79 An unbelted 34-year-old woman was involved in a motor vehicle accident in which she struck her forehead to the windshield with loss of consciousness. The patient was unconscious with no gross focal neurologic deficits, and her hemodynamic status was stable. No clear rhinorrhea was evident. Neurosurgical consultation and head computed tomography (CT) scan evaluation showed anterior and posterior table commuted fractures with pneumocephalus. No evidence of intracranial parenchymal injuries or of intracranial bleeding was seen. The lateral cervical spine film was clear, and she had no other bodily injuries. The patient was emergently taken to the operating room by neurosurgery to rule out intracranial injuries and for her severe frontal sinus fractures. The otolaryngology service was consulted while the patient was being transported to the operating room to participate in the frontal sinus fracture repair. 1. In a patient with multiple trauma, the overall status must be emergently evaluated and be the top priority (airway, breathing, circulation, cervical status, intracranial status). Only after these steps are stabilized can facial injuries be addressed. In some instances, facial fractures may need to be addressed in a later setting, depending on the medical status. In this instance, the major goal of the neurosurgical team was to evaluate for intracranial injuries and to address her comminuted frontal sinus fractures with the assistance of otolaryngology. 2. It is optimal to obtain a CT of the face (axial and coronal views) in patients with significant head trauma correlating it to a complete facial exam. In other instances, due to the patient’s changing clinical status, the otolaryngology service may be contacted while the patient is being expeditiously transported to the operating suite by the trauma surgical services. 3. In a patient who has multiple major body traumas, it is imperative to have a clear communication with all the involved surgical teams to approach the patient in a staged coordinated manner to prevent lengthy procedures by multiple services at one sitting if the patient’s status is precarious. 4. For any head trauma, the possibility of cervical spine injury must be ruled out with cervical spine radiographs and clinical examination. However, if the patient is unconscious, the clinical assessment of a cervical spine cannot be performed, and frequently the patient is left in a cervical collar because an occult cervical injury may still be present. Even in the emergent setting when the clinical situation dictates against complete cervical spine radiographs, the neck must be immobilized and protected from any out-of-axis movements until appropriate cervical injury is ruled out. In some instances low cervical spine injury can be missed despite performance of full cervical radiographic series owing to the difficulty of radiographically imaging this area. 5. In depressed anterior frontal sinus wall fractures, soft tissue edema can mask a contour deformity in the acute phase. Thus, a CT scan is required. High-resolution CT scan (axial and coronal images using 1.5-mm cuts) is very helpful in delineating the extent of bony displacement. Associated findings with frontal sinus fractures are central nervous system (CNS) injuries and cerebrospinal fluid (CSF) leaks. As in this case, injury to the posterior frontal sinus wall significantly increases the risk of dural tears (70% of displaced posterior walls have CSF leaks). Other possible CNS injures includes brain contusion, subdural hematoma, pneumocephalus, and frontal lobe laceration.
Frontal Sinus Fracture
History
Differential Diagnosis—Key Points
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