YIJOM-3002; No of Pages 4
Int. J. Oral Maxillofac. Surg. 2014; xxx: xxx–xxx http://dx.doi.org/10.1016/j.ijom.2014.09.019, available online at http://www.sciencedirect.com
Clinical Paper Trauma
Closed reduction of the isolated anterior frontal sinus fracture via percutaneous screw placement
G. Spinellia,b, D. Lazzeric, F. Arcuria,b, T. Agostinia,b a
CTO-AOUC, ‘‘Careggi Hospital’’, Florence, Italy; bUnit of Cranio-Maxillo-Facial Surgery, ‘‘Meyer Children’s Hospital’’, Florence, Italy; c Plastic Reconstructive and Aesthetic Surgery Unit, Villa Salaria Clinic, Rome, Italy
G. Spinelli, D. Lazzeri, F. Arcuri, T. Agostini: Closed reduction of the isolated anterior frontal sinus fracture via percutaneous screw placement. Int. J. Oral Maxillofac. Surg. 2014; xxx: xxx–xxx. # 2014 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Abstract. Fractures of the frontal sinus are a common maxillofacial trauma and constitute 5–15% of all maxillofacial fractures. Conventional surgical approaches include the coronal flap, direct cutaneous incision, and endoscopic techniques. Minimally invasive techniques have recently been described for the reduction of the isolated anterior frontal sinus fracture via a closed approach. The medical records and radiological findings of all patients who underwent surgical treatment for anterior frontal sinus fractures from January 2009 to December 2013 at the study hospital in Florence, Italy, were reviewed. The final study sample consisted of 15 patients (13 males and two females) with isolated anterior frontal sinus fractures who were treated with closed reduction using percutaneous screws. The mean age was 32.1 years. The skin incisions healed without any visible scarring, and no depressions of the frontal sinuses were evident in the postoperative period. Computed tomography scans performed at 6 months postoperatively showed adequate reduction of the displaced fragments. This closed technique is a good option for displaced isolated fractures of the anterior frontal sinus. However, the technique is not adequate for complex fractures of the frontal sinus.
Introduction
Fractures of the frontal sinus are a common maxillofacial trauma and constitute 5–15% of all maxillofacial fractures. Onethird of frontal sinus fractures involve only the anterior wall, and two-thirds affect the anterior wall or the posterior wall and/or the frontonasal duct. The signs of such fractures are depression of the supraorbital area, anaesthesia/paraesthesia of the supraorbital nerves, orbital ecchymosis, and 0901-5027/000001+04
cerebrospinal fluid rhinorrhoea. Undisplaced or minimally displaced anterior table fractures are commonly managed by observation. More extensively displaced anterior table fractures are managed using several techniques, which are progressing towards adequate reductions with fewer complications.1,2 Various surgical techniques have been used to manage isolated anterior frontal sinus fractures. Conventional surgical approaches include the coronal flap, direct
Keywords: closed reduction; frontal sinus fracture; percutaneous screw placement. Accepted for publication 25 September 2014
cutaneous incision, and endoscopic techniques. The standard coronal approach allows for adequate visualization of the fracture site and adequate plating of the fractured fragments. This technique is associated with risks of complications such as nerve injuries, scarring, alopecia, and paraesthesia.3,4 Direct cutaneous incision allows for adequate access to the fracture site, which enables reconstruction and osteosynthesis. However, this technique is rarely utilized due to the risk of facial
# 2014 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Spinelli G, et al. Closed reduction of the isolated anterior frontal sinus fracture via percutaneous screw placement, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.09.019
YIJOM-3002; No of Pages 4
2
Spinelli et al.
scarring. Endoscopic approaches have been advocated because they avoid external incisions, either by utilizing a small incision in the hairline or a transnasal approach. However, the endoscopic approach is associated with a steep learning curve and is limited by narrow fields of view. Further difficulties are related to the navigation of the complex and variable frontal sinus and nasofrontal duct; moreover surgical access can be troublesome due to the convexity of the frontal bone.5 Minimally invasive techniques have recently been described for the reduction of the isolated anterior frontal sinus fracture via a closed approach. Hwang and Song6 reported the use of a stab incision at the end of the eyebrow to allow for the insertion of a periosteal elevator. This transcutaneous transfrontal approach through an eyebrow incision was also later used by Kim et al.7 The aim of this study was to report our experience in the management of isolated anterior frontal sinus fractures using a minimally invasive closed approach with the placement of percutaneous screws.
