|Year : 2015 | Volume
| Issue : 2 | Page : 66-69
Challenges in the management of comminuted fronto-naso-ethmoidal fracture in a resource-limited environment
Abdulrazaq Olanrewaju Taiwo1, Ramat Oyebunmi Braimah2, Adebayo Aremu Ibikunle2, Ali Lasseini3
1 Department of Surgery, College of Health Sciences, Usmanu Danfodiyo University, Sokoto, Nigeria
2 Department of Dental and Maxillofacial Surgery, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
3 Department of Surgery, Neurosurgery Unit, College of Health Sciences, Usmanu Danfodiyo University/Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
|Date of Web Publication||22-Mar-2016|
Dr. Ramat Oyebunmi Braimah
Department of Dental and Maxillofacial Surgery, Usmanu Danfodiyo University Teaching Hospital, Sokoto
Source of Support: None, Conflict of Interest: None
This report describes the challenges in the management of a comminuted fronto-naso-ethmoidal fracture secondary to road traffic crash (RTC) in a resource-limited environment. A 55-year-old homemaker referred from Federal Medical Centre with a 3 days history of trauma to the face following RTC. Examination revealed an oblique laceration extending from the right supraorbital region and over the frontonasal region to the left nasolabial fold with exposed comminuted and depressed frontal bone and naso-ethmoidal bone. She had wound exploration, elevation of depressed frontal bone, and soft-tissue repair under general anesthesia without a computed tomography scan.
Keywords: Comminuted, fronto-naso-ethmoidal, road traffic crash
|How to cite this article:|
Taiwo AO, Braimah RO, Ibikunle AA, Lasseini A. Challenges in the management of comminuted fronto-naso-ethmoidal fracture in a resource-limited environment. Afr J Trauma 2015;4:66-9
|How to cite this URL:|
Taiwo AO, Braimah RO, Ibikunle AA, Lasseini A. Challenges in the management of comminuted fronto-naso-ethmoidal fracture in a resource-limited environment. Afr J Trauma [serial online] 2015 [cited 2022 Jan 25];4:66-9. Available from: https://www.afrjtrauma.com/text.asp?2015/4/2/66/179223
| Introduction|| |
The frontal sinus is an important structure located between the junction of the cranium and the face. Injury in this region almost always involves the brain, skull, orbits, globes, midface, and overlying soft tissue that often require a multidisciplinary evaluation and management. The earliest sign of frontal sinus development shows in utero by 4 months.  It pneumatizes over time and is radiographically evident by age 6 years and does not show appreciable development until puberty.  About 4% of the population shows no development of the frontal sinus while about 5% shows minimal development.  Unilateral development is seen in about 10% of the population.  The frontal sinus capacity ranges from 5 to 16 ml.  The location of the frontal sinus makes it to serve as a protective role to the brain in addition to sinus functions. It asks as a shock-absorbing barrier to the intracranial contents.  The frontal bone can absorb direct trauma of up to 990 kg in an unrestricted passenger in motor vehicular crash.  As this force is exceeded, concomitant intra- and extra-cranial injuries should be anticipated. 
| Case Report|| |
A 55-year-old homemaker referred from Federal Medical Centre with a 3 days history of trauma to the face following a road traffic crash (RTC). She was said to be a passenger in a fast moving vehicle without any form of restraint when they had a head-on collision with another vehicle. There was a loss of consciousness immediately with associated injury to the frontal area of the scalp and the face. She regained consciousness after 24 hours. There was no associated vomiting or convulsion. On general examination, the Glasgow Coma Scale was 12; however, there was right eye exposure keratopathy with extensive chemosis and left eye corneal ulceration. Extraoral examination revealed an oblique laceration extending from the right supraorbital region and over the frontonasal region to the left nasolabial fold with exposed comminuted and depressed frontal bone and naso-ethmoidal bone [Figure 1]a and b. No abnormal mobility along the Le-fort fracture lines. On intraoral examination, there was no occlusal derangement; all teeth were intact. A diagnosis of depressed and comminuted fronto-naso-ethmoidal fracture was made. True lateral radiograph of the skull showed a depressed frontal bone [Figure 2]. She was prepared for wound exploration, elevation of depressed frontal bone, and soft-tissue repair under general anesthesia without a computed tomography (CT) scan since patient could not afford it. Postoperative care was uneventful.
|Figure 1: (a) Extensive facial laceration of the patient (down black arrow). Up black arrow showing chemosis (side view). (b) Extensive facial laceration of the patient (front view)|
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|Figure 2: Preoperative true lateral view of the skull showing depressed frontal bone black arrow|
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| Discussion|| |
Frontal sinus fractures are usually caused by anterior blunt force trauma. This type of fracture is rare although it has been underreported in about 5-15% of all facial fractures.  Most of these injuries are caused by RTC, particularly motor vehicular accidents.  Although young and old ages are reported in the literature, the average age is repeatedly in the fourth decade of life. This is because the frontal sinus is not appreciable in the childhood and gradually develops throughout teen years.  The age of the patient in the present case was 45 years, which is consistent with reported age. Overwhelming male preponderance has been reported in the literature;  however, our patient is a female. Perhaps, increase economic activities of the female gender could explain this trend.
