DISCUSION

Frontal sinus fracture treatment and complications

Tratamiento y complicaciones de las fracturas de seno frontal

The article in question+ provides an excellent up-dated guide on the therapeutic management of frontal sinus fractures. The authors present a large series that shows their vast experience in the complex area of traumatology in this region. In addition, the study has a long-term follow-up, which is of great importance due to the high rate of delayed complications with these injuries. In this sense the authors present a low rate of complications (16.4%) of which 38.46% were late. Patients with shorter follow-ups should be assessed with a certain amount of caution when extracting reliable conclusions. Some authors¹ consider that all patients with frontal sinus fractures should be monitored for at least 5 years, even by means of annual CT scans.

The frequent use of vascularized tissue such as the galeopericranial flap probably contributed to the low complication rate. The authors defend the use of autologous calvarial bone as obturation material for the sinus, and they report that it can be used in conjunction with other alloplastic material. Although some teams have published good results regarding obturation of the frontal sinus with alloplastic grafts,² it would appear that there is considerable consensus in the literature as to the use of autologous material and vascularized material when ever possible.³ Some publications even refer to high complication rates with autologous fat.^4,5

With regard to the epidemiological data in the study, the high polytrauma rate (44.2%) stands out, probably as a result of high-energy impacts that produce complex fractures, while the simple fractures, such as unilateral depressed fractures of the anterior table, are relatively high. In this sense, the authors do not refer to any changes in etiology during the study period, if they encountered a progressive reduction in the fractures as a result of traffic accidents with complex lesions of the frontal sinus, and a progressive increase in fractures as a result of aggression and other lower energy direct impact lesions, which would explain the greater number of less severe lesions. With regard to this, the low rate of surgical treatment carried out stands out, as of the 86 patients included in the study only 45 were treated surgically.

In this article, the therapeutic approach taken by the authors is not included with regard to the pneumoencephalus cases such as the one that appears in figure 2, and that are associated with a lineal fracture of the posterior wall. In this work the therapeutic management of pneumoencephalus cases of this type is not indicated, nor are the surgical criteria or the waiting period until surgery.

The exact criteria followed by the authors for obliterating or re-establishing patency the nasofrontal conducts are not reflected either. In our experience, in cases where there is no great bone disruption nor mucosa in the ducts, good results were obtained with prolonged patency periods, and the function of the sinus was preserved.⁶ In spite of this we agree with the authors on the high risk that conserving the nasofrontal ducts entails in fractures of the posterior table, and we also defend obliteration of the ducts in the vast majority of cases. Like other authors⁷ we prefer obliteration of the ducts with calvarial bone blocks that ensures obtaining a safe sinus, which is the principal objective of any therapeutic action in the frontal sinus. The authors report that they use calvarial bone chip for obliterating the sinus but without making any reference to their preferences as to the duct.

Of great interest is the subcranial approach for obtaining better control of the focal points with greater risk and for minimizing brain damage. In any event, the indications for this approach in trauma are few, as surgical access is determined largely by the fracture centers.

With regard to the use of endoscopes, there is consensus on treating fractures of the anterior table that are not comminuted and that reduce their use to a minimal percentage of the frontal sinus fractures. However, Tiwari et al3 defend their use in order to improve the examination of the nasofrontal ducts.

Finally we would like to congratulate the authors on their work and thank them for providing an algorithm for the therapeutic management of frontal sinus fractures. Although there is a fair amount of consensus in the literature, some aspects related with these complex fractures are still controversial.

Álvaro García-Rozado González

Servicio de Cirugía Oral y Maxilofacial, Complejo
Hospitalario Juan Canalejo, La Coruña, España

References

1. Yazuver R, Sari A, Nelly CP, Tuncer S, Latifoglu O, Selebi MC, Jackson IT. Management of frontal sinus fractures. Plast Reconstr Surg 2005;115:79-93.

2. Fattahi T, Johnson C, Steinberg B. Comparison of 2 preferred methods used for frontal sinus obliteration. J Oral Maxillofac Surg 2005;63:487-91.

3. Tiwari P, Higuera S, Thornton J, Hollier LH. The management of frontal sinus fractures. J Oral Maxillofac Surg 2005;63:1354-60.

4. Hardy J, Montgomery W. Osteoplastic frontal sinusotomy: An analysis of 250 operations. Ann Otol Rhinol Laryngol 1976;85:523-9.

5. Keerl R, Weber R, Kahle G, y cols. Magnetic resonance imaging after frontal sinus surgery with fat obliteration. J Laryngol Otol 1995;109:1115.

6. García-Rozado A. Traumatología del complejo fronto-naso-órbito-etmoidal: Estado actual, manejo terapéutico, y revisión de 15 años de experiencia. Rev Esp Cir Oral Maxilofac 1998;20:303-21.

7. Metzinger S, Guerra A, García R. Frontal sinus fractures: Management guidelines. Facial Plast Surg 2005;21:199-206.