FRONTAL BONE FRACTURE AND ITS MANAGEMENT.pptx

frontal bone fracture and their management

1. FRONTAL BONE FRACTURE AND ITS MANAGEMENT A presentation by Dr. Abhijeet Kamble Junior resident II

2. GOOD MORNING

3. CONTENTS 1 Introduction 2 embryology 3 SURGICAL ANATOMY 4 DIAGNOSIS 5 TREATMENT PLANNING 1 9th Century skull showing sword-blade trauma on frontal bone .

4. INTRODUCTION Fontal sinus is most frequently damaged as a result of high velocity motor vehicle accidents. 70% of frontal sinus fractures were due to automobile accidents and 20% due to assaults . . Fractures involving frontal bone is rather rare because of its protected location 1 . It is basically protected from trauma by the prominence formed by the nasal pyramid. 2 . Incidence of fractures involving this area ranges between 5-15% 3 . Fractures involving this bone is considered to be rather dangerous because of its proximity to brain as well as due to the cosmetic defects it can produce. The proximity of this bone to the orbit and naso frontal duct doesn’t help matters either. Fractures involving this area if not treated promptly can lead to : 1. Meningitis 2. Mucopyocele 3. Encephalitis 4. Cerebral abscess 4 Frontal bone facture and its management 20XX

5. EMBRYOLOGY FRONTAL BONE FRACTURE

6. EMBRYOLOGY OF FRONTAL BONE 6 presentation title 20XX Structure of the frontal bone The frontal bone is one of the skull bones enclosing the brain ( neurocranium ) and it consists of the following  parts : The squamous part; The nasal part; Two orbital plates; Two zygomatic processes. Begin as an outgrowth from nasal chamber in utero Absent at birth Do not develop until 2" year of life Develop from ethmoidal infundibular air cells by invagination of frontal bone through frontal recess or from superior meatus Cannot be identified radiographically until about age of 8 years Development Orbital surface of frontal bone

7. EMBRYOLOGY OF FRONTAL BONE 7 presentation title 20XX

8. EMBRYOLOGY OF FRONTAL BONE 8 presentation title 20XX Structure of the frontal bone The frontal bone is made up of two main parts. These are the  squamous part , and the  orbital part . The squamous part marks the vertical, flat, and also the biggest part, and the main region of the  forehead . The orbital part is the horizontal and second biggest region of the frontal bone. It enters into the formation of the roofs of the  orbital  and  nasal cavities . Sometimes a third part is included as the  nasal part of the frontal bone , and sometimes this is included with the squamous part. The nasal part is between the  brow ridges , and ends in a serrated  nasal notch  that articulates with the  nasal bones  inferiorly, and with the  lacrimal  and  maxilla bones  laterally The frontal bone is presumed to be derived from  neural crest cells . [3] The frontal bone is  ossified  in membrane from two primary centers, one for each half, which appear toward the end of the second month of  fetal  life, one above each  supraorbital margin . From each of these centers, ossification extends upward to form the corresponding half of the  squama , and backwards to form the orbital plate. The spine is ossified from a pair of secondary centers, on either side of the middle line; similar centers appear in the nasal part and zygomatic processes. At birth the bone consists of two pieces, separated by the  frontal suture , which is usually obliterated by  Intramembranous ossification , except at its lower part, by the eighth year, but occasionally persists throughout life. It is generally maintained that the development of the  frontal sinuses  begins at the end of the first or beginning of the second year, but may begin at birth. The sinuses are of considerable size by the seventh or eighth year, but do not attain their full proportions until after  puberty . Development

9. 9 presentation title 20XX SURGICAL ANATOMY From the Nasion the bone extends approximately 12.5cm superiorly, 8.0 cm laterally and 5.5 cm posteriorly. Two frontal tuberosities are noted lateral to the midline and superior to the supraorbial rim. The thickest area of the bone is the supraorbial rim from the frontozygomatic process to the nasal bones. The supraorbital foramen are located at the most superior portion of orbital rim. supratrochlear foramen is located medial to the supraorbital foramen or notch and lateral to the nasal bones. A spine or concavity exists on the frontal bone along the medial orbital roof; the trocha of the superior oblique muscle is attached to this spine.

