1Johns Hopkins Medical Institutions, Baltimore, MD, USA, 2University of Toronto, Toronto, ON, Canada, 3Louisiana State University School of Medicine, New Orleans, LA, USA.
Frontal sinus fractures (FSF) are a frequently-occurring injury with a wide spectrum of morbidity and mortality depending on the anatomic characteristics of the fracture and treatment rendered. FSF are categorized clinically as involving the anterior wall, posterior wall, both walls, and/or the nasofrontal drainage pathway. Treatments are categorized as sinus preservation, osteoneogenesis, obliteration, or cranialization. In past studies, the classical division of FSF patients into multiple groups, each with multiple treatment options, has made it difficult to accumulate a statistically significant number of patients in each treatment group. Due to this problem, it has been difficult to validate statistically a specific treatment option. Our objective is to evaluate which factors affect outcomes for patients with FSF treated surgically.
A retrospective review analyzing the database of the Frontal Sinus Fracture Multi-Institutional Study containing information on 892 patients treated for FSF in four Level 1 Trauma Centers in North America was conducted. The main outcome measures were the rates of early and late complications according to anatomic lesion (anterior wall, posterior wall, both walls, and/or nasofrontal duct obstruction), treatment rendered (sinus preservation, osteoneogenesis, obliteration, or cranialization), age, mechanism of injury, and related injuries.
Median age of the patient population was 32 years. Males accounted for 88% of patients, females for 12 %. Anterior wall fractures accounted for 43% of FSF, posterior wall for 7%, and combined anterior and posterior walls for 49%. Motor vehicle accidents were the most common mechanism at 62%, assaults 12%, and falls 11%. Displaced anterior wall fractures had a complication rate of 8% while those involving the anterior wall and nasofrontal drainage pathway had complication rates of 8% or less with any treatment except osteoneogenesis which had a complication rate of 67%. In patients with combined displaced anterior and posterior wall fractures there was no correlation between complication rates and whether they were treated by obliteration or cranialization. Interestingly, the OR ratio demonstrated a correlation of concomitant midface fractures with frontal sinus complications.. The OR showed a correlation between frontal sinus complications and a GCS of 13 or below compared with patients with a GCS of 14 or 15 on admission
Patients with FSF present with a wide range of anatomic lesions and co-morbidities. Patients with isolated anterior wall fractures may be treated with sinus preservation with low expectation of complications. Those with combined anterior wall and nasofrontal duct injuries may be treated with sinus obliteration with a low complication rate, while treatment by osteoneogenesis trended towards higher complication rates and this approach was abandoned by most surgeons. The rate of complications in combined anterior and posterior displaced fractures was associated with patient factors, specifically the presence of a NOE fracture, or a GCS 13 or less, and not whether they were treated with obliteration or cranialization. Therefore, it is likely that pre-hospitalization factors affects the rate of complications in combined anterior and posterior wall fractures and not the choice of procedure.