Endoscopic Management of Frontal Sinus Fractures

Endoscopic management of frontal sinus fractures 

Endoscopic forehead lifting has been accepted for the past 10 years and has provided significant experience with endoscopic management of the frontal region for aesthetic purposes [17], [18], [19], [20], [21], [22], [23]. With this experience has come well-developed exposures and instrumentation. Using endoscopic techniques, several authors have reported case reports detailing successful management of anterior wall fractures of the frontal sinus [24], [25], [26], [27], [28], [29]. These reports have dealt exclusively with eggshell fractures of the anterior wall that simply are popped back into position and allowed to heal without fixation. Strong and colleagues reported on a cadaver study looking at the feasibility of performing endoscopic reduction and fixation. They found that the fractures could be visualized, but they encountered difficulty with complete reduction and were unable to perform rigid fixation in a noninvasive manner. As an alternative, Stronge and colleagues recommended camouflaging the anterior wall depression by endoscopically applying hydroxyapatite bone cement.

At the University of Cincinnati, the author and colleagues have attempted endoscopic reduction of frontal sinus fractures on 19 patients and have been successful in 12 of them. Success is defined as a reduction sufficiently anatomic and stable that no further treatment was felt to be necessary (by the physician or patient) The author's technique is similar to endoscopic forehead lifting, with one central and two lateral hairline incisions [Fig. 4, Fig. 5]. It is preferred to work through separate ports for the endoscope and instruments to avoid crowding of the instruments and scope at the anterior portion of the incision. The forehead soft tissues are elevated subperiosteally, and the fractures are visualized by means of a 30° endoscope with an external sheath for soft tissue retraction [Fig. 6, Fig. 7]. Once the fracture site is visualized, one attempts to elevate the fragments with endoscopic elevators. The author, however, has found that it is usually necessary to approach the fragments directly through small forehead incisions (preferably hidden in the brow). Using small external incisions directly over the fractures allows the surgeon to apply anterior force for anatomic reduction of the fracture segments. This approach has been more successful than trying to work within the forehead skin envelope, which requires more of a prying motion to elevate the fractures; this tips the fragments. The fractures are elevated using percutaneous nerve hooks, or by drilling into the fragments and grabbing them with threaded Steinmann pins [see Fig. 5, Fig. 6, Fig. 7]. With gentle retraction, the fragments often elevate into a reduced position and are frequently stable without the need for rigid fixation. Given the fact that the fracture segments are not approached directly, it is common to have residual surface irregularities. These irregularities are considered a trade off for avoiding long, approach incisions, and they are camouflaged with patches of Vicril Mesh (Ethicon, Inc., Somerville, New Jersey) [Fig. 7].

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Fig. 5. (A) Endoscopic view of frontal sinus anterior wall fracture. (B) Direct percutaneous approach with threaded Steinman pin and nerve hook to elevate bone fragments. (C) Combination of nerve hook and threaded Steinman. (D) Instruments in midline and paramedian incisions.

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Fig. 6. The surgeon sits at the head of the table, and the monitor is at the foot.

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Fig. 7. (A) Frontal sinus anterior wall fracture. This is a good candidate for endoscopic reduction, because it is not comminuted. (B) Incisions planned. (C) Threaded Steinman pin used to reduce fracture fragments while the endoscope is used to monitor the reduction. (D) Endoscopic view of Vicryl mesh placement for camouflage of residual irregularities. (E) Six-week postreduction photo.

In the four patients whose endoscopic fracture repair was felt to be unsuccessful, the reason was that the fracture segments were unstable after endoscopic reduction. The fragments continued to collapse despite having been reduced. In retrospect, these unsuccessful reductions were more extensively comminuted then was appreciated on the initial review of the coronal and axial CT scans. This highlights the importance of careful patient selection and the need for fully informing patients that the endoscopic approach may not reduce their fractures fully. Cases with unstable anterior walls after endoscopic reduction were converted to an open approach with coronal incisions and rigid fixation in the standard fashion [Fig. 8]. Based on this experience, the author feels that the endoscopic technique is appropriate only for anterior wall frontal sinus fractures that have several large segments without extensive comminution. It goes without saying that more extensive fractures with involvement of the nasofrontal ducts or posterior wall should have open approaches . Additionally, the surgeon should be prepared to camouflage any residual irregularities with the material of choice. As mentioned, the author prefers Vicril mesh, but alternatives would include bone cement, Gore-Tex, Alloderm, or Surgicell.

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Fig. 8. (A) Unsuccessful attempt at endoscopic reduction. The fracture was too comminuted and unstable. (B) Fracture was managed with a coronal approach and rigid fixation with titanium mesh.