10. 10 presentation title 20XX FRONTAL SINUS Anatomy Evolution over age The frontal sinus is generally absent at birth. At one year the anterior ethmoid air cells begin to invade the frontal bone. Frontal sinus growth is then complete at approximately 15 years of age. The frontal sinus is irregularly shaped and scalloped at its margins. Asymmetry of the sinus is the rule rather the exception (10% of individuals have a unilateral sinus, 9% of individuals have a rudimentary or absent sinus). Applied Anatomy of Frontal Sinus

11. 11 presentation title 20XX FRONTAL SINUS Functions of Frontal Sinus Following are the various functions of the frontal sinus: 1. Production and storage of mucus 2. Resonator for voice 3. Humidification and warming of inhaled air 4. Accessory area of olfaction 5. Conservation of heat from the nasal fossae 6. Definition of facial contours 7.“ Surge Tank” to dampen the pressure differential that develops during inspiration

12. 12 presentation title 20XX FRONTAL SINUS Anatomic relationships The frontal sinus has several critical anatomic relationships. These include: Sinus floor -> orbital roof/anterior ethmoid air cells Posterior table -> anterior cranial fossa Anterior table -> frontal contour Drainage The frontal sinus drains via a small outflow tract into the ethmoid sinus/nasal cavity. The outflow tract is hour-glass shaped with the true ostium (3-4 mm) at the narrowest portion.

13. Epidemiology 13 presentation title 20XX Frontal sinus fractures are relatively uncommon and account for only 5-15% of maxillofacial fractures with a preponderance of male patients. The most common frontal sinus fractures involve a combination of the anterior and posterior tables with or without frontal recess involvement (about 2/3). Isolated posterior table fractures are extremely uncommon (< 1%). This 3D CT reconstruction shows an isolated anterior table fracture .

14. CLASSIFICATION 14 20XX Frontal sinus fractures are usually classified based on: Location Extent of injury Involvement of frontonasal duct Current injury to the dura Stanley’s Classification of Frontal Sinus Fracture Type I: Anterior Table Fracture Isolated to anterior table Accompanied by supraorbital rim fracture Accompanied by naso -ethmoid complex fracture Type II: Anterior and Posterior Table Fractures It is a linear fracture either on transverse direction or in vertical direction Type III: Comminuted Fractures Isolated to both tables Accompanied by naso -ethmoid complex fracture Gonty Et al. Classification of Frontal Sinus Fracture  Type I: Anterior Table Fracture Isolated to anterior table Accompanied by supraorbital rim fracture Accompanied by naso -ethmoid complex fracture Type II: Anterior and Posterior Table Fractures A linear fracture either on transverse direction or in vertical direction Comminuted fracture either isolated to both tables or accompanied by naso -ethmoid complex fracture Type III: Posterior Table Fracture Type IV: Through and Through Frontal Sinus Fracture

15. CLASSIFICATION 15 Type I : Anterior table fracture with minimum comminution Type II : Anterior Wall comminuted fracture with - Possible NOE or Orbital rim fracture Type III : Anterior & Posterior Wall fracture (Posterior wall fracture without significant displacement or ductal injury) Type IV : Anterior & Posterior Wall fracture with Dural injury & CSF leak Type V :Anterior & Posterior Wall fracture with Dural injury, CSF leak, soft tissue or bone loss and/or severe disruption of anterior cranial fossa Gerbino G, Roccia F, Benoch A, ot al. Analyss of 158 fontalsinus fractures: Current surgical management and complications. J Craniomaxilofac Surg 2000; 28133

