Endoscopic management of the frontal recess in frontal sinus fractures: A shift in the paradigm?

Objectives: To evaluate alternative management strategies for anterior table frontal sinus fractures involving the frontal sinus outflow tract. Study Design: A prospective cohort of patients with anterior table frontal sinus fracture with frontal outflow tract involvement documented by computed tomography (CT) scan was examined between 1999 and 2001. Methods: A select group of patients with anterior table frontal sinus fracture involving the frontal outflow tract was treated with open reduction of bony fracture without osteoplastic obliteration of the frontal sinus. Serial CT scans were obtained starting at 8 weeks after injury. Patients with persistent frontal sinus obstruction after medical treatment underwent an extended endoscopic frontal sinusotomy or a modified endoscopic Lothrop procedure. Results: Fourteen patients sustained frontal sinus fractures and were treated during the study period. Seven patients were included in the modified treatment algorithm, with a mean follow-up of 18 months. All patients had concurrent facial fractures: superior orbital rim (n = 5), naso-orbital-ethmoid complex (n = 2), mandible (n = 2), and midface (n = 2). All 7 patients underwent open repair of the facial fractures. Postoperatively, 5 patients had spontaneous frontal sinus ventilation. Two patients, both of whom had naso-orbito-ethmoid fractures, had persistent frontal sinus obstruction clinically and radiographically. These patients were successfully managed with an endoscopic front sinus procedure. Conclusions: A select group of patients with frontal sinus and outflow tract fracture may be managed with open repair of the anterior table fracture without obliteration. In these cases, suspected frontal outflow tract obstruction can be managed expectantly. Failed frontal sinus ventilation may require endoscopic frontal sinus surgery to reestablish mucociliary clearance.