(two consultants and two registrars). This research was approved by the local ethics committee.
Materials and methods
Results
The medical records and radiological findings of all patients who underwent surgical treatment for anterior frontal sinus fractures from January 2009 to December 2013 at the maxillofacial surgery unit of the study hospital in Florence, Italy, were reviewed. The following demographic and surgical data were recorded: age, gender, time of surgery, mechanism of injury, length of hospital stay, preoperative and postoperative computed tomography (CT) findings, and complications. The inclusion criteria were isolated anterior frontal sinus fracture and treatment via closed reduction using percutaneous screws. The exclusion criteria were concomitant posterior wall and nasofrontal duct fractures, treatment with conventional surgical approaches, and insufficient preoperative or postoperative data. Surgery was performed within 1 week of injury for all patients. Clinical follow-ups were performed at 1 week and at 1, 3, 6, and 12 months and then yearly thereafter. The follow-ups included an accurate physical examination and clinical photography. CT scans were performed during the follow-up period to evaluate the anatomical reduction and to detect any postoperative complications. Postoperative reductions of the frontal sinus fractures were assessed on a 4point Likert scale (1 = poor; 2 = fair; 3 = good; and 4 = excellent) by four clinicians who were blinded to the study conditions
Applying the inclusion criteria, of the 22 patients with anterior frontal sinus fractures who underwent surgical treatment in the department between January 2009 and December 2013, only 15 were included in the investigation. Two patients were excluded due to insufficient preoperative and postoperative data. Five patients were not included due to concomitant posterior wall and nasofrontal duct fractures. The final study sample consisted of 15 patients (13 males and two females) with isolated anterior frontal sinus fractures who were treated with closed reduction using percutaneous screws. The patients ranged in age from 17 to 62 years; the mean age was 32.1 years. The injuries resulted from physical assaults (seven patients; 47%), falls (three patients; 20%), sporting accidents (three patients; 20%), and car accidents (two patients; 13%). The median hospital stay was 2.2 days (range 1–4 days). Among the patients included, three (20%) required intraoperative conversion to an open approach due to unstable reduction and a failure to achieve anatomical reconstruction using the minimally invasive technique. In these cases, after manipulation of the fragments with the screws and wires, we were unable to achieve a stable reduction, and the result was evaluated as unacceptable; thus, the intraoperative decision to proceed with
Surgical technique
Under local anaesthesia and with the patient in the supine position, two percutaneous titanium screws (16 mm in length) are inserted into the fractured and depressed fragments through two separate skin stab incisions. The traction forces necessary to properly reduce the fragments are evaluated in the preoperative phase based on clinical and radiological analyses and intraoperatively by clinical assessment. Steel wires are tied around the heads of the two screws. The reduced fragments are clinically assessed as stable after the removal of the traction. The sinus mucosa and bone periosteum that were attached to the fragments are preserved to maintain the positions. Skin closure is performed with 6–0 non-absorbable sutures. The head is elevated for the first few days after the operation to drain the frontal sinus.
open reduction and internal fixation was made. These cases were treated by open reduction and internal fixation via coronal access. The follow-ups ranged from 6 to 93 weeks, and we observed no major complications such as infection, haemorrhage, nerve damage, or brain injuries during this time. The skin incisions healed without any visible scarring, and no depressions of the frontal sinuses were evident in the postoperative period. The patients exhibited no displacements of the fragments during the follow-up period. Transient forehead numbness occurred in six patients, and all cases had resolved within 1 year after surgery. Postoperative CT scans were performed on average 6.2 months (standard deviation 2.3 months) after the procedure. The CT scan revealed the absence of complications, such as chronic frontal sinusitis, mucopyocele, or mucocele, in all cases. The postoperative reductions of the displaced fragments were excellent in 12
Fig. 1. (A) Preoperative view of the depression area over the forehead. (B) Preoperative CT scan showing an isolated anterior fracture of the frontal sinus.
