Management of frontal sinus fractures

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand the radiographic and clinical diagnosis of frontal sinus fractures. 2. Identify various management approaches to the frontal sinus fracture and the indications for each. 3. Understand the rationale behind the decision of sinus obliteration when needed. 4. Recognize the most common complications arising from frontal sinus fracture treatment and the methods of avoiding or managing these complications. SUMMARY: Frontal sinus fracture management is still controversial and involves preserving function when feasible or obliterating the sinus and duct, depending on the fracture pattern. There is no single algorithm for the choice of management, but appropriate treatment depends on an accurate diagnosis using physical examination, computed tomography data, and the findings of intraoperative exploration. The amount and location of fixation and the need for frontonasal duct and sinus obliteration or elimination of the entire sinus depend on the anatomy of the fracture in general and the extent of involvement of the anterior wall of the sinus, the frontonasal duct, and the posterior wall in particular. This article discusses an algorithm for frontal sinus fractures that was obtained from the literature and modified according to the authors' experience. The decision-making process presented by the authors has withstood the test of time over a period of more than 20 years in their practice and has been proven to be safe and efficacious in treating frontal sinus fractures of all types.     

Assessing the variation in individual frontal sinus outlines

It is often suggested that the frontal sinus morphology of no two individuals is alike, and that the configuration of the frontal sinus is as unique to an individual as his or her fingerprints. However, no empirical, quantitative testing of the uniqueness of frontal sinus outlines has ever been performed. Such testing is necessary for frontal sinus identifications to be admissible in many courts. This study investigated frontal sinus outline variability using elliptic Fourier analysis (EFA), a geometric morphometric approach that fits a closed curve to an ordered set of data points, generating a set of coefficients that can be used to reproduce the outline. Two-dimensional representations of 808 frontal sinuses (as seen in posterior-anterior cranial radiographs) were digitized, and differences in their shapes were assessed quantitatively by comparing the Euclidean distances between EFA-generated outlines. Results show that Euclidean distances between outlines of different individuals are significantly larger than those between replicates of the same individual, and typicalities show that the probability of finding two different individuals with Euclidean distances less that that between a particular case's replicate is very small. Thus, there is a quantifiable and significant difference between the shapes of individuals' frontal sinus outlines.     

New treatment for frontal sinus hypertrophy

A new treatment of frontal sinus hypertrophy is described. The anterior wall is removed, inverted, and attached again. The resulting depression is filled with bone dust. Details are discussed, and a case is presented.     

The frontal sinus in ancient and modern Greenlandic Inuit

The purpose of this study was to compare the frontal sinus size of ancient Greenlandic Inuit with ancient Inuit of Alaska and Canada, and to compare sinus size between ancient and modern Greenlandic Inuit. Also, it was analyzed whether cranial size was a determinant of frontal sinus size. Frontal sinus size was evaluated in terms of absence frequency and planimetrically. Absence was defined as a frontal sinus not exceeding a line drawn between the supraorbital rims. A significant increase in absence frequency was noted from Alaska over Canada to Greenland (males: p<0.03; females p<0.0001). This is in accordance with earlier studies, indicating that although these Inuit populations once have been commonly related to the Old Bering Sea population, the Greenland Inuit represent an endpoint in an eastward migration. There was a significant increase (p<0.0001) in frontal sinus size from ancient to modern Greenlandic Inuit, probably indicative of a high degree of admixture with non-Inuit after modern colonization. The results regarding craniofacial size parameters and frontal sinus side were inconclusive. No single craniofacial variable showed significant effect on frontal sinus size, but the area displayed sexual dimorphism, females having smaller frontal sinuses.     

An allometric study of the frontal sinus in Gorilla, Pan and Pongo

There is considerable speculation about the role and significance of the paranasal sinuses in the Hominoidea, and this study aims to present new data about an old problem from cephalograms of dried crania. Measurements of frontal sinus volumes were determined for Gorilla gorilla gorilla; G. gorilla beringei and Pan troglodytes. By adopting an allometric approach it was determined that the frontal sinus volume of Gorilla is relatively smaller than that of Pan, and that the frontal sinus of G. g. gorilla is relatively smaller than that of G. g. beringei. Frontal sinus volume scales in a positive allometric fashion relative to skull length. Since the slope is steeper for Pan, frontal sinus volume is increasing at a faster rate than in Gorilla. Sexual dimorphism in frontal sinus volume is present. Thirty crania of Pongo were investigated for evidence of pneumatization of the frontal bone. In no case was secondary invasion of the frontal bone by the maxillary antrum observed. In Gorilla, the nasal cavity volume scales isometrically with skull length. The scaling relationships discussed do not support any 'functional' role of the frontal sinus associated with nasal function but suggest a 'structural' role associated with craniofacial architecture.     

