Minimally Invasive Repositioning of a Frontal Sinus Anterior Wall Fracture Using Intraoperative Sonographic Guidance

Background

In rare cases, trauma to the midface can result in isolated fractures of the frontal sinus wall. Dislocated fractures usually require surgical treatment. Possible complications of a frontal sinus fracture include (persistent) CSF leaking, pneumocephalus, frontal sinusitis or meningitis, chronic headaches or dysesthesia, and the formation of a mucocele (Metzinger et al., Craniomaxillofac Trauma Reconstr. 2009; 2 (1): 27–34). Computed tomography (CT) is the imaging method of choice, ideally with high resolution (Kühnel et al., GMS Curr Top Otorhinolaryngol Head Neck Surg. 2015;14).

There are different surgical approaches to repositioning, each with specific advantages and disadvantages depending on the exact injury pattern and the individual anatomical conditions. Sometimes it is possible to operate through existing wound surfaces (“trauma approach”), and sometimes endoscopic treatment through an endonasal or transorbital approach is possible (Kühnel et al., GMS Curr Top Otorhinolaryngol Head Neck Surg. 2015;14) (Vincent et al., Management of Frontal Sinus Fractures. Facial Plast Surg. 2019; 35 (6): 645–50).

In some cases, open surgical repositioning of the fracture is needed. Established surgical approaches are the coronal incision, the blepharoplasty access, and the eyebrow margin cut. These approaches provide a broad view of the frontal sinus. Disadvantages are the relatively large procedure with a risk of permanent aesthetic disfigurement from scarring, the risk of damage to the supraorbital nerve, as well as the longer inpatient stay (Kühnel et al., GMS Curr Top Otorhinolaryngol Head Neck Surg. 2015;14). In 2007, Mavili et al. described a minimally invasive, closed reduction technique to treat isolated fractures of the anterior wall of the frontal sinus (Mavili et al., J Craniofac Surg. 2007 Mar;18 (2): 415–9).

A recent meta-analysis however, did not make any general recommendations regarding the surgical procedure (Le et al., Sinus Fracture Management Meta-analysis: Endoscopic Versus Open Repair. J Craniofac Surg. 2021; 32 (4): 1311–5). Vincent et al. described a possible algorithm for choosing the appropriate therapy of frontal sinus fractures (Vincent et al., Management of Frontal Sinus Fractures. Facial Plast Surg. 2019; 35 (6): 645–50).

There is an increasing amount of literature describing the value of intraoperative sonography in midface fractures. Noy et al. reported superior results for closed reduction of fractures of the nasal bone in children when performed under ultrasound guidance (Noy et al., Rhinology. 2023; 61 (6): 568–573). Successful reduction under sonographic control has also been described for isolated extracapsular condylar fractures (Kucukguven et al., J Craniomaxillofac Surg. 2022 Jun;50 (6): 473–477). In some cases, intraoperative CT scan is used to check the reposition of midface fractures. An advantage here is the more accurate three-dimensional representation, especially of complex bony anatomy (for example, the orbit) as well as the more deeply located structures. The disadvantages compared to sonography are the radiation exposure as well as the higher time requirement and the lower availability of intraoperative CT. For more complex reductions, however, CT remains the gold standard (Wilde et al., Facial Plast Surg. 2014 Oct; 30 (5): 545–53).

In this article, we describe a minimally invasive method for repositioning an impression fracture of the frontal sinus anterior wall.

Publication History

Article published online:
26 January 2024