Sinus Preservation Management for Frontal Sinus Fracturesin the Modern Era: A Systematic Review

Objective To systematically review the existing literature supporting the efficacy and safety of sinus preservation management for frontal sinus fractures in the modern era of endoscopic frontal sinus surgery. Study Design A systematic review of the English literature for the targeted objective was conducted using the PubMed database between January 1995 and August 2008. Methods The PubMed database was queried using two major search terms of frontal sinus fracture or frontal sinus injury along with manual review of citations within bibliographies. Citations acquired from the primary search were filtered and relevant abstracts were identified that merited full review. Articles were identified that included any cohort of patients with frontal sinus fractures involving the frontal sinus outflow tract or posterior wall with sinus preservation management. Results A total of 231 citations were generated and 56 abstracts were identified as potentially relevant articles. Sixteen articles merited full review, with 7 articles meeting inclusion criteria for sinus preservation. There were 515 total patients in the studies with 350 patients managed with frontal sinus preservation. Similar short-term complications and effectiveness were found between fractures managed with sinus preservation and those with traditional management. Conclusions Sinus preservation appears to be a safe and effective management strategy for select frontal sinus fractures. Many of the complications encountered with sinus preservation can be successfully managed with endoscopic frontal sinus surgery. More transparent reporting of management strategies for individual cases or cohorts is needed. A standardized algorithm and categorization framework for future studies are proposed. Longer-term follow-up and larger prospective studies are necessary to assess the safety and efficacy of sinus preservation protocols. The incidence of frontal sinus fractures ranges from 5-15% of all facial fractures.1, 2 Motor vehicle crashes are the most common cause of frontal sinus fractures and often result in concomitant orbital, nasal, and midfacial fractures. Several options for management of frontal sinus fractures have been described in the literature based on fracture pattern and associated injuries. The degree of fracture displacement, status of the frontal sinus outflow tract (FSOT), and any associated intracranial injuries may dictate management by observation, open reduction and internal fixation (ORIF) of the anterior table, obliteration, or cranialization. Management of isolated anterior table fractures without FSOT involvement has generally met consensus in the literature.1, 3 However, there is still controversy over the management of fractures with suspected involvement of the FSOT or posterior table. Fractures involving the FSOT have traditionally been obliterated or cranialized.4, 5 Posterior table fractures associated with brain injury and persistent cerebrospinal fluid leak often require dural repair and sinus cranialization.5, 6 The goal of this study was to systematically review the literature to identify the effectiveness and safety of sinus preservation for management of frontal sinus fractures. Specifically, we narrowed our study to address the question: “In the modern era of endoscopic frontal sinus surgery, what is the role of sinus preservation in the management of frontal sinus fractures?” In the last 15 years, endoscopic technology has become standard in the management of frontal sinus disease, including sinusitis, mucoceles, and cerebrospinal fluid leaks, all of which are common complications encountered with frontal sinus fractures.7-9 More recently, endoscopic approaches have even been utilized in facial fractures repair.10 We limited our literature search to articles published from January 1995 to the present, which we arbitrarily defined as the “endoscopic sinus surgery era.” In addition, we propose a reporting system that may help standardize classification of frontal sinus fractures based on degree of anterior table, posterior table, and FSOT involvement. Ultimately, patient outcomes should include any complications with specific management, as well as information about frontal sinus ventilation. This reporting system may help standardize patient reporting and outcomes which will facilitate comparison of patient cohorts across institutions and the development of a uniform treatment algorithm for management of frontal sinus fractures. 1. Bell RB, Dierks EJ, Brar P, Potter JK, Potter BE. A protocol for the management of frontal sinus fractures emphasizing sinus preservation. J Oral Maxillofac Surg. 2007 May;65(5):825-39. 2. Rohrich RJ, Hollier LH. Management of frontal sinus fractures. changing concepts. Clin Plast Surg. 1992 Jan;19(1):219-32. 3. McRae M, Momeni R, Narayan D. Frontal sinus fractures: A review of trends, diagnosis, treatment, and outcomes at a level 1 trauma center in connecticut. Conn Med. 2008 Mar;72(3):133-8. 