USE OF OSTEOTOMY IN POST-TRAUMATIC DEFORMITY OF FRONTAL SINUS ANTERIOR WALL. CASE REPORT

INTRODUCTION

Frontal sinus fractures represent 5–15% of all maxillofacial injuries ^1–3. These fractures pose a long-term risk of facial deformity⁴. In addition, they may cause sinusitis, mucocele, meningitis, brain abscesses ^4,5 and encephalitis ⁴. Strong et al. report that isolated anterior table injuries account for 33% of frontal sinus fractures ¹. Gossman et al. describe 96 cases of frontal sinus injuries. Fifty percent of the fractures involved the anterior table of frontal sinus alone, and fifty percent involved both anterior and posterior tables ⁶.

Our patient with post-traumatic deformity of the anterior table of frontal sinus is presented in this case report.

CASE REPORT

A 35-year-old patient suffered an impressive fracture of the anterior table of frontal sinus, which was not primarily treated by surgery (Fig. 1a, b). Computed tomography (CT) scans performed after 3 months from the injury clearly showed a healed, impressive anterior table frontal sinus fracture (Fig. 2a, b). Under general anaesthesia, bicoronary access was used to expose the dislocated anterior table of frontal sinus, and a pericranial flap was prepared (Fig. 3a). We osteotomized the deformed part of the bone (using rotatory instruments), which was temporarily removed (Fig. 3b, c). Additional osteotomies were done in this bone fragment at the place of original fracture lines. Loose bone fragments were reduced to restore the original contour of the frontal bone. In our case, there were minimal gaps between the fragments, which did not require the addition of bone grafts. Titanium miniplates and screws were used for fixation (Fig. 3d). The osteosynthesis was covered with the pericranial flap, with subsequent skin closure. The wound was drained until the next day. Peri-operative antibiotic therapy was maintained for a period of 7 days. The patient healed without any complications. A good cosmetic effect was seen 5 months after the surgery (Fig. 4a, b). CT scans showed a satisfactory finding (Fig. 5a, b).

DISCUSSION

Calvarial vault defects may be repaired with autologous bone or alloplastic materials ⁷. The main problem for the isolated anterior wall fractures is the aesthetic deformity of the forehead, which seldom causes functional complications ⁸.

Strong et al. performed a study in cadavers using endoscopic miniplate reduction of frontal sinus fractures. The success rate depended on fracture comminution. Furthermore, the authors used bone cement to camouflage the defect. The best results were achieved by augmentation with bone cement ¹.

Strong used an endoscopic method to resolve isolated anterior table frontal sinus fractures above the orbital rim. The repair is generally performed 2 to 4 months after the injury when all forehead swelling has resolved. Porous polyethylene sheet was applied endoscopically and the fracture was camouflaged ⁵.

Arcuri et al. used a titanium mesh to treat post-traumatic deformity of anterior table frontal sinus. The implant was applied endoscopically ⁴.

Chen et al. used hydroxyapatite cement to reconstruct the post-traumatic frontal bone depression in 20 patients. The frontal bone was exposed through a bicoronal incision in the subperiosteal plane ⁹.

Duman et al. describe 12 cases where they used a porous polyethylene implant for reconstruction of contour and anterior wall defects of frontal bone. The time span between the trauma and reconstruction was 0–24 months ¹⁰.

There is a possibility to use a custom-made implant. These patient-specific alloplastic implants are used in larger craniofacial defects, which cause aesthetic and functional difficulties ¹¹.

In our case, osteotomy of the broken part of the frontal sinus anterior table was performed, with subsequent reduction using fixation with titanium miniplates and screws. The surgery result provided a good effect. Bicoronary access is needed to expose the fracture as needed. A disadvantage of osteotomy can be seen in the opening of healed fron-tal sinus. The procedure provides the advantage of reconstructing the original shape and size of sinus without the need of augmentation or bridging the defect using an implant.

Since this is an isolated case, the risk of possible complications that may be associated with this procedure cannot be evaluated. No similar case managed as described above was found in literature. As reported by Altman, frontal sinus infection is rare in association with forehead reduction in feminization of the face. The feared complication of total loss of the anterior table due to bone resorption or infection seems to pose a negligible risk ¹².

CONCLUSION

The described case indicates a potential use of this method in patients with more extensive frontal sinus and distinct post-traumatic deformity of frontal sinus anterior table. Osteotomy of frontal sinus anterior table represents an alternative management in these cases.

Declaration of interest: The author report no conflict of interest. The author alone is responsible for the content and writing of this article.

Corresponding author:

Ivo Němec, M.D.

Trauma Center, Military University Hospital Prague, U Vojenské nemocnice 1200

Prague 6, 169 02, Czech Republic

E-mail: Ivo.Nemec@uvn.cz