Frontal sinus fracture: Clinical presentation and radiographic evaluation

Clinical Presentation

The individual suffering from a frontal sinus fracture includes a characteristic history. A traumatic episode towards the forehead has occurred involving considerable force, and also the patient usually reports loss of consciousness. Initial management is directed at life-threatening conditions and stabilizing the patient's condition. Physical findings can include but are not restricted to frontal swelling, pain, lacerations over the forehead skin and numbness over the forehead. A bony defect may be palpated over depressed anterior wall fractures.

Epistaxis is often present and could be combined with cerebrospinal fluid (CSF) from the dural tear caused by either a depressed posterior wall fracture or coincidental fracture from the anterior cranial fossa floor. A fracture of the superior orbital rim could be present, causing the globe to become displaced or trapped. A fracture from the nasoethmoidal complex can manifest as flattening of the pyramid and telescoping from the nose.

Radiographic Evaluation

The clinical picture in most instances does not allow clear differentiation between the fracture of the various frontal sinus walls or across the frontonasal duct. Radiographic evaluation, in particular computed tomography (CT), is clearly the most valuable diagnostic tool in frontal sinus fractures. CT clearly depicts fractures, the quantity of depression, and the nature from the items in the sinus cavity, adjacent brain and overlying soft tissue.

Fine axial sections are helpful for evaluating anterior and posterior table fractures of the frontal sinus and intracranial injuries. "True" coronal scans are useful for assessing the ground from the frontal sinus, the frontonasal duct and cribiform plate. Coronal images that are reconstructed from axial scans do not provide adequate resolution to assess these structures.

Classification

For ease of diagnosis and formulation of the treatment algorithm, frontal sinus fractures can be split into two types: anterior table fractures and posterior table fractures. Each kind of fracture can further be divided into displaced or nondisplaced fractures.

Management

The goals in management of frontal sinus fractures are: (1) protection against intracranial infection; (2) protection against frontal sinus disease (for example sinusitis and mucocele); and (3) a cosmetically acceptable outcome. Antibiotic prophylaxis is generally recommended.

Antibiotics with high CSF penetration, such as ceftriaxone, as well as metronidazole for anaerobic coverage are good choices if you find risk of intracranial sepsis. For Gram-positive coverage in cases of skin contamination, cefazolin can be added. For compound fractures, antibiotic treatments are maintained for 2 weeks. In cases of closed or isolated fractures, antibiotic me is controversial.

Although this simplifies frontal sinus fractures based on the involved walls, the surgeon is often confronted with someone with multiple fractures. A good approach is to have a treatment scheme that addresses each specific site and then apply those principles to each particular case.

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