Frontal Sinus Fx Slides 070117

8/9/2019 Frontal Sinus Fx Slides 070117

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Frontal Sinus FracturesFrontal Sinus Fractures

Jeffrey Buyten, MDJeffrey Buyten, MD

Matthew Ryan, MDMatthew Ryan, MD

University of Texas Medical Branch

Department of OtolaryngologyJanuary 17, 2006


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OutlineOutline

EtiologyEtiology

Associated injuriesAssociated injuries

ManagementManagement Fixation methodsFixation methods

Sinus obliterationSinus obliteration

CranializationCranialization


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Frontal Sinus Anatomy FactsFrontal Sinus Anatomy Facts

Absent @ birthAbsent @ birth

Radiographically evident @ 8 yearsRadiographically evident @ 8 years

Adult size by 15 yrsAdult size by 15 yrs 15% with unilateral sinus15% with unilateral sinus

4% with no sinus4% with no sinus

Anterior table 2Anterior table 2--12 mm thick12 mm thick Posterior table 0.1 to 4.8 mm thickPosterior table 0.1 to 4.8 mm thick

Strong,EB et al. Frontal sinus fractures: A 28Strong,EB et al. Frontal sinus fractures: A 28--year retrospective review. Otolaryngologyyear retrospective review. OtolaryngologyHead and Neck Surgery (2006) 135, 774Head and Neck Surgery (2006) 135, 774--779779


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Demographics/EtiologyDemographics/Etiology

55 -- 12% of facial fractures12% of facial fractures

30 year old males30 year old males

800800 1600 ft lb to fracture1600 ft lb to fracture



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High velocity impactsHigh velocity impacts MVA 71% to 52%MVA 71% to 52%

19741974--86 to 198786 to 1987--0202


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MVA

Assault

Recreational

Accidents

Industrial

Accidents

52%52%

26%26%

9%9%5%5%



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Soccer

Rugby

Extreme sports

Martial Arts

Other

Sports InjuriesSports Injuries

Maladiere et al. Aetiology and Incidence of Facial Fractures Sustained During Sports: A Prospective Study of 140 Patients. InMaladiere et al. Aetiology and Incidence of Facial Fractures Sustained During Sports: A Prospective Study of 140 Patients. Int Jt J OralOralMaxillofac Surg, 2001: 30; 291Maxillofac Surg, 2001: 30; 291--295.295.

34%34%

25 %

15%

6%

20%


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FractureDistributionFractureDistribution

AnteriorAnterior PosteriorPosterior Ant/PostAnt/Post Frontal recessFrontal recess TotalTotal

Wallis et alWallis et al19741974--19861986 13 (18%)13 (18%) 2 (3%)2 (3%) 55 (79%)55 (79%) 22 7070

Strong et alStrong et al19871987--20022002 35 (28%)35 (28%) 4 (3%)4 (3%) 88 (69%)88 (69%) 33 127127

Gossman et alGossman et al 19901990--20032003 48 (50%)48 (50%) 00 48 (50%)48 (50%) n/an/a 9696

Chen et alChen et al 19941994--20022002 22 (28%)22 (28%) 00 56 (72%)56 (72%) n/an/a 7878


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Associated injuriesAssociated injuries

Loss of consciousnessLoss of consciousness 72%72%

Obtunded/intubatedObtunded/intubated 21%21%

Intracranial injuriesIntracranial injuries

Pneumocephalus 26%Pneumocephalus 26%

Cerebral contusion 18%Cerebral contusion 18%

Dural tear 14%Dural tear 14%

CSF leak 11%CSF leak 11%

5% with persistent CSF leaks5% with persistent CSF leaks

Epidural hematoma 8%Epidural hematoma 8%



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Taiwan dataTaiwan data

Other Facial FracturesOther Facial Fractures Multiple facial fractures in 75% of pts.Multiple facial fractures in 75% of pts.

Pediatric frontal sinus fracturesPediatric frontal sinus fractures

100% with concomitant orbital fractures100% with concomitant orbital fractures

California dataCalifornia data


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ComplicationsComplications

Major complications 5%Major complications 5%

MeningitisMeningitis

MucoceleMucocele Minor complications 8%Minor complications 8%

Wound infections, frontal paresthesias, temporalWound infections, frontal paresthesias, temporalnerve paresis, frontal bone irregularities, diplopia onnerve paresis, frontal bone irregularities, diplopia on

upward gazeupward gaze

Strong,E

B et al. Frontal sinus fractures: A 28Strong,E

B et al. Frontal sinus fractures: A 28--year retrospective review. Otolaryngologyyear retrospective review. OtolaryngologyHead and Neck Surgery (2006) 135, 774Head and Neck Surgery (2006) 135, 774--779779


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CSF leakCSF leak

1212--30% basilar skull fx30% basilar skull fx

Spontaneous resolution 24Spontaneous resolution 24--48 hrs48 hrs

Temporal bone > Ant cranial fossaTemporal bone > Ant cranial fossa SxsSxs

Postural headachePostural headache

Bacterial meningitisBacterial meningitis 77--30%30%

Friedman, JA et al. Persistent Posttraumatic Cerebrospinal Fluid Leakage. Neurosurg Focus. 2000 (9), 1Friedman, JA et al. Persistent Posttraumatic Cerebrospinal Fluid Leakage. Neurosurg Focus. 2000 (9), 1--5.5.