16. CLASSIFICATION 1 Frontal recess involvement A frontal recess injury involves the floor of the frontal sinus and the outflow tract. It may also involve the anterior skull base. Anterior table fractures Fractures of the anterior table of the frontal sinus vary from minimally displaced to severely displaced/comminuted depending upon the severity of the trauma and size of the sinus. Minimal displacement Less severe trauma may result in fractures of the anterior table which are minimally (as illustrated) or nondisplaced. 2 3 4 Posterior table fracture Posterior table fractures carry a higher risk of intracranial injury because they create a communication with the intracranial space. The degree of fracture displacement gives some insight into the severity of the injury. While there is no commonly agreed upon classification for displacement, many authors have used the width of the posterior table (0.1 mm – 4 mm) as a “measuring stick” to describe displacement because it is readily visible on axial CT-scans. . 3 16 presentation title 20XX

17. DIAGNOSIS The diagnosis of frontal bone fracture is based upon proper history and physical examination of the patient This includes Inspection and palpation of the affected area Detailed History includes: Information about events Visual difficulties Numbness Pain Rhinorrhea Sense of smell Previous history of nasal or sinus disease surgery 17 presentation title 20XX

18. CLINICAL FEATURES Forehead laceration (58%) Forehead pain (82%) swelling 18 presentation title 20XX Frontal bone depression (25%) Csf rhinorrhea (1/3 rd patients Periorbital ecchymosis

19. 19 presentation title 20XX Clinical evaluation General Facial pain Forehead paraesthesia or anaesthesia Forehead laceration Visible and/or palpable frontal bone depression CSF Rhinorrhoea Neurological injuries Cerebral contusion Subdural & epidural haematoma. Ophthalmic injuries Pupillary defect Optic neuropathy Hyphaema Disc oedema Corneal defect Loss of globe integrity Associated maxillofacial Injuries NOE fracture Orbital fracture Zygomatic fracture

20. RADIOGRAPHIC EVALUATION 20 presentation title 20XX PLAIN RADIOGRAPHS are of little use in the diagnosis of frontal sinus fractures Caldwell's view EVIDENCE OF AIR FLUID LEVEL, CLOUDING OF FRONTAL SINUS, PNEUMOCEPHALUS Lateral view High Resolution CT Scan CT Scans are the GOLD standard for imaging of these fracture

21. CT SCANS 21 presentation title 20XX AXIAL CT VIEW A xial images reveals location, severity and degree of comminution of anterior and posterior table fractures . A thin cut (1.0 to 1.5 mm), axial computed tomography (CT) scan is the gold standard .  It is recommended to obtain coronal, sagittal, and three-dimensional (3-D) reconstructions for diagnostic accuracy Coronal images for the Frontal sinus floor and orbital Roof fracture Coronal CT VIEW

22. CT SCANS 22 presentation title 20XX Sagittal images can be useful in assessing the patency of the frontal recess  while 3-D reconstructions help define the shape, location, and orientation of individual bone fragments that are seen less clearly on 2-D views sagittal CT VIEW The 3-D information can reduce the need for surgical dissection, because the surgeon knows the number, location, and orientation of the larger bone fragments. It can also help the patient and/or family to understand the bony anatomy and severity of the injury.

23. MANAGEMENT. FRONTAL BONE FRACTURE 23 presentation title 20XX

24. PRINCIPLES OF FRONTAL BONE FRACTURE MANAGEMENT 24 presentation title 20XX SAFE SINUS RESTORE FACIAL CONTOUR AVOID SHORT & LONG TERM COMPLICATIONS

25. Objectives of management To avoid immediate and short-term complications such as CSF leak, meningitis, spreading infection. To avoid long-term complications such as frontal bone osteomyelitis, chronic frontal sinusitis, mucocele, mycopyocele, and brain abscess. To provide adequate exposure for anatomic reduction of naso -orbito-ethmoidal (NEO) fractures. To restore proper aesthetic contour of the forehead . 25 presentation title 20XX TREATMENT OPTIONS Conservative Fracture reduction & fixation Sinus obliteration Sinus cranialization

26. Management generally based on Three clinical factors: 26 presentation title 20XX Fracture location and displacement Dural and cerebral involvement Damage to the frontal sinus drainage systems