Please cite this article in press as: Spinelli G, et al. Closed reduction of the isolated anterior frontal sinus fracture via percutaneous screw placement, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.09.019
YIJOM-3002; No of Pages 4
Isolated anterior frontal sinus fracture
Fig. 2. (A) Intraoperative image showing a screw placed in the frontal bone. (B) Intraoperative image showing steel wire tied around the head of a screw.
patients (80%) and good in three (20%) (Figs 1–3). Discussion
Frontal sinus fractures are often reduced and fixated via an open approach because of the necessity for sufficient exposure of the fractured bone and careful plating of the fractured segments. This technique allows for adequate exposure of the surgical field and immediate reconstruction of the frontal bone. However, this method is associated with some disadvantages, including scarring, nerve damage, and alopecia.3–5,7 Endoscopic techniques are performed via the transnasal approach or a coronal incision. The transnasal approach allows for drainage of the nasofrontal duct and has aesthetic advantages because it does not require an external incision. However, endoscopic surgery in the frontal sinus is technically demanding and requires dedicated training. Moreover, the endoscopic reduction via a coronal incision is difficult because of the depressed and inferior position of the surgical field.5
Fig. 3. (A) Closed reconstruction of the forehead 6 months after the surgical procedure. (B) Postoperative CT scan showing the anatomical reduction of the fractured fragments at 6 months after the surgical treatment.
The closed reduction of anterior frontal fractures is adequately described in the scientific literature.8 Hwang and Song6 reported two cases of frontal sinus fracture that were treated successfully by closed reduction with the aid of a periosteal elevator. The technique used by these authors involves a 5-mm stab incision made at the medial end of the eyebrow to allow for the passage of a small elevator through the edge of the fracture. More recently, Mavili and Canter9 described a case treated by closed reduction that utilized screw manipulation. Kim et al.7 used a transcutaneous transfrontal approach through a peri-eyebrow incision to treat 17 patients; they recommended this method as the treatment of choice for isolated anterior fractures of the frontal sinus. According to these authors, these procedures are simple, the operation times are short, and extensive incisions are avoided. Our minimally-invasive technique avoids the complications of internal fixation via screws and plates and has a faster recovery time compared to traditional
3
techniques.10 We did not observe any neurological damage, metal sensitivity, infection, chronic pain, or palpability of the implants. We decided in favour of intraoperative conversion to the open approach in three cases. The median length of hospital stay in this study was 2.2 days, which is consistent with the findings of Meiklejohn et al.8; these authors reported a median hospital stay of 1.8 days for the minimally invasive technique and 4.4 days for the open approach. The main disadvantages of our closed approach utilizing percutaneous screw placement are the blind manipulation of the fragments and the potential for inadequate fixation. The former issue decreases with increases in surgical experience, and the latter issue can lead to an immediate conversion to an open approach or to a delayed open reduction and internal fixation. Three cases required an intraoperative conversion to the conventional surgical approach by open reduction and internal fixation because of poor closed reduction. In conclusion, this closed technique is a good option for displaced isolated fractures of the anterior frontal sinus. However, the technique is not adequate for complex fractures of the frontal sinus that involve the posterior table or the nasofrontal duct. Such fractures might require cranialization and/or obliteration of the nasofrontal duct. Further studies should employ a homogeneous cohort of patients to adequately compare the conventional approaches to the minimally invasive techniques. Funding
None. Competing interests
None. Ethical approval
Approved by the local ethics committee (OSS.14.121). Patient consent
Obtained. References 1. Strong EB. Frontal sinus fractures: current concepts. Craniomaxillofac Trauma Reconstr 2009;2:161–75. 2. Manolidis S, Hollier Jr LH. Management of frontal sinus fractures. Plast Reconstr Surg 2007;120:32S–48S.
