Delayed endoscopic assisted percutaneous reduction of anterior table frontal sinus fractures





Abstract


Endoscopic approaches to the management of frontal sinus fractures continue to become more commonplace. Anterior table fractures amenable to reduction by these techniques are optimally managed within the first five to ten days to avoid fibrosis of the injury. We present a case of endoscopic transnasal reduction of an anterior table frontal sinus fracture over six weeks after the injury.


Introduction


Frontal sinus fractures comprise 5–15% of all facial trauma, a third of which are isolated to the anterior table [ ]. Management necessitates protection of intracranial structures, maintenance of sinus function and drainage, and restoration of facial aesthetics. These goals have classically required a bicoronal incision for management of the fracture.


Improved endoscopic techniques have made their way into craniomaxillofacial trauma. In frontal sinus fractures, applications range from placement of overlay implants for camouflaging contour, assisting reduction through trephine incisions, to complete transnasal reduction, including fractures of the poserior table and frontal sinus outflow tract (FSOT) [ ].


However, not all anterior table fractures are easily reduced transnasally. We present a case of an anterior table fracture that, despite the ease of exposure via transnasal techniques, required external reduction through a minimally invasive approach.


Case report


A 24 year old male was in an unhelemeted all terrrain vehicle (ATV) accident. He presented with headache and obvious forehead deformtity. Facial CT scan demonstrated a depressed fracture of the right anterior table of the frontal sinus ( Fig. 1 a ). A non-displaced fracture of the left frontal sinus with a small posterior table component (small arrow) was also present. No other significant maxillofacial trauma was identified.




Fig. 1a


Anterior table frontal sinus fracture at presentation. Small, non-displaced posterior table fracture (arrow) also present.



Fig. 1b


Axial postoperative CT demonstrating reduction of the fracture.



Fig. 1c


Coronal postoperative CT demonstrating fracture reduction and patent frontal sinus outflow tract.


Clinic follow up occurred over two weeks after the injury. After some additional delay, the plan was to proceed with endoscopic transnasal reduction of his fractures. Outpatient scheduling and patient related factors resulted in the procedure occurring 45 days after the injury.


Intraoperatively, a Draf IIb frontal sinusotomy was performed under image guidance [ ]. This involved an anterior ethmoidectomy with exposure of the frontal sinus ostium. The insertion of the middle turbinate and the medial floor of the frontal sinus was removed using an angled burr ( Fig. 2 a), allowing wide access to the frontal sinus ( Fig. 2 b). A 70° endoscope was inserted into the frontal sinus identifying the fracture ( Fig. 2 c). The fracture, although readily visible, was not readily mobile. Multiple attempts with numerous frontal sinus instruments were unsuccessful in reducing the fracture. Balloon catheter reduction was also unsuccessful. A stab incision was then made directly over the fracture and a hole was drilled into the depressed fragment. A Carroll Girard screw ( Fig. 3 a) was inserted under transnasal visualization ( Fig. 2 d) and the fracture was mobilized and successfully reduced. The posterior table fracture in the contralateral sinus was simply observed.


Jul 5, 2021 | Posted by in OTOLARYNGOLOGY | Comments Off on Delayed endoscopic assisted percutaneous reduction of anterior table frontal sinus fractures
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