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PURPOSE:
Frontal sinus cranialization is traditionally indicated for posterior table fractures with significant comminution, displacement, or cerebrospinal fluid (CSF) leak. In our experience we have found that a conservative approach can yield good short-term results with minimal morbidity. This study assesses clinical outcomes of conservative management of frontal sinus fractures involving the posterior table.
METHODS:
A 10-year retrospective review of all frontal sinus fractures treated at a Level 1 trauma center was performed using medical records and radiographic images. Hospital records were reviewed to collect information on age, sex, mechanism of injury, concomitant injuries, the presence and duration of CSF leak, surgical/conservative management and complications. Surgical management was defined as ORIF with sinus preservation, obliteration, and cranialization and conservative management was defined as all non-operative interventions including lumbar drains, medical measures to reduce ICP, and observation. Patients were included if there was adequate chart information for the listed parameters and if there was a computed tomography (CT) scan confirming a frontal sinus fracture. Patients were excluded if they expired within the first 48 hours of their admission from causes other than their frontal sinus injury.
RESULTS:
875 patients with frontal sinus fractures were identified and 68 had posterior table involvement. Nine expired within the first 48 hours from other injuries. The remaining 59 patients comprised the study population. Average follow-up approached 1 year (342 days). The more common mechanisms of injury were blunt interpersonal violence (29%) and motor vehicle accident (27%). Concurrent CNS injury was common (73%) and average Glasgow Coma Scale (GCS) was 12. Posterior wall fracture pattern for the study population was non-displaced and non-comminuted in 33 patients (56%) and comminuted and/or displaced fractures in 26 (44%). CSF leak was recorded in 11 patients (19%). Overall, conservative management was the more common strategy (78%), followed by ORIF with sinus preservation (12%), obliteration (8%) and cranialization (2%). Of the 26 patients with comminuted and/or displaced fractures, 13 (50%) underwent conservative management and 13 (50%) underwent surgical management but only one patient (2%) underwent cranialization.
Of the 11 patients with CSF leak, 3 occurred in non-comminuted and non-displaced fractures. All 3 patients were treated conservatively, time to resolution was 1-4 days and there were no complications. 8 CSF leaks occurred in comminuted and/or displaced fractures. 3 patients were treated conservatively, time to resolution was 1-10 days and there were no complications. The remaining 5 patients with CSF leaks underwent surgical management such as ORIF or obliteration but none underwent cranialization and the time of resolution was 1-10 days. One of these patients who had a severe intracranial injury due to a penetrating gunshot wound to the head ultimately died of encephalitis. There were no other intracranial complications recorded in our study population.
CONCLUSION:
In contrast to current recommendations, our study demonstrates the majority of frontal sinus fractures involving the posterior table, including those with comminution, displacement, or CSF leak, can be safely managed without cranialization.