Please cite this article in press as: Spinelli G, et al. Closed reduction of the isolated anterior frontal sinus fracture via percutaneous screw placement, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.09.019
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Spinelli et al.
3. Javer A, Alandejani T. Prevention and management of complications in frontal sinus surgery. Otolaryngol Clin North Am 2010;43:827–38. 4. Swinson BD, Jerjes W, Thompson G. Current practice in the management of frontal sinus fractures. J Laryngol Otol 2004;118: 927–32. 5. Steiger JD, Chiu AG, Francis DO, Palmer JN. Endoscopic-assisted reduction of anterior table frontal sinus fractures. Lanygoscope 2006;116:1936–9. 6. Hwang K, Song YB. Closed reduction of fractured anterior wall of the frontal bone. J Craniofac Surg 2005;16:120–2.
7. Kim KS, Kim ES, Hwang JH, Lee SY. Transcutaneous transfrontal approach through a small peri-eyebrow incision for the reduction of closed anterior table frontal sinus fractures. J Plast Reconstr Aesthet Surg 2010;63:763–8. 8. Meiklejohn BD, Lynham A, Borgna SC. A simplified approach for the reduction of specific closed anterior table frontal sinus fractures. Br J Oral Maxillofac Surg 2014;52:81–4. 9. Mavili ME, Canter HI. Closed treatment of frontal sinus fracture with percutaneous screw reduction. J Craniofac Surg 2007;18:415–9.
10. Bell RB, Dierks EJ, Brar P, Potter JK, Potter BE. A protocol for the management of frontal sinus fractures emphasizing sinus preservation. J Oral Maxillofac Surg 2007;65:825–39.
Address: Francesco Arcuri CTO-AOUC ‘‘Hospital Careggi’’ Largo Palagi 1 50100 Florence Italy Tel: +39 0557948212 E-mail: [email protected]
Please cite this article in press as: Spinelli G, et al. Closed reduction of the isolated anterior frontal sinus fracture via percutaneous screw placement, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.09.019
Int. J. Oral Maxillofac. Surg. 2014; xxx: xxx–xxx http://dx.doi.org/10.1016/j.ijom.2014.09.019, available online at http://www.sciencedirect.com
Clinical Paper Trauma
Closed reduction of the isolated anterior frontal sinus fracture via percutaneous screw placement
G. Spinellia,b, D. Lazzeric, F. Arcuria,b, T. Agostinia,b a
CTO-AOUC, ‘‘Careggi Hospital’’, Florence, Italy; bUnit of Cranio-Maxillo-Facial Surgery, ‘‘Meyer Children’s Hospital’’, Florence, Italy; c Plastic Reconstructive and Aesthetic Surgery Unit, Villa Salaria Clinic, Rome, Italy
G. Spinelli, D. Lazzeri, F. Arcuri, T. Agostini: Closed reduction of the isolated anterior frontal sinus fracture via percutaneous screw placement. Int. J. Oral Maxillofac. Surg. 2014; xxx: xxx–xxx. # 2014 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Abstract. Fractures of the frontal sinus are a common maxillofacial trauma and constitute 5–15% of all maxillofacial fractures. Conventional surgical approaches include the coronal flap, direct cutaneous incision, and endoscopic techniques. Minimally invasive techniques have recently been described for the reduction of the isolated anterior frontal sinus fracture via a closed approach. The medical records and radiological findings of all patients who underwent surgical treatment for anterior frontal sinus fractures from January 2009 to December 2013 at the study hospital in Florence, Italy, were reviewed. The final study sample consisted of 15 patients (13 males and two females) with isolated anterior frontal sinus fractures who were treated with closed reduction using percutaneous screws. The mean age was 32.1 years. The skin incisions healed without any visible scarring, and no depressions of the frontal sinuses were evident in the postoperative period. Computed tomography scans performed at 6 months postoperatively showed adequate reduction of the displaced fragments. This closed technique is a good option for displaced isolated fractures of the anterior frontal sinus. However, the technique is not adequate for complex fractures of the frontal sinus.