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ManagementManagement

Weigh intervention risks in critical patientsWeigh intervention risks in critical patients

PE, CT scanPE, CT scan

Primary goalPrimary goal Protect brain from further injuryProtect brain from further injury

Secondary goalsSecondary goals

+/+/-- Sinus functionSinus function CosmeticCosmetic

Anterior, Posterior, Nasofrontal duct, CSF leakAnterior, Posterior, Nasofrontal duct, CSF leak


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Anterior TableManagementAnterior TableManagement

NonNon--displaceddisplaced

ObservationObservation

DisplacedDisplaced ORIF (coronal, midORIF (coronal, mid--brow approach)brow approach)

Endoscopic vs openEndoscopic vs open

Comminuted fracturesComminuted fractures ORIF (mesh vs miniplates)ORIF (mesh vs miniplates)

Ensure no mucosa trapped between fragmentsEnsure no mucosa trapped between fragments

Rice, DH. Management of Frontal Sinus Fractures. Curr Opin Otolaryngol Head Neck Surg. Curr Opin Otolaryngol Head Neck SurgRice, DH. Management of Frontal Sinus Fractures. Curr Opin Otolaryngol Head Neck Surg. Curr Opin Otolaryngol Head Neck Surg12:4612:4648. 2004 Lippincott Williams & Wilkins.48. 2004 Lippincott Williams & Wilkins.


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Posterior TableManagementManagement

Separate nasal cavity/sinus from intracranialSeparate nasal cavity/sinus from intracranial

cavitycavity

CSF leakCSF leak No spontaneous resolutionNo spontaneous resolution exploreexplore

Repair dural tearsRepair dural tears

Sinus obliterationSinus obliteration Severely comminutedSeverely comminuted

CranializationCranialization



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Nasofrontal DuctManagementDuctManagement

ObliterationObliteration

Endoscopic Lothrup procedureEndoscopic Lothrup procedure

ObservationObservation Minor injury in a reliable patientMinor injury in a reliable patient

Reimage the patient in 1 to 3 monthsReimage the patient in 1 to 3 months



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Chen et al. Frontal Sinus Fractures: A Treatment Algorithm and Assessment of Outcomes Based on 78 Clinical Cases. Plast.Chen et al. Frontal Sinus Fractures: A Treatment Algorithm and Assessment of Outcomes Based on 78 Clinical Cases. Plast.Reconstr. Surg. 118: 457, 2006.Reconstr. Surg. 118: 457, 2006.


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Gossman et alGossman et al 19901990--20032003 48 (50%)48 (50%) 00 48 (50%)48 (50%) ???? 9696

Observation

ORIF

tent

ranialization

Obliteration

47%

30%

11%

8%

3%

Gossman et Laryngoscope al. Management of Frontal Sinus Fractures: A Review of 96 Cases., 116: 1357Gossman et Laryngoscope al. Management of Frontal Sinus Fractures: A Review of 96 Cases., 116: 1357--136, 2006.136, 2006.


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Anterior Posterior Ant/Post

Chen et al 94-2002 22 00 56

Chen et al. Frontal Sinus Fractures: A Treatment Algorithm and Assessment of Outcomes Based on 78 Clinical Cases. Plast.Chen et al. Frontal Sinus Fractures: A Treatment Algorithm and Assessment of Outcomes Based on 78 Clinical Cases. Plast.Reconstr. Surg. 118: 457, 2006.Reconstr. Surg. 118: 457, 2006.


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Strong,E

B et al. Frontal sinus fractures: A 28Strong,E

B et al. Frontal sinus fractures: A 28--year retrospective review. Otolaryngologyyear retrospective review. OtolaryngologyHead and Neck Surgery (2006) 135, 774Head and Neck Surgery (2006) 135, 774--779779


Wallis et alWallis et al19741974--19861986 13 (18%)13 (18%) 2 (3%)2 (3%) 55 (79%)55 (79%) 22 7070

Strong et alStrong et al19871987--20022002 35 (28%)35 (28%) 4 (3%)4 (3%) 88 (69%)88 (69%) 33 127127


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Endoscopic RepairEndoscopic Repair

Allows fixation of favorable ant table fxsAllows fixation of favorable ant table fxs

Opportunity for nasofrontal aperture proceduresOpportunity for nasofrontal aperture procedures

at same setting.at same setting.