4. Tiwari P, Higuera S, Thornton J, Hollier LH. The management of frontal sinus fractures. J Oral Maxillofac Surg. 2005 Sep;63(9):1354-60. 5. Manolidis S, Hollier LH,Jr. Management of frontal sinus fractures. Plast Reconstr Surg. 2007 Dec;120(7 Suppl 2):32S-48S. 6. Chen KT, Chen CT, Mardini S, Tsay PK, Chen YR. Frontal sinus fractures: A treatment algorithm and assessment of outcomes based on 78 clinical cases. Plast Reconstr Surg. 2006 Aug;118(2):457-68. 7. Smith TL, Han JK, Loehrl TA, Rhee JS. Endoscopic management of the frontal recess in frontal sinus fractures: A shift in the paradigm? Laryngoscope. 2002 May;112(5):784-90. 8. Batra PS, Citardi MJ, Lanza DC. Combined endoscopic trephination and endoscopic frontal sinusotomy for management of complex frontal sinus pathology. Am J Rhinol. 2005 Sep-Oct;19(5):435-41. 9. Kanowitz SJ, Shatzkes DR, Pramanik BK, Babb JS, Jacobs JB, Lebowitz RA. Utility of sagittal reformatted computerized tomographic images in the evaluation of the frontal sinus outflow tract. Am J Rhinol. 2005 Mar-Apr;19(2):159-65. 10. Mueller R. Endoscopic treatment of facial fractures. Facial Plast Surg. 2008 Jan;24(1):78-91. 11. Xie C, Mehendale N, Barrett D, Bui CJ, Metzinger SE. 30-year retrospective review of frontal sinus fractures: The charity hospital experience. J Craniomaxillofac Trauma. 2000 Spring;6(1):7,15; discussion 16-8. 12. Gabrielli MF, Gabrielli MA, Hochuli-Vieira E, Pereira-Fillho VA. Immediate reconstruction of frontal sinus fractures: Review of 26 cases. J Oral Maxillofac Surg. 2004 May;62(5):582-6. 13 Weber R, Draf W, Kratzsch B, Hosemann W, Schaefer SD. Modern concepts of frontal sinus surgery. Laryngoscope. 2001 Jan;111(1):137-46. Article Selection Process A multi-step search of the PubMed database was performed using the major search terms of frontal sinus fracture or frontal sinus injury. The initial search was limited to include articles published between January 1995 and September 2008. Citations acquired from the primary search were filtered; all non-English and nonrelevant articles were excluded at this time. Citations that did not appear to focus on the management of frontal sinus fractures were deemed non-relevant. Abstracts were eliminated if they did not address the target question or did not contain patient data. Articles were included if they reported patients with FSOT or posterior table fractures managed with sinus preservation. “Sinus preservation” included all fractures managed by observation, endoscopic or open reduction of the anterior and/or posterior table, and ORIF of the anterior table. The goals of frontal sinus fracture repair include restoration of frontal contour and cosmesis, establishment of normal sinus ventilation, isolation of intracranial contents, and most importantly, prevention of the numerous complications that can arise in the setting of frontal sinus injury.11, 12 With the widespread acceptance of endoscopic management of sinus disease, endoscopic techniques directed at the frontal sinus have gained acceptance. Procedures such as the Draf type III or frontal sinus drillout have been well established and accepted.13 These techniques have been proven effective in management of frontal sinus mucoceles and chronic sinusitis, both known complications of frontal sinus fractures. These techniques have also been effectively used to manage complications from failed attempts at frontal sinus obliteration. The establishment of these procedures and their application for management of frontal sinus fractures allows for more conservative management and sinus preservation in these patients. Sinus preservation offers several advantages over traditional management with obliteration or cranialization: 1. Shorter operative time and exposure to anesthesia. 2. Negates need for wide exposure to remove all sinus mucosa and risk of bone devitalization 3. Complications that arise in the setting of a preserved sinus would be more apparent on imaging studies and potentially identified sooner. In addition, the status of the frontal sinus can be evaluated in the clinic with endoscopic examination. Sinus preservation may be considered in patients with frontal sinus fractures and the following characteristics: 1. Non-displaced or minimally displaced fractures of the anterior wall 2. Non-displaced or minimally displaced posterior wall fractures without significant intracranial injury or persistent csf leak (traditionally cranialized) 3. Displaced anterior wall fractures with suspected FSOT involvement (traditionally obliterated) 4. Displaced anterior and minimally displaced posterior wall fractures without significant intracranial injury or persistent csf leak (traditionally obliterated or cranialized) Introduction Results Discussion References Conclusion Sinus preservation appears to be a safe and effective management strategy for select frontal sinus fractures. Several recent studies have proposed sinus preservation protocols using endoscopic management of the FSOT