Introduction
Fractures of the frontal sinus are a common maxillofacial trauma and constitute 5–15% of all maxillofacial fractures. Onethird of frontal sinus fractures involve only the anterior wall, and two-thirds affect the anterior wall or the posterior wall and/or the frontonasal duct. The signs of such fractures are depression of the supraorbital area, anaesthesia/paraesthesia of the supraorbital nerves, orbital ecchymosis, and 0901-5027/000001+04
cerebrospinal fluid rhinorrhoea. Undisplaced or minimally displaced anterior table fractures are commonly managed by observation. More extensively displaced anterior table fractures are managed using several techniques, which are progressing towards adequate reductions with fewer complications.1,2 Various surgical techniques have been used to manage isolated anterior frontal sinus fractures. Conventional surgical approaches include the coronal flap, direct
Keywords: closed reduction; frontal sinus fracture; percutaneous screw placement. Accepted for publication 25 September 2014
cutaneous incision, and endoscopic techniques. The standard coronal approach allows for adequate visualization of the fracture site and adequate plating of the fractured fragments. This technique is associated with risks of complications such as nerve injuries, scarring, alopecia, and paraesthesia.3,4 Direct cutaneous incision allows for adequate access to the fracture site, which enables reconstruction and osteosynthesis. However, this technique is rarely utilized due to the risk of facial
# 2014 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Spinelli G, et al. Closed reduction of the isolated anterior frontal sinus fracture via percutaneous screw placement, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.09.019
YIJOM-3002; No of Pages 4
2
Spinelli et al.
scarring. Endoscopic approaches have been advocated because they avoid external incisions, either by utilizing a small incision in the hairline or a transnasal approach. However, the endoscopic approach is associated with a steep learning curve and is limited by narrow fields of view. Further difficulties are related to the navigation of the complex and variable frontal sinus and nasofrontal duct; moreover surgical access can be troublesome due to the convexity of the frontal bone.5 Minimally invasive techniques have recently been described for the reduction of the isolated anterior frontal sinus fracture via a closed approach. Hwang and Song6 reported the use of a stab incision at the end of the eyebrow to allow for the insertion of a periosteal elevator. This transcutaneous transfrontal approach through an eyebrow incision was also later used by Kim et al.7 The aim of this study was to report our experience in the management of isolated anterior frontal sinus fractures using a minimally invasive closed approach with the placement of percutaneous screws.
(two consultants and two registrars). This research was approved by the local ethics committee.
Materials and methods
Results
The medical records and radiological findings of all patients who underwent surgical treatment for anterior frontal sinus fractures from January 2009 to December 2013 at the maxillofacial surgery unit of the study hospital in Florence, Italy, were reviewed. The following demographic and surgical data were recorded: age, gender, time of surgery, mechanism of injury, length of hospital stay, preoperative and postoperative computed tomography (CT) findings, and complications. The inclusion criteria were isolated anterior frontal sinus fracture and treatment via closed reduction using percutaneous screws. The exclusion criteria were concomitant posterior wall and nasofrontal duct fractures, treatment with conventional surgical approaches, and insufficient preoperative or postoperative data. Surgery was performed within 1 week of injury for all patients. Clinical follow-ups were performed at 1 week and at 1, 3, 6, and 12 months and then yearly thereafter. The follow-ups included an accurate physical examination and clinical photography. CT scans were performed during the follow-up period to evaluate the anatomical reduction and to detect any postoperative complications. Postoperative reductions of the frontal sinus fractures were assessed on a 4point Likert scale (1 = poor; 2 = fair; 3 = good; and 4 = excellent) by four clinicians who were blinded to the study conditions