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Endoscopic RepairEndoscopic Repair

Fracture reductionFracture reduction

Endoscopic browlift (subperiosteal)Endoscopic browlift (subperiosteal)

30 degree scope w/endosheath30 degree scope w/endosheath Central stab incisionCentral stab incision

Lateral incision to assist with the reductionLateral incision to assist with the reduction

Fracture camouflageFracture camouflage

Old fracturesOld fractures

Alloplastic implant hides defectAlloplastic implant hides defect

Pham, A and Strong, EB. Endoscopic management of facial fractures. Curr Opin Otolaryngol Head Neck Surg 14:234Pham, A and Strong, EB. Endoscopic management of facial fractures. Curr Opin Otolaryngol Head Neck Surg 14:234241. 2006241. 2006

Lippincott Williams & Wilkins.Lippincott Williams & Wilkins.


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FrontalDepressionsFrontalDepressions

Alloplastic fillersAlloplastic fillers

Acrylic implantsAcrylic implants

Commonly usedCommonly used Hydroxyapatite cementHydroxyapatite cement

OsseointegrationOsseointegration

Good biocompatibilityGood biocompatibility

Friedman, C et al. Reconstruction of the Frontal Sinus and Frontofacial Skeleton With Hydroxyapatite Cement. Arch Facial PlasFriedman, C et al. Reconstruction of the Frontal Sinus and Frontofacial Skeleton With Hydroxyapatite Cement. Arch Facial Plastt

Surg.2000;2:124Surg.2000;2:124--129129


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Friedman, C et al. Reconstruction of the Frontal Sinus and Frontofacial Skeleton With Hydroxyapatite Cement. Arch Facial PlasFriedman, C et al. Reconstruction of the Frontal Sinus and Frontofacial Skeleton With Hydroxyapatite Cement. Arch Facial Plastt

Surg.2000;2:124Surg.2000;2:124--129129


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TitaniumMeshTitaniumMesh

Severely Comminuted fxsSeverely Comminuted fxs

Lakhani, Raam S. MD et al. Titanium Mesh Repair of the Severely Comminuted Frontal Sinus Fracture. Arch Otolaryngol Head NecLakhani, Raam S. MD et al. Titanium Mesh Repair of the Severely Comminuted Frontal Sinus Fracture. Arch Otolaryngol Head Neckk

Surg.2001;127:665Surg.2001;127:665--669669


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Closed ReductionClosed Reduction

Case reportCase report

Lost tip of probe in sinusLost tip of probe in sinus

Hwang et al. Closed Reduction of Fractured Anterior Wall of the Frontal bone. Journal of Craniofacial Surgery. 2005 (16); 120Hwang et al. Closed Reduction of Fractured Anterior Wall of the Frontal bone. Journal of Craniofacial Surgery. 2005 (16); 120--12122.2.


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Obliteration HistoryObliteration History

Dates back to 1950s (Bergara)Dates back to 1950s (Bergara)

HypothesisHypothesis

Transplanted fat would remain vascularizedTransplanted fat would remain vascularized NonNon--viable fat would fibroseviable fat would fibrose

Weber, R, Draf, W et al. Osteoplastic Frontal Sinus Surgery With Fat Obliteration: Technique andLongWeber, R, Draf, W et al. Osteoplastic Frontal Sinus Surgery With Fat Obliteration: Technique and Long--Term Results Using MagnetTerm Results Using MagneticicResonance Imaging in 82 Operations. Laryngoscope. 2000. 1037Resonance Imaging in 82 Operations. Laryngoscope. 2000. 1037--44.44.

Fattahi et al. Comparison of 2 Preferred Methods Used for Frontal Sinus Obliteration. J Oral Maxillofac Surg 63; 487Fattahi et al. Comparison of 2 Preferred Methods Used for Frontal Sinus Obliteration. J Oral Maxillofac Surg 63; 487--91, 2005.91, 2005.


