**12. Our experience in treatment of frontal bone fractures**

#### **12.1. Patients' demographics**

During a period of 10 years beginning from 2004 we treated 188 males (90%) and 22 females (10%) admitted with diagnosis of FBF. The most frequent etiology overall was road traffic accidents (43%), followed by falls from heights (26%) and impact of fast moving objects (11%). Fifty injuries (24%) were work-related, most of them falls from heights at construc‐ tion sites. However, in females 70% of accidents were caused by falls from heights. These female patients were mostly domestic helpers, who either tried to commit suicide or avoid abuse (Graphs 1and 2).

**Graph 1.** Age and sex distribution

serious are early infectious complications that can endanger patient's life. There is a greater urgency of operative treatment in cases where intracranial infection can develop through potential communication of the neurocranium with the non-sterile sinuses. Bellamy et al. [68] found that delay in repair beyond 48 hours was associated with a greater than fourfold increased risk of serious infection, even when controlling for clinical and statistical confound‐ ers. However, FS fracture patients often present with other, more severe intracranial and bodily injuries. Thus, definitive management is often delayed until the patient's neurologic and medical condition has stabilized. Several additional factors are associated with serious infection, among them use of an external cerebrospinal fluid drainage catheter and soft-tissue

The recommendation of 7-days waiting period for management of persistent CSF leaks was borne out of historical studies that predate the modern research. According to recent opinion, there is no evidence to support 7 days as a particularly important threshold for cerebrospinal

The efficacy of antibiotic prophylaxis, especially beyond the perioperative period, in frontal sinus and skull base injury remains unclear. The risks of antibiotic use, evolving drug resis‐ tances and associated patient and epidemiologic costs require careful evaluation. To date, there is no standard of care for postoperative antibiotic administration, though many surgeons continue to administer antibiotics beyond the immediate perioperative period.[68] A variety of adverse events can occur after fixation of a frontal sinus fracture, such as frontal sinusitis, mucocele, mucopyocele, cerebrospinal fluid leakage, deformity, hardware infection, head‐ ache, and chronic pain in the area of the injury.[67] Potentially life threatening late complica‐ tions include thrombosis of the cavernous sinus, encephalitis, mucopyocele, or brain abscess. [21] In the literature there is no consensus regarding the follow-up. Because of the possible long period after trauma until complications, namely mucocele, develops, some advise to continue to follow these patients for a lifetime. Others suggest a follow-up period of 5 or 7

During a period of 10 years beginning from 2004 we treated 188 males (90%) and 22 females (10%) admitted with diagnosis of FBF. The most frequent etiology overall was road traffic accidents (43%), followed by falls from heights (26%) and impact of fast moving objects (11%). Fifty injuries (24%) were work-related, most of them falls from heights at construc‐ tion sites. However, in females 70% of accidents were caused by falls from heights. These female patients were mostly domestic helpers, who either tried to commit suicide or avoid

infection that predisposes to deeper infection in these patients.

460 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

fluid leak management to prevent intracranial infection. [68]

**12. Our experience in treatment of frontal bone fractures**

years. [26]

**12.1. Patients' demographics**

abuse (Graphs 1and 2).

**Graph 2.** Etiology distribution by sex: males; outer circle, females; inner circle

#### **12.2. Associated injuries**

Solitary FBF was found in 116 patients, 82 patients suffered concomitant midfacial fracture(s), 3 patients associated mandibular fracture and 9 patients had panfacial fractures. Central nervous injury was found in 80 patients, of whom 11 died. Seven of these fatalities were polytraumatized with multiple non-head fractures and internal organ injuries. Non-head injuries were found altogether in 74 patients. Serious ocular injuries (bulbus rupture and/or traumatic optic neuropathy) were present in 14 patients (below).


#### **12.3. Our classification scheme**

We founded our classification solely on CT examination. We did not attempt to include involvement of FSOT, because its CT evaluation is often not reliable. Decisions based on status of FSOT were done intraoperatively. We had five types namely:


**Figure 12.** Type 1: fracture outside sinus.

**Figure 13.** Type 2: nondisplaced fracture involving anterior and/or posterior sinus wall.

Contemporary Management of Frontal Sinus Injuries and Frontal Bone Fractures http://dx.doi.org/10.5772/59096 463

**Figure 14.** Type 3: displaced fracture of anterior sinus wall with posterior sinus wall intact or undisplaced.

**Figure 15.** Type 4: displaced fracture of both anterior and posterior sinus walls.

**Figure 16.** Type 5: displaced and comminuted posterior sinus wall with anterior wall intact or nondisplaced.

**Graph 3.** Distribution by types of fracture.

Brain injury, contusion, edema, bleeding (died) 80 (11) Non-facial fractures (spine) 68 (17)

Eye injuries 14 Internal organ injuries 9

of FSOT were done intraoperatively. We had five types namely:

**Type 2** Non-displaced, involving one or both frontal sinus walls (Figure 13)

**Type 4** Displaced anterior + posterior sinus wall (Figure 15)

**Type 3** Displaced anterior sinus wall, posterior wall intact or nondisplaced (Figure 14)

**Type 5** Displaced posterior sinus wall, anterior wall intact or non-displaced (Figure 16)

**Figure 13.** Type 2: nondisplaced fracture involving anterior and/or posterior sinus wall.

We founded our classification solely on CT examination. We did not attempt to include involvement of FSOT, because its CT evaluation is often not reliable. Decisions based on status

**12.3. Our classification scheme**

462 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

**Type 1** Outside frontal sinus (Figure 12)

**Figure 12.** Type 1: fracture outside sinus.

## **12.4. Surgical procedures**

From patients with **Type 1** injuries 4 patients died due to concomitant CNS trauma. Two patients were operated: both of them were children with severe disruption of FB and the purpose of surgeries was to repair calvarial defects. Only one patient from **Type 2** group was operated to remove a foreign body from the FS. In patients with **Type 3** fractures, there was the highest relative incidence of operative treatment: 24 patients were operated with 1 sinus obliteration and 23 anterior wall reconstructions.

**Type 4** group had 33 operated patients, 31 of them received cranialization and 2 obliteration of FS. Dural tears were found in 21 patients in this group despite only 5 cases of CSF leak noticed preoperatively.

**Type 5** group had the lowest relative incidence of operated cases and only 4 patients were operated. In five cases we were not able to reach an agreement with neurosurgery service about the indication to operate. The overview of operative treatment and reasons for not operating cases are given in the following table.


#### **12.5. Discussion**

Surprisingly, only one of our operated patients developed an early infectious complicationsoft tissue abscess in the vicinity of the orbital rim, which responded to local incision and antibiotic treatment. The other 2 patients had persistent postoperative CSF leakage and were successfully treated by lumbar drain and bed rest. Similar to other studies we were not able to maintain long term follow-up in the majority of operated cases, not mentioning conserva‐ tively managed cases. Supposedly, had serious complication developed and the patient was still living in Kuwait, he/she would have looked for help in our unit, like other maxillofacial trauma patients, who are usually refused even simple tooth extraction in other facilities other than ours once the patient's trauma history is known to a care provider.

We recognize the importance of close cooperation with the neurosurgery service in instances of cranio-facial injuries. However, we sometimes run into difficulties when deciding on indications for operative treatment in patients who are in good general condition and without signs of external deformity or CSF leakage. These are mainly patients with type 5 injuries. More often than not a neurosurgeon takes only short term perspective on a case without consider‐ ation of possible development of late complications many years later.