Applying the inclusion criteria, of the 22 patients with anterior frontal sinus fractures who underwent surgical treatment in the department between January 2009 and December 2013, only 15 were included in the investigation. Two patients were excluded due to insufficient preoperative and postoperative data. Five patients were not included due to concomitant posterior wall and nasofrontal duct fractures. The final study sample consisted of 15 patients (13 males and two females) with isolated anterior frontal sinus fractures who were treated with closed reduction using percutaneous screws. The patients ranged in age from 17 to 62 years; the mean age was 32.1 years. The injuries resulted from physical assaults (seven patients; 47%), falls (three patients; 20%), sporting accidents (three patients; 20%), and car accidents (two patients; 13%). The median hospital stay was 2.2 days (range 1–4 days). Among the patients included, three (20%) required intraoperative conversion to an open approach due to unstable reduction and a failure to achieve anatomical reconstruction using the minimally invasive technique. In these cases, after manipulation of the fragments with the screws and wires, we were unable to achieve a stable reduction, and the result was evaluated as unacceptable; thus, the intraoperative decision to proceed with
Surgical technique
Under local anaesthesia and with the patient in the supine position, two percutaneous titanium screws (16 mm in length) are inserted into the fractured and depressed fragments through two separate skin stab incisions. The traction forces necessary to properly reduce the fragments are evaluated in the preoperative phase based on clinical and radiological analyses and intraoperatively by clinical assessment. Steel wires are tied around the heads of the two screws. The reduced fragments are clinically assessed as stable after the removal of the traction. The sinus mucosa and bone periosteum that were attached to the fragments are preserved to maintain the positions. Skin closure is performed with 6–0 non-absorbable sutures. The head is elevated for the first few days after the operation to drain the frontal sinus.
open reduction and internal fixation was made. These cases were treated by open reduction and internal fixation via coronal access. The follow-ups ranged from 6 to 93 weeks, and we observed no major complications such as infection, haemorrhage, nerve damage, or brain injuries during this time. The skin incisions healed without any visible scarring, and no depressions of the frontal sinuses were evident in the postoperative period. The patients exhibited no displacements of the fragments during the follow-up period. Transient forehead numbness occurred in six patients, and all cases had resolved within 1 year after surgery. Postoperative CT scans were performed on average 6.2 months (standard deviation 2.3 months) after the procedure. The CT scan revealed the absence of complications, such as chronic frontal sinusitis, mucopyocele, or mucocele, in all cases. The postoperative reductions of the displaced fragments were excellent in 12
Fig. 1. (A) Preoperative view of the depression area over the forehead. (B) Preoperative CT scan showing an isolated anterior fracture of the frontal sinus.
Please cite this article in press as: Spinelli G, et al. Closed reduction of the isolated anterior frontal sinus fracture via percutaneous screw placement, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.09.019
YIJOM-3002; No of Pages 4
Isolated anterior frontal sinus fracture
Fig. 2. (A) Intraoperative image showing a screw placed in the frontal bone. (B) Intraoperative image showing steel wire tied around the head of a screw.
patients (80%) and good in three (20%) (Figs 1–3). Discussion
Frontal sinus fractures are often reduced and fixated via an open approach because of the necessity for sufficient exposure of the fractured bone and careful plating of the fractured segments. This technique allows for adequate exposure of the surgical field and immediate reconstruction of the frontal bone. However, this method is associated with some disadvantages, including scarring, nerve damage, and alopecia.3–5,7 Endoscopic techniques are performed via the transnasal approach or a coronal incision. The transnasal approach allows for drainage of the nasofrontal duct and has aesthetic advantages because it does not require an external incision. However, endoscopic surgery in the frontal sinus is technically demanding and requires dedicated training. Moreover, the endoscopic reduction via a coronal incision is difficult because of the depressed and inferior position of the surgical field.5
Fig. 3. (A) Closed reconstruction of the forehead 6 months after the surgical procedure. (B) Postoperative CT scan showing the anatomical reduction of the fractured fragments at 6 months after the surgical treatment.