Relationships between the frontal sinus and climatic conditions: a skeletal approach to cold adaptation

Previous studies in physical anthropology, using superficial facial features, show that the relationship between human facial morphology and climate is not clear. An alternate approach to the problem is the investigation of the deeper facio-anatomical structures (i.e., cranial sinuses and/or foramina) in relation to climatic variables. The present investigation statistically analyses the relationship between climatic conditions (wind chill equivalent temperatures and absolute humidities) and the occurrence and size of frontal sinuses in 153 Eskimo crania. Conditional results from tests of significance of differences and correlation suggest a relationship between low wind chill equivalent temperatures and small frontal sinus surface areas. These results are interpreted in light of cranial sinus function and environmental physiology.     

Wildervanck syndrome with hypoplastic frontal sinus: A rare case presentation

We report a case of Wildervanck syndrome exhibiting Klippel–Feil anomaly, Duane''s retraction syndrome and congenital deafness. Since the first case was reported in 1952, there have been more reports describing this triad either complete or incomplete. Our case has a complete triad of the syndrome along with frontal sinus hypoplasia. Our case is unique as the triad was associated with frontal sinus hypoplasia, which is very rare association.     

Statistical estimators of frontal sinus cross section ontogeny from very noisy data

Cross-sectional areas of human frontal sinuses in the occipitofrontal projection are a good surrogate for frontal sinus volumes. This study looks at these areas in a dataset of some 200 children and 100 adults of both sexes. As measured by planimetry of roentgenograms, the areas are extremely variable ("noisy" in a statistical sense). In fact, they appear to be distributed log-normally with quite high variance. The mean of the distribution is evidently a function of age and the variances differ by sex. After logarithmic transformation, the data are adequately fitted by one sigmoid curve for each sex. Our discussion highlights implications of this finding for the biological aspects of frontal sinuses and methodological issues in ontogenetic analysis of data so noisy.     

Fine needle aspiration in aspergilloma of frontal sinus: a case report

BACKGROUND: The increased incidence of fungal diseases in humans is most likely due to indiscriminate use of broad-spectrum antibiotics and increased numbers of immunocompromised patients. Although Aspergillus species are ubiquitous and normally nonpathogenic, they can be opportunistic pathogens in immunocompromised individuals. CASE: A 22-year-old immunocompetent man presented with a gradually increasing subcutaneous swelling near the root of his nose for previous 6 months. The mass was soft to firm, solid, nontender and immobile. There was no superficial skin ulceration and no local signs of inflammation. Proptosis of the left eye was present without any visual impairment. An osteolytic lesion that was contiguous with the subcutaneous mass, with the opacities of both the fontal sinuses was observed radiographically. Fine needle aspiration cytology (FNAC) demonstrated presence of branching hyphae in the cytoplasm of multinucleated giant cells along with mixed inflammatory cells. The species was identified by culture in Sabouraud's agar with chloramphenicol and wet mount with lactophenol cotton blue stain. CONCLUSION: Aspergillosis can remain dormant over a long period. Although uncommon, it can occur in immunocompetent patients. FNA is a very useful tool in establishing the diagnosis     

Obliteration of decompressed frontal sinus by means of a deepithelialized island forehead flap

A new surgical procedure for the treatment of chronic unilateral suppurative frontal sinusitis was described. A vascularized composite tissue--forehead island flap--was used for obliteration of the decompressed left frontal sinus. In the author's opinion (in selected cases) it is more physiologically sound than the use of abdominal fat or bone graft as an alternative for obliteration. It will withstand the test of time, since myocutaneous flaps have been used reliably as vascularized tissues for anatomic regions troubled by infection and radiation.