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Obliteration HistoryObliteration History

Goodale and MontgomeryGoodale and Montgomery (late 50s and 60s)(late 50s and 60s) Fat obliterationFat obliteration standard of care for difficult frontal sinusstandard of care for difficult frontal sinus

diseasedisease

No sx recurrence or radiographic recurrence after 5 yearsNo sx recurrence or radiographic recurrence after 5 years

Hardy and Montgomery (1976)Hardy and Montgomery (1976) 250 patients; median follow250 patients; median follow--up 8 yearsup 8 years

Complication rate 18%Complication rate 18% Abdominal woundAbdominal wound -- 5.2%5.2% Acute postoperative infections (necrosis of implanted fat)Acute postoperative infections (necrosis of implanted fat) -- 3%3% Recurrent chronic sinusitisRecurrent chronic sinusitis -- 3%3% 4% of cases had to be revised4% of cases had to be revised No report on the occurrence of mucocelesNo report on the occurrence of mucoceles

Weber, R, Draf, W et al. Osteoplastic Frontal Sinus Surgery With Fat Obliteration: Technique andLongWeber, R, Draf, W et al. Osteoplastic Frontal Sinus Surgery With Fat Obliteration: Technique and Long--Term Results Using MagnetTerm Results Using MagneticicResonance Imaging in 82 Operations. Laryngoscope. 2000. 1037Resonance Imaging in 82 Operations. Laryngoscope. 2000. 1037--44.44.



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Obliteration IndicationsObliteration Indications

Mucopyocele, orMucopyocele, or

recurrent acuterecurrent acutesinusitissinusitis

Severe fracturesSevere fractures

Chronic sinusitisChronic sinusitis

TumorTumor


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Obliteration PrinciplesObliteration Principles

Meticulous removal of all visible mucosaMeticulous removal of all visible mucosa Removal of the inner cortexRemoval of the inner cortex Cutting burr for thick bone and a diamond burr for theCutting burr for thick bone and a diamond burr for the

dura and orbital roofdura and orbital roofperiorbitaperiorbita Results do not depend on the choice of microscope orResults do not depend on the choice of microscope orLoupe magnificationLoupe magnification

Permanent occlusion of the nasofrontal ductPermanent occlusion of the nasofrontal duct Material that forms a fibrous barrier between theMaterial that forms a fibrous barrier between the

obliterated sinus and the nasal cavity.obliterated sinus and the nasal cavity. Prevents the implanted material from sliding downward andPrevents the implanted material from sliding downward and

impairs the ingrowth of nasal mucosa.impairs the ingrowth of nasal mucosa.

Weber, R, Draf, W et al. Osteoplastic Frontal Sinus Surgery With Fat Obliteration: Technique and LongWeber, R, Draf, W et al. Osteoplastic Frontal Sinus Surgery With Fat Obliteration: Technique and Long--Term Results Using MagnetTerm Results Using Magneticic

Resonance Imaging in 82 Operations. Laryngoscope. 2000. 1037Resonance Imaging in 82 Operations. Laryngoscope. 2000. 1037--44.44.


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ObliterationMaterialsObliterationMaterials

Adipose tissueAdipose tissue

PericraniumPericranium

HydroxyapatiteHydroxyapatite

Temporalis fasciaTemporalis fascia Bone chipsBone chips

Bio glassBio glass

Polytetrafluoroethylene carbon fiberPolytetrafluoroethylene carbon fiber

Calcium sulfate methylmethacrylateCalcium sulfate methylmethacrylate

Oxidized celluloseOxidized cellulose

GelfoamGelfoam

Lyophilized cartilageLyophilized cartilage



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HydroxyapatiteObliterationHydroxyapatiteObliteration

Friedman and Costantino (1991)Friedman and Costantino (1991)

HAC obliteration feline frontal sinuses.HAC obliteration feline frontal sinuses.

30% replacement of the HAC with bone at 1230% replacement of the HAC with bone at 12monthsmonths

63% at 18 months.63% at 18 months.

There was no evidence of mucosal membraneThere was no evidence of mucosal membrane

ingrowth or mucocele formationingrowth or mucocele formation No complications in recent report in humansNo complications in recent report in humans



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Pericranial Flap ObliterationPericranial Flap Obliteration

Vascularized flapVascularized flap

Does not rely on sinus walls for blood supplyDoes not rely on sinus walls for blood supply

Low post op infection rateLow post op infection rate Bulky enough to obliterate frontal sinusBulky enough to obliterate frontal sinus

Axial or random flapAxial or random flap

Axial flapsAxial flapsAnteriorAnterior supraorbital / supratrochlear arteriessupraorbital / supratrochlear arteries

LateralLateral -- anterior division of superficial temporal arteryanterior division of superficial temporal artery

Parhiscar et al. Frontal Sinus Obliteration with the Pericranial Flap. Otolaryngol Head Neck Surg 2001; 124: 304Parhiscar et al. Frontal Sinus Obliteration with the Pericranial Flap. Otolaryngol Head Neck Surg 2001; 124: 304--7.7.

Ducic, Y et al. Frontal Sinus Obliteration Using a Laterally Based Pedicled Pericranial Flap.Laryngoscope 1999; 109 (4), p 5Ducic, Y et al. Frontal Sinus Obliteration Using a Laterally Based Pedicled Pