**7. Frontal recess fracture**

**5. Treatment modalities**

474 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

**6. Surgical approach**

Isolation of the neurocranium, cessation of any CSF leak, prevention of early and delayed postoperative complications and restoration of the preoperative facial aesthetics are the aims of treatment of frontal sinus fractures. The integrity of the posterior wall and/or involve‐ ment of the nasofrontal duct are the factors influencing treatment. The integrity of the posterior wall is the main factor for the separation of the intracranial contents from the outer environment. The nasofrontal duct involvement is the decisive factor for the poten‐ tial dysfunction of the sinus mucosa. Closed fractures of the anterior wall of the frontal sinus without displacement do not require surgical treatment and only observation is required. The treatment of depressed fracture of the anterior wall without involvement of the nasofrontal duct is simple elevation of the fracture and plate fixation. However, if the duct is involved, the treatment should include the obliteration of the sinus cavity after the sealing of the injured duct. In this way the frontal sinus is treated as an isolated cavity precluding any potential mucosal regrowth from the nasal epithelium. If the posterior wall is involved the determinant of successful management of the frontal sinus fracture is removal of the displaced bony fragments of the posterior sinus wall, restoration of the dural integrity and complete isolation of the brain from potential communication with the nose

through the injured frontal sinus and cranialization of the frontal sinus [11].

The most common approach is the bicoronal flap. It has several advantages including provid‐ ing the best exposure of the frontal bone and the best cosmetic result in patients without alopecia. Its disadvantages are increased intraoperative blood loss and risk of injury to the frontal branch of the facial nerve. When using this approach, the hair is parted at the anticipated incision site and the tufts of parted hair are brought together and secured with small rubber bands on each side of the incision. Shaving of hair is not necessary. The incision site is infused with local anesthetic with 1:100,000 epinephrine in a subgaleal plane. The scalp is then incised from one temporal line to the other through the skin and subcutaneous tissues. A scalpel is used to incise the galea. Once the galea is violated, there will be an obvious separation between the galea and the pericranium. Bleeding from larger vessels should be tied off individually. The application of Raney clips minimizes the risk of bleeding. Finger dissection can then be used to elevate 2 to 3 cm on either sides of the incision, taking care to maintain the integrity of the pericranium. Overlying the temporalis muscle superiorly, the plane of dissection should remain in the loose areolar layer, which is deep to the temporoparietal fascia containing the frontal branch and superficial to the deep temporal fascia. In other areas overlying bone, the flap is raised in a plane immediately superficial to the pericranium. Carrying out the dissection in the correct anatomic plane minimizes the risk of injury to the frontal branch of the facial nerve. At the region of the zygomatic arch, the frontal branch of the facial nerve is most vulnerable to injury. If the dissection is carried within 1 to 2 cm of the arch, the plane of dissection should be one layer deeper in this area and dissection should be just deep to the

Frontal recess fractures only result in disruption of the frontal sinus outflow tract. Regardless of anterior or posterior table injuries, frontal recess fractures that result in sinus outflow obstruction will require frontal sinus obliteration. Endoscopic frontal sinusotomy has also been described for the management of persistent obstruction. However, endoscopic frontal sinus‐ otomy following frontal recess trauma is technically challenging and should only be consid‐ ered in reliable patients.
