Other Fractures

Frontal sinus Fractures

Frontal sinus fractures account for 5-15% of all craniofacial fractures and often present themselves in conjunction with other fractures of the facial skeleton. Generally, they are managed conservatively however it is important to be aware of the treatment modalities and when to intervene.

Examination

Often these patients have been involved in a major trauma incident such as a road traffic accident or severe assault. They will often require input from other surgical specialities such as neurosurgery.
With regards to clinical examination the soft tissue overlying the forehead should be examined. Commonly, patient with a frontal sinus fracture will have an overlying laceration. Due to the position of the supraorbital and supratrochlear nerves, there may also be numbness/paraesthesia of the forehead.

If the patient has sustained multiple facial injuries involving the forehead, often a CT Head is requested to evaluate the presence of any bony damage but also soft tissues and the brain. Three parts of the CT scan are scrutinised:
• Anterior table
• Posterior table
• Nasofrontal outflow tracts
When analysing the CT scans, the degree of displacement must be noted as well the involvement of anterior +/- posterior table. We are generally more concerned if there is a breach of the posterior table as this means there is a communication between the frontal sinus and the intra-cranial space. This predisposes the patient to infection or the patient could have a concommitant brain injury and therefore must be discussed with the neurosurgeons.

Figure 1. Anterior and posterior wall fracture [1]

Anterior table fractures

Most anterior table fractures are managed conservatively. If there is an overlying laceration this should be thoroughly cleaned and sutured to prevent bacterial contamination. However if the anterior table fracture is very displaced (open) and there is a visible aesthetic deformity this may warrant surgical reduction and fixation of the fracture. The patient should also be advised to not blow their nose, go diving or flying for 2 weeks as this can alter the pressure within the sinus and result in an infection [2].

Posterior table fractures

On occasion it may be possible to suspect a posterior table fracture from your clinical examination. The patient may have fluid leaking from their nose or a postnasal drip. This CSF leak results from a tear in the dura due to displaced posterior table fragments. Another major concern is entrapment of the mucosa within the intracranial space which could lead to mucoceles and complications.
As mentioned previously when analysing the nasofrontal outflow tracts, if there is severe trauma in this region, it is likely the sinus will not drain properly and result in a mucocele.
One of the main procedures of choice for posterior table fractures is cranialisation or endoscopic repair (which is usually completed by the ENT/neurosurgical teams) [2].

Maxillary sinus fractures

You will frequently come across maxillary sinus fractures in major trauma cases. There is often fracture of the maxillary sinus walls accompanying other facial fractures such as le Fort fractures, ZMC fractures etc.
Sometimes, there may be no clinical signs of a maxillary sinus fracture especially if it is isolated. You may notice air under the skin of the cheek or bleeding during nose blowing. They are usually diagnosed from CT scans; there may be complete or partial opacification of the sinus which represents an air-fluid level.
Maxillary sinus fractures in isolation do not require repair. However, if there are concomittant midface fractures surgical intervention may be indicated which would involve reduction of the fractured segments and plating.