27. Guiding Principles for Frontal Sinus Management 27 presentation title 20XX To separate nasal cavity from sinus To eliminate dead space To separate the frontonasal duct from frontal sinus by obstructing the duct To eliminate a functional sinus, sinus mucosa is removed, and sinus is obliterated

28. MANAGEMENT Surgical Access 28 presentation title 20XX 1. Through existing laceration 2. Butterfly incision 3. Gullwing or eyeglass incision 4. Bicoronal approach suggests sterile surgical glove tourniquet intraoperatively to get the hemorrhage control and blood less surgical field in elevation of bicoronal flap for the surgical management of frontal sinus fracture. Gullwing or eyeglass incision

29. Surgical Access 29 presentation title 20XX Use of existing laceration to access left-sided frontal sinus fracture. Extensive transverse laceration of the forehead with easy access to the frontal sinus. The fractured segments have been removed to gain access to the nasofrontal duct . Through existing laceration

30. Surgical Access 30 presentation title 20XX Irregular outline of a coronal incision in two different patients

31. Surgical Access 31 presentation title 20XX Bicoronal approach Access areas The following areas can be exposed: Entire calvarial vault Anterior and lateral skull base Frontal sinus/Ethmoid Zygoma Zygomatic arch Orbit (lateral/cranial/medial) Nasal dorsum Temporomandibular joint ( TMJ ) and condylar/ subcondylar region

32. 32 presentation title 20XX Indications of Surgery in Frontal Sinus Fractures 1. To avoid immediate complications such as CSF leak, meningitis 2. To avoid long-term complications such as frontal sinusitis, meningitis and brain abscess formation 3. To provide aesthetic contour to the forehead 4. To provide exposure for anatomic reduction of NOE fractures

33. 33 presentation title 20XX History of frontal sinus surgery Surgical approaches to frontal sinus Frontal sinus surgery was first described in the 18th century. It is noted that as early as 1750 Runge performed an obliteration procedure of the frontal sinus. The first published report in 1870 by Wells described an external and intracranial drainage procedure for a frontal sinus mucocele. In 1884 Alexander Ogston described a trephination procedure through the anterior table to evacuate the frontal sinus Kuhnt in 1895 described removing the anterior wall of the frontal sinus in an attempt to clear disease In 1898 Riedel/ Schenke described the first procedure for obliteration of the frontal sinus the Lynch and Howarth operation Lynch incision (A) with resulting access to frontal sinus and ethmoid sinuses (B)

34. 34 presentation title 20XX History of frontal sinus surgery Surgical approaches to frontal sinus

35. MANAGEMENT. 35 presentation title 20XX

36. 36 presentation title 20XX Management of Anterior Table Fracture Decision-Making Simple greenstick or undisplaced fracture does not require surgical intervention. In depressed anterior wall fracture, frontal sinus explored, careful irrigation carried out, fragments reduced and stabilize by internal fixation. In posterior wall fracture without CSF leak or pneumocephalus, reconstruction of only anterior wall is done. Other than surgical intervention, antibiotics, sinus decongestants and analgesics are prescribed to keep the frontonasal duct patent and to prevent infection. Rai et al . suggested bone mapping/sketching in management of anterior table frontal sinus fracture with great success Bone mapping/sketching in management of anterior table frontal sinus fracture Yoo MH et al . suggested endoscopic trans nasal reduction of anterior table fracture To support the reduced fragments, they advocated use of custom made latex glove balloon to be inserted into the frontal sinus then expanded and maintained for 3 weeks

37. ANTERIOR table fracture FRONTAL BONE FRACTURE 37 presentation title 20XX (Nondisplaced, linear/isolated) Conservative treatment Local wound care Antibiotics, nasal decongestant, analgesics Follow up evaluation

38. Operative Indication of FS injury FRONTAL BONE FRACTURE 38 presentation title 20XX Nasofrontal duct involvement/obstruction Displacement of posterior table with underlying neurological injury Aesthetic forehead deformity