High-resolution CT scanning together with image-guided endoscopy gives sufficient information to predict a disruption of the frontonasal drainage system.  This was not possible in our case because of financial reasons. The patient could only afford plain radiographs [Figure 2]. It has however been reported that there is nothing as good as direct visualization of the nasofrontal ostia and fracture. , Direct visualization was employed in this patient because of nonavailability of CT scan [Figure 3]. Due to severe comminution at the frontonasal complex region, the frontonasal outflow could not be visualized clearly. Although there was comminution of both the anterior and posterior tables of the frontal sinus, there was no dural tear [Figure 4]. It has been reported that most fractures involve the anterior table alone in about 43-61%, anterior and posterior tables in about 19-51% while isolated posterior table fracture is rare (0.6-6%). 
The history of surgical intervention of the frontal sinus was initially based on the treatment of complications of frontal sinus fracture.  The surgical intervention has evolved over the years.  Recently, treatment has largely focused on variations of techniques of cranialization, obliteration, anterior table reconstruction, and management of nasofrontal outflow tract. Cranialization of the frontal sinus was first described by Donald and Bernstein.  They described it as a procedure whereby the posterior frontal sinus wall removed, all sinus mucosa eliminated and intracranial contents were isolated from the nose by obstructing the nasofrontal outflow tract in severe comminuted frontal sinus fracture. Although comminuted frontal sinus was diagnosed in the present patient, modified cranialization of the frontal sinus was done by partial removal of the nonviable posterior table bone fragments with preservation of the stable fragments. Further, nonviable anterior plate bony fragment measuring about 1 cm by 2 cm was removed with preservation of majority of the stable fragments after elevation [Figure 5]. Titanium mesh or miniplates were not available for open reduction and fixation; therefore, minimal bone exposure with preservation of the pericranium was used as support for the fragments. Acceptable frontal contour was achieved intraoperatively [Figure 6]. Most of the frontal sinus mucosa was removed by curettage and remaining cauterized with hydrogen peroxide. This was to prevent late complications of frontal sinus fractures such as mucoceles and sinusitis. Patient's relatives were satisfied with facial form 2 weeks postsurgery [Figure 7]. The patients' relatives were able to raise funds for postoperative CT and scout CT showed acceptable frontal bone contour [Figure 8].
|Figure 5: Preservation of viable periosteum and bone fragments (black arrow)|
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|Figure 8: Scout computed tomography showing acceptable frontal bone contour (white arrow)|
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| Conclusion|| |
Frontal sinus management requires high-resolution CT; however, in a resource limited setting-like Sub-Saharan Africa, healthcare funding is out-of-pocket policy, and its management could be very challenging. This report showed that such complex injuries can be managed with limited resources successfully.
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Conflicts of interest
There are no conflicts of interest.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
| References|| |
Helmy ES, Koh ML, Bays RA. Management of frontal sinus fractures. Review of the literature and clinical update. Oral Surg Oral Med Oral Pathol 1990;69:137-48.
Manolidis S. Frontal sinus injuries: Associated injuries and surgical management of 93 patients. J Oral Maxillofac Surg 2004;62:882-91.
McLaughlin RB Jr., Rehl RM, Lanza DC. Clinically relevant frontal sinus anatomy and physiology. Otolaryngol Clin North Am 2001;34:1-22.
Cormier J, Manoogian S, Bisplinghoff J, Rowson S, Santago A, McNally C, et al.
The tolerance of the frontal bone to blunt impact. J Biomech Eng 2011;133:021004.
Tan L. Fractures of the frontal sinus. In: Bailey BJ, Johnson JT, Newlands SD, editors. Head and Neck Surgery-otolaryngology. 4 th
ed. Philadelphia: Lippincott Williams and Wilkins; 2006. p. 1009-15.
Bell RB, Chen J. Frontobasilar fractures: Contemporary management. Atlas Oral Maxillofac Surg Clin North Am 2010;18:181-96.
Manolidis S, Hollier LH Jr. Management of frontal sinus fractures. Plast Reconstr Surg 2007;120 7 Suppl 2:32S-48S.
Golden BA, Jaskolka MS, Vescan A, MacDonald KI. Evaluation & management of frontal sinus injuries. In: Fonseca RJ, Barber HD, Walker RV, Powers MP, Frost DE, editors. Oral and Maxillofacial Trauma. 4 th
ed. St. Louis, Missouri: Elsevier Saunders; 2013. p. 473-4.
Metzinger SE, Guerra AB, Garcia RE. Frontal sinus fractures: Management guidelines. Facial Plast Surg 2005;21:199-206.
Donald PJ, Bernstein L. Compound frontal sinus injuries with intracranial penetration. Laryngoscope 1978;88 (2 Pt 1):225-32.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]