The closed reduction of anterior frontal fractures is adequately described in the scientific literature.8 Hwang and Song6 reported two cases of frontal sinus fracture that were treated successfully by closed reduction with the aid of a periosteal elevator. The technique used by these authors involves a 5-mm stab incision made at the medial end of the eyebrow to allow for the passage of a small elevator through the edge of the fracture. More recently, Mavili and Canter9 described a case treated by closed reduction that utilized screw manipulation. Kim et al.7 used a transcutaneous transfrontal approach through a peri-eyebrow incision to treat 17 patients; they recommended this method as the treatment of choice for isolated anterior fractures of the frontal sinus. According to these authors, these procedures are simple, the operation times are short, and extensive incisions are avoided. Our minimally-invasive technique avoids the complications of internal fixation via screws and plates and has a faster recovery time compared to traditional
3
techniques.10 We did not observe any neurological damage, metal sensitivity, infection, chronic pain, or palpability of the implants. We decided in favour of intraoperative conversion to the open approach in three cases. The median length of hospital stay in this study was 2.2 days, which is consistent with the findings of Meiklejohn et al.8; these authors reported a median hospital stay of 1.8 days for the minimally invasive technique and 4.4 days for the open approach. The main disadvantages of our closed approach utilizing percutaneous screw placement are the blind manipulation of the fragments and the potential for inadequate fixation. The former issue decreases with increases in surgical experience, and the latter issue can lead to an immediate conversion to an open approach or to a delayed open reduction and internal fixation. Three cases required an intraoperative conversion to the conventional surgical approach by open reduction and internal fixation because of poor closed reduction. In conclusion, this closed technique is a good option for displaced isolated fractures of the anterior frontal sinus. However, the technique is not adequate for complex fractures of the frontal sinus that involve the posterior table or the nasofrontal duct. Such fractures might require cranialization and/or obliteration of the nasofrontal duct. Further studies should employ a homogeneous cohort of patients to adequately compare the conventional approaches to the minimally invasive techniques. Funding
None. Competing interests
None. Ethical approval
Approved by the local ethics committee (OSS.14.121). Patient consent
Obtained. References 1. Strong EB. Frontal sinus fractures: current concepts. Craniomaxillofac Trauma Reconstr 2009;2:161–75. 2. Manolidis S, Hollier Jr LH. Management of frontal sinus fractures. Plast Reconstr Surg 2007;120:32S–48S.
Please cite this article in press as: Spinelli G, et al. Closed reduction of the isolated anterior frontal sinus fracture via percutaneous screw placement, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.09.019
YIJOM-3002; No of Pages 4
4
Spinelli et al.
3. Javer A, Alandejani T. Prevention and management of complications in frontal sinus surgery. Otolaryngol Clin North Am 2010;43:827–38. 4. Swinson BD, Jerjes W, Thompson G. Current practice in the management of frontal sinus fractures. J Laryngol Otol 2004;118: 927–32. 5. Steiger JD, Chiu AG, Francis DO, Palmer JN. Endoscopic-assisted reduction of anterior table frontal sinus fractures. Lanygoscope 2006;116:1936–9. 6. Hwang K, Song YB. Closed reduction of fractured anterior wall of the frontal bone. J Craniofac Surg 2005;16:120–2.
7. Kim KS, Kim ES, Hwang JH, Lee SY. Transcutaneous transfrontal approach through a small peri-eyebrow incision for the reduction of closed anterior table frontal sinus fractures. J Plast Reconstr Aesthet Surg 2010;63:763–8. 8. Meiklejohn BD, Lynham A, Borgna SC. A simplified approach for the reduction of specific closed anterior table frontal sinus fractures. Br J Oral Maxillofac Surg 2014;52:81–4. 9. Mavili ME, Canter HI. Closed treatment of frontal sinus fracture with percutaneous screw reduction. J Craniofac Surg 2007;18:415–9.
10. Bell RB, Dierks EJ, Brar P, Potter JK, Potter BE. A protocol for the management of frontal sinus fractures emphasizing sinus preservation. J Oral Maxillofac Surg 2007;65:825–39.
Address: Francesco Arcuri CTO-AOUC ‘‘Hospital Careggi’’ Largo Palagi 1 50100 Florence Italy Tel: +39 0557948212 E-mail: [email protected]
Please cite this article in press as: Spinelli G, et al. Closed reduction of the isolated anterior frontal sinus fracture via percutaneous screw placement, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.09.019
