Saleh Mohebbi1, Ahmad Daneshi2, Shahabeddin Goudarzi3, Fatemeh Abedin4 and Hadi Ghanbari5*
Received: July 06, 2023; Published: July 14, 2023
*Corresponding author: Hadi Ghanbari, ENT and head and Neck Research Center, Department of Otolaryngology, Head and Neck surgery, The Five senses institute, Hazrat Rasoul Hospital, Iran University of Medical sciences (IUMS), Tehran, Iran
Frontal sinus fracture comprises about 5-15% of maxillofacial fractures [1,2] that is categorized as anterior, posterior, and combined table fractures . Anterior table fracture may have aesthetic importance, while posterior involvement requires attention for CSF leakage. Frontal Sinus Drainage Pathway (FSDP) involvement should be ruled out in any of these fractures, that is under-appreciated in early literature reviews . Isolated anterior table fractures account for about one third. Approaches to isolated anterior table fractures are still controversial  . This article introduces an approach for more scarless closed reduction and internal fixation (ORIF) in selected frontal sinus anterior table fractures.
A 30-year-old man with car accident multiple traumas consulted with otolaryngology service for ruling out frontal sinus fracture. At initial evaluation a depressed fracture in the lower half of forehead with tenderness and edema realized. A 3D reformatted CT- Scan showed frontal sinus anterior table depressed fracture with left ascending maxillary crest fracture and posterior table fracture with no evidence of displacement or Dural involvement (Figures 1 & 2). There was no evidence of CSF leakage in history and physical exam. Patient had temporal male pattern alopecia. Patient declined any routine methods as: such as bi-coronal or trans-incisional or langer’s lines or trans-rhytids approach. We also described the cosmetic advantages and disadvantages of each approach have been described. Finally, the seiner author and the colleagues decided to utilize endoscopic trans-nasal, unilateral inter-cartilaginous and subgalea approach. An acceptance of the patient’s decision was confirmed. Under general anesthesia, before any direct approach, frontal recess bilaterally was evaluated and drainage pathways were intact in both sides. Nasal cavity mucosa was clear had no secretion, polyps or allergic view. we confronted a challenge in elevating the depressed parts of the fracture.
The team decided to have a hidden approach as a trans-nasal approach, with an intercartilaginous incision and dissection supra- perichondrially and subperiosteally making tunneling over the nasal bones to access to the glabellar area (Figure 3). The inferior fragments were successfully kept elevated by passing an elevator through the access route and all the bony particles kept in place and fixed with titanium mini plates externally with transbuccal trocar and holder, the defect area was fixed with titanium mesh too, without any additional skin incision. Immediately after surgery, the depressed fracture was acceptably corrected, and in 2 months follow-up, the forehead contour and skin scar were acceptable (Figures 4-6). As an efficient experience is recommend using this endoscopic approach or combined approaches, even better to superiorly approach by a forehead lift 30° endoscope, via endoscopic forehead lift incisions behind the hair line and fix the plates with bioscrews or meshes by a trocar, passed through a little stab, which will be headed to an almost scarless results.
Isolated anterior table fractures count about one-third of frontal sinus fractures and are aesthetically important, although attention must be paid to frontal sinus drainage pathway (FSDP) during evaluation and treatment. Aesthetic and scar concerns are one of the challenges in surgical approach selection as it depends on many other factors, leaving this choice still controversial . Shumrick, et al.  managed 19 patients with frontal sinus fracture endoscopically via endoscopic forehead lift incisions and had 12 successful reductions. They had difficulties in reducing some of the fragments, needed to be approached using small external incisions directly over the forehead . To reduce this problem and consequent scars, we recommend applying the inferior access to manage inferior part of fractured area via his route is a novel hidden access for approaching by direct vision or endoscopically through intranasal incision unilaterally or bilaterally as nasal dorsal degloving approach for inserting one or more instruments from the wide incision. This technique and incisional route are not good for the patients who have high arched or protruded brows as Neandertalian figures or decreased nasofrontal angles with low radix which might somehow impact or make some difficulties to access via this route.
Arcuri, et al.  managed a frontal sinus anterior table fracture, via endoscopic brow lift incisions in 2012 and fixed a titanium mesh on the fracture site using a stab directly above the lesion, which we have consensus on for fixation method . Fattahi, et al.  used endoscopic forehead lift approach for frontal sinus anterior table fracture reduction but offered no way for fixation . In the method we propose, for appropriately selected patients, complete fixation will be possible in addition to reduction, and the risk of remnant deformity will be minimized. But via utilizing this route the risk of scar formation might be as minimize as possible even if it uses in multiple fractured area in anterior table of frontal sinus, though this route has not yet been used for the posterior table or combined ones. The combined endoscopic-transnasal approach may allow to reach lower fractures even in glabella to make fixed and reduction of the part of fractured area, in a scarless route, although it has its own limitations such as in patients with deep radix, or very small bony particles, The advantages of this technique is endoscopic or direct visualization and handling of multiple bony fractured area.
This route might be used in its own or as combined approaches for many other conditions such as frontal table osteoma or many other conditions as scarless resection or so on. In this approach we can reach to frontal posterior table endoscopically via anterior table fracture or drilling a hole in anterior table unless hyponeumatized, underdeveloped or frontal sinus hypoplasia. It is important to have a precise patient selection in this approach or combined approaches, to reach a successful reduction and fixation with minimal scars or managing some other deformities. It is better not to use this technique if there are any sinonasal infections, nasofacial deformities, history of previous nasal cosmetic surgery, nasal and facial burns and nasal reconstruction surgeries by skin graft or flaps around the healing period..