Endoscopic Management of Frontal Sinus Fractures

Management of facial trauma always has been a balancing act between achieving accurate fracture reduction and stabilization, while causing as little morbidity as possible. Until roughly the 1930s, management of facial fractures consisted of external splints and bandages, which simply immobilized the fractures and allowed them to heal. Although external splints imparted little morbidity, the fractures rarely were reduced anatomically. Later, interfragment wires and suspension wires were developed, somewhat improving reduction and stabilization. Wire placement and fracture reduction, however, required multiple small keyhole incisions, and the reductions rarely were completely accurate or rigidly stabilized. In the late 1980s and early 1990s, the development of plate and screw fixation placed by means of extended-access approaches provided excellent fracture reduction and fixation but required long incisions and extensive soft tissue elevation . As surgeons continued to refine their management of facial trauma, it was only natural that a less invasive approach to fractures would be found.

Endoscopes have had a profound effect on nearly every surgical specialty over the past 20 years. Using endoscopic approaches, excellent visualization of the surgical site can be achieved while avoiding extensive external incisions, thus, dramatically reducing morbidity compared with traditional surgical approaches. The specialties of orthopedics, gynecology, abdominal surgery, thoracic surgery, and paranasal sinus surgery have been enhanced by the ability to perform accurate endoscopic surgery while virtually eliminating the long surgical scars and pain of surgical approaches. To perform effective endoscopic surgery, a cavity is required to keep soft tissue from draping over the endoscope and obscuring visualization of the surgical site. The use of endoscopes for facial surgery has lagged behind these other specialties primarily because of the lack of a readily usable optical cavity, but also difficulty working around the curve of the skull. In the aforementioned surgical specialties, the optical cavities are either natural (as with sinus and thoracic surgery) or created by infusing gas (abdominal surgery) or saline (orthopedic surgery). Unfortunately, for most facial skeletal surgery, there is no readily available cavity in which an endoscope can function. To overcome this deficiency, special sheaths have been designed for the scopes with extensions that hold soft tissue away from the surgical site. Typically, a 30° scope is used in conjunction with the sheath and extension. These tent the soft tissues away from the surgical site. This tenting of the soft tissue creates an optical cavity, allowing the surgeon to look down on the surgical site using a 30° scope [ Figs. 1–4 ]. This article outlines the state of the art with regard to the use of endoscopes for managing frontal sinus fractures, which are one of the most common fractures treated with endoscopic techniques.