![]() The management of frontal sinus fractures has become increasingly conservative because of the accumulated experience and the advent of endoscopic sinus surgery. The posterior wall of the sinus is removed, the mucosa is meticulously stripped, and the dura and brain are brought to rest against the surgically repaired outer table of calvarium. The sinus mucosa is removed to prevent mucocele and subsequent mucopyocele formation.įractures that cause significant displacement of the posterior table and/or compromise of the dura are cranialized. These procedures are best performed within 2 weeks posttrauma.įrontal sinus obliteration is best achieved if, after the sinus mucosa is exenterated, the cavity is filled with vascularized pericranial flap (rather than devascularized abdominal fat, muscle, or bone graft). The nasofrontal outflow tract is eliminated with a graft. If normal frontal sinus drainage pathway cannot be restored, the frontal sinus is surgically eradicated by obliteration or cranialization (ie, the cranial cavity is expanded into the former sinus space). These complications may develop in delayed fashion, years after the inciting trauma.Ī patent frontal sinus outflow tract deems the frontal sinus salvageable and the comminuted outer table is then repaired with plates and screws. Injury to the outflow tract can result in a frontal sinus mucocele and creation of an anaerobic environment with subsequent osteomyelitis and possible intracranial extension leading to a brain abscess. A distracted fracture of the left superolateral orbital wall is also noted ( circle ). ( B ) Axial CT demonstrates bilateral comminution of the anterior ethmoids ( arrows ). ( A ) Sagittal CT reformation shows a large nasoethmoidal fragment extending into the inferior frontal sinus ( arrow ) and obstructing the outflow tract. This 30-year-old man fell from a ladder onto his face. Traumatic obstruction of the nasofrontal outflow tract. The posteromedial position of the nasofrontal outflow tract within the sinus makes it particularly susceptible to injury. Nasofrontal outflow tract injury is strongly suspected when the CT examination demonstrates involvement of the base of the frontal sinus, the anterior ethmoids, or both ( Fig. 5 ). Fractures through the lateral aspect of the frontal sinus floor often involve the orbital roof (see Fig. 4 A), depending on the lateral extent of frontal sinus pneumatization.įrontal Sinus (Nasofrontal) Outflow Tract ![]() Fractures through the medial aspect of the floor of frontal sinus typically involve the cribriform plate and fovea (roof) ethmoidalis and may result in a dural tear and/or chronic sinusitis. Isolated fractures of the inner table are uncommon and usually result from an occipital impact. ( B ) Postoperative CT demonstrates good cosmetic alignment following fixation of the outer table with mini-plates and screws. ( A ) Preoperative axial CT shows the fracture extending into medial left orbital roof ( arrows ). Preoperative and postoperative views of a comminuted fracture involving both tables of the frontal sinus and orbital roof. 1 and 2 ) helps with the understanding of the fracture patterns and the identification of osseous segments that require surgical reconstruction for restoration of the normal facial skeleton. Awareness of the facial buttresses ( Figs. However, the distribution of forces via the areas of thicker bone (facial buttresses) may still be transmitted to the cranial vault and cervical spine. It is well known that traumatic collapse of the face has a “cushion” or “bumper” effect that helps dissipate the impact force and thereby protect the neurocranium and cervical spine. The three-dimensional images are particularly helpful for the assessment of complex facial deformities, preoperative planning, and patient consultation. Occasionally, such as in the detailed evaluation of the orbit, oblique reformations are useful. Axial submillimeter bone algorithm images with sagittal, coronal, and three-dimensional reformations are routinely obtained. Multidetector computerized tomography (CT) is the imaging study of choice currently used to evaluate acute and nonacute facial trauma. This article reviews, from cranial to caudal, the most common fracture patterns and the clinical relevance of the imaging findings as they impact patient management. ![]() The partition of the face into thirds (upper, middle, and lower) has particular relevance for surgical intervention. ![]() By far the most common injuries are the fractures of the midface, followed by fractures of the lower face (mandible) and the upper face (frontal bone and superior orbital rim). At our level I trauma center, the interpretation of facial fractures is routine in daily imaging. Traumatic facial fractures are caused most often by motor vehicle accidents, falls, and assaults. ![]()
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