaluation, but frontal sinus fractures can be subtle on these films. Sinus pathology is strongly suspected when the x-rays show air-fluid levels, a diffusely cloudy sinus, or pneumocephalus.
Lab
None recommended
Imaging
Requires acute examination and imaging
  • CT scanning is the imaging modality of choice.
    • Serial 1.5-mm cuts in both the axial and coronal planes
    • Identification of frontal sinus fractures and concomitant paranasal and facial fractures
    • Anterior table fracture, displaced or nondisplaced; displacement is defined as bony displacement more than or equal to the width of the outer table.
    • Posterior table fracture identification: Associated intracranial injuries on CT scan may include subdural hemorrhage or pneumocephalus.
    • Frontonasal duct integrity

    • P.199


  • Caldwell and lateral radiographic views are good for preliminary evaluation, but frontal sinus fractures can be subtle on these films. Sinus pathology is strongly suspected when the x-rays show air-fluid levels, a diffusely cloudy sinus, or pneumocephalus.
Differential Diagnosis
  • Nasofrontoethmoid fractures
  • Cribriform plate fractures
  • Facial fractures, including the orbits, maxilla, nasal, and zygomatic bones
  • Frontal fractures not involving the frontal sinus (may have a similar presentation)
Treatment
Pre-Hospital
  • Physical examination including complete neurologic exam
  • High suspicion for fracture given nature of trauma and physical findings
  • Airway, breathing, and circulation (ABCs)
  • Cervical immobilization as needed
ED Treatment
  • If while irrigating a laceration overlying the frontal sinus the patient can taste the irrigating solution or notes the irrigating fluid in the nose, the frontal sinus is disrupted.
  • Lacerations overlying frontal sinus fractures involving only the anterior table may be sutured in the ED. ENT or plastic surgery should evaluate lacerations associated with more complex sinus injuries.
  • If an isolated simple anterior table fracture is noted without a posterior table fracture and intracranial injuries are rules out, the presence of a frontonasal duct injury should be evaluated by instilling fluorescein into the frontal sinus. Lack of visualization of the fluorescein in the nose is indicative of disruption of the duct.
  • Antibiotics are indicated in all patients with frontal sinus fractures. IV antibiotics are indicated in patients with posterior table fractures or CSF leaks.
  • Nondisplaced frontal sinus fracture with a patent nasofrontal duct and no neurologic involvement usually can be managed nonsurgically.
  • All displaced anterior wall fractures, all posterior wall fractures, all frontal sinus fractures with involvement/obstruction of the nasofrontal duct, and all frontal sinus fractures with neurologic involvement require further surgical evaluation and probable surgical repair.
Medication
  • Cefotaxime: Adult: 2 g IV; children: 50 mg/kg IV single dose
  • Cephalexin: Adult: 250–500 mg PO q.i.d.; children: 25–50 mg/kg/day divided q.i.d.
Additional Treatment
The approach to each patient should be individualized but, in general, is based on 3 clinical factors:
  • Fracture location and displacement
  • Dural and cerebral involvement
  • Damage to the frontal sinus drainage system
In-Patient Considerations
Initial Stabilization
  • ABCs of trauma care: Attend to the airway as the 1st priority.
    • RSI is the initial airway management of choice.
    • Massive facial injuries may require a surgical airway if RSI is unsuccessful.
  • If associated injuries are present, protect the cervical spine until cleared.
  • Other major injuries and life threats take precedence over the frontal sinus fracture.
Admission Criteria
  • Patients with other significant associated trauma
  • Patients with posterior table fractures (neurosurgery or ENT evaluation)
  • Patients with associated intracranial injuries (neurosurgery)
  • Patients with CSF leak
Discharge Criteria
  • Patients with frontal sinus fractures who may be discharged are those with isolated frontal sinus fracture, those who have no involvement of the posterior table or evidence of an intracranial injury on CT scan.
  • Oral antibiotics are indicated in these patients.
  • Referral to ENT in 24–36 hr is appropriate.
  • Patients with complex fractures may be discharged when cleared by neurosurgery and/or ENT.
Ongoing Care
Patient Education
  • Avoid Valsalva maneuvers (eg, sneezing, nose blowing, etc.) to minimize risk of subcutaneous emphysema.
  • Avoid air travel for a period (individualize for each patient) after frontal sinus fracture.
Complications
  • Early complications:
    • Contour deformity postoperatively
    • Sinusitis: Treat with antibiotics and decongestants. If swelling and/or pain to periorbital region persists, may need to refer for surgical sinus mucosal obliteration.
    • Meningitis
  • Late complications:
    • Thrombosis of cavernous sinus
    • Encephalitis
    • Mucocele
    • Mucopyocele
    • Osteomyelitis
    • Brain abscess
    • Surgical referral for any of these
Additional Reading
Bell RB, Dierks EJ, Brar P, et al. A protocol for the management of frontal sinus fractures emphasizing sinus preservation. J Oral Maxillofac Surg. 2007;65:825–839.
Bell RB. Management of frontal sinus fractures. Oral Maxillofac Surg Clin North Am. 2009;21:227–242.
Brasileiro BF, Cortez AL, Asprino L, et al. Traumatic subcutaneous emphysema of the face associated with paranasal sinus fractures: a prospective study. J Oral Maxillofac Surg. 2005;63:1080–1087.
Kalavrezos N. Current trends in the management of frontal sinus fractures. Injury. 2004;35:340–346.
Kaufman BR, Heckler FR. Sports-related facial injuries. Clin Sports Med. 1997;16:543–562.
Keefe SO, et al. Frontal sinus fractures. In: English GM, ed. Otolaryngology. Vol 4. Rev ed. Philadelphia: JB Lippincott, 1994:342–364.
Manson PN. Maxillofacial injuries. Emerg Med Clin North Am. 1984;2:761–782.
Rohrich RJ, Hollier LH. Management of frontal sinus fractures. Changing concepts. Clin Plast Surg. 1992;19:219–232.
Tiwari P, Higuera S, Thornton J, et al. The management of frontal sinus fractures. J Oral Maxillofac Surg. 2005;63:1354–1360.
Codes
ICD9
  • 801.00 Closed fracture of base of skull without mention of intra cranial injury, with state of consciousness unspecified
  • 801.50 Open fracture of base of skull without mention of intracranial injury, with state of consciousness unspecified
Clinical Pearls
For lacerations, ecchymosis, and/or edema to frontal sinus region following trauma, consider and evaluate with CT scan for frontal sinus fracture.


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