39. ANTERIOR table fracture 39 presentation title 20XX Modified treatment algorithm for highly selected patients

40. ANTERIOR table fracture 40 presentation title 20XX (Displaced) Approaches Intraoperative assessment Any kind of fluid Nasofrontal duct patency Nasofrontal duct injury Nasofrontal duct filling with frontal sinus obliteration Grafting Reduction & fixation Existing laceration Butterfly/seagull/open sky approaches, coronal flap

41. Isolated Anterior Table Fracture FRONTAL BONE FRACTURE 41 presentation title 20XX Open Reduction Internal Fixation If the degree of displacement, as visualized on axial or sagittal sections of CT scans, is >1–2 mm , that is, more than a table’s width, it warrants an open reduction and fixation within 7–10 days*

42. Open reduction internal fixation 42 Principles The goal of open reduction is to reapproximate the bone fragments into their premorbid position and use internal fixation hardware to maintain them in their position. Approach coronal approach Reduction General considerations The anterior table of the frontal sinus is normally convex. Compressive forces on the frontal bone deform the convexity into a concavity. This may or may not result in fracture comminution. Mobilization of the depressed bone fragment(s) may require significant effort to overcome compressive forces between bone fragments.

43. Reduction techniques 43 Mobilizing the bone fragments using an elevator There are several techniques to reduce the fragments: Inserting a screw into a bony fragment and reducing it by pulling it outwards Fixation Simple reduction

44. Postop care following management of frontal sinus fractures 44 Evaluation of the patient’s vision performed as soon as they are awakened from anesthesia and then at regular intervals until they are discharged from the hospital. Postoperative positioning Keeping the patient’s head in a raised position both preoperatively and postoperatively may significantly improve edema and pain. Nose-blowing Nose-blowing should be avoided for at least 3 weeks following frontal sinus and skull base repair.

45. Frontal sinus Obliteration FRONTAL BONE FRACTURE 45 presentation title 20XX Steps Sinus Exploration Mucosal Exenteration Nasofrontal Duct obturation Frontal sinus Obliteration Fracture Reduction

46. Frontal sinus FRONTAL BONE FRACTURE 46 presentation title 20XX Filling materials for obturation and obliteration Autogenous Material Synthetic materials Autologous Fat Polyfluorotetraethylene, ePTFE Cancellous bone’ Methylmethacrylate, MMA Muscle Pericranial flap Banked cadaveric tissue

47. Indication for Bone Grafting FRONTAL BONE FRACTURE 47 presentation title 20XX 1. Extensive loss of support at the skull base over the fovea ethmoidalis and cribriform plate, in combination with a peri cranial flap. 2. Superior orbital roof fractures, to avoid pulsatile exophthalmos and orbital deformity. 3. Extensive bone loss of the anterior table, which cannot be replaced with elements of the posterior table. 4. In combination with NOE and orbital reconstruction as layered bone grafts to obliterate the ethmoids and reconstruct the medial orbital wall.

48. posterior table fracture FRONTAL BONE FRACTURE 48 presentation title 20XX CSF leak Absent and No displacement Frontal Sinus Obliteration CSF leak Absent and/or Displacement Frontal Sinus Cranialization

49. Frontal Sinus Cranialization FRONTAL BONE FRACTURE 49 presentation title 20XX It is another technique to minimize the dead space in sinus. It involves removing posterior table thus permitting brain to expand into frontal sinus resulting in confuence between sinus cavity and anterior cranial fossa. It is done in cases with CSF leak and neurological injury due to displaced posterior table fracture. To isolate the splanchnocranium from the frontal sinus, a pericranial fap is used.

50. Frontal Sinus Cranialization FRONTAL BONE FRACTURE 50 presentation title 20XX Although obliteration has been touted as the gold standard and safest method to treat the injured frontal sinus, there are many disadvantages including :

51. Complications FRONTAL BONE FRACTURE 51 presentation title 20XX

52. Recent Advancements FRONTAL BONE FRACTURE 52 presentation title 20XX Virtual Surgery Augmented Reality Stereolithography or 3D printing Virtual Endoscopy

53. Preoperative Photographs and radiographs 53 A 48‑year‑old female patient who sustained a frontal bone fracture right side having a H/O fall from a hill

54. Intraoperative & postoperative Photographs 54 A 48‑year‑old female patient who sustained a frontal bone fracture right side having a H/O fall from a hill

55. Preoperative Photographs and radiographs 55 A 22‑year‑old male patient who sustained a frontal bone having a H/O RSA, having fallen form his bike

56. Intraoperative & postoperative Photographs 56 A 22‑year‑old male patient who sustained a frontal bone having a H/O RSA, having fallen form his bike

57. Follow up Photographs 57 A 22‑year‑old male patient who sustained a frontal bone having a H/O RSA, having fallen form his bike

58. Conclusion The management of NOE and frontal sinus fracture is always a challenging task .The proper handling of MCL and nasofrontal duct is mandatory to get good post-operative results. Proper treatment planning in the form of incision selection, method of fixation and use of bone graft should be done to avoid unaesthetic results. 58 presentation title 20XX

59. references 59 NOE FRACTURES 20XX 1. Milad Etemadi SH, Shahnaseri S, Soltani P, Motamedi MRK .  Management of naso -orbito-ethmoid fractures: a 10-year review. Trauma Mon. 2017;22:292–30. 2. Brasileiro BF, Passeri LA. Epidemiological analysis of maxillofacial fractures in Brazil: a 5-year prospective study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod . 2006;102(1):28–34. 3. Rosenberger E, Kriet JD, Humphrey C.  Management of nasoethmoid fractures. Curr Opin Otolaryngol Head Neck Surg. 2013;21:410–6. (Anatomy of MCL, physical examination of the complex and displacement) 4. Poh E, Kakizaki H, Selva D, Leibovitch I. Anatomy of medial canthal tendon in Caucasians. Clin Exp Ophthalmol . 2012;40:170–3. 5. Merkx MA, Freihofer HP, Borstlap WA, van’t Hoff MA. Effectiveness of primary correction of traumatic telecanthus . Int J Oral Maxillofac Surg. 1995;24:344–7. 6. Heine D, Catone GA, Bavitz B, Grenadier MR.  Naso-orbitalethmoid injury: report of a case and review of the literature. Oral Surg Oral Med Oral Path. 2005;69(5):542–9. 7. Rowe NL. Rowe and Williams’ maxillofacial injuries, vol. 2. 2nd ed. Edinburgh: Churchill Livinstone ; 1994. 8. Markowitz BL, Manson PN , Sargent L, et al. Management of the medial canthal tendon in nasoethmoid orbital fractures: the importance of the central fragment in classifcation and treatment. Plast Reconstr Surg. 1991;87:843–853. 9. Burstein F, Cohen S, Hudgins R, Boydston W.  Frontal basilar trauma: classifcation and treatment. Plast Reconstr Surg. 1997;99(5):1314–21. 10. Balaraman K, Ramani V, Bharathi R, Venkataramani H, Sabapathy SR.  Outcome assessment of Nasoethmoid fractures. Int J Oral Maxillofac Surg. 2013;42(10):1220. 11. Ellis E III. Sequencing treatment for naso -orbito-ethmoid fractures. J Oral Maxillofac Surg. 1993;51:543–558. 12. Nguyen M, Koshy JC, Hollier LH Jr. Pearls of nasoorbitoethmoid trauma management. Semin Plast Surg. 2010;24:383–8. 13. Dingman RO, Grabb WC, Oneal RM. Management of injuries of the naso -orbital complex. Arch Surg. 1969;98:566–71. 14. Mustarde JC.  Epicanthus and telecanthus . Int Opthalmol Clin. 1964;4:359. 15. Cruse C, Blevins PK, Luce EA.  Naso -ethmoid-orbital fractures. J Trauma. 1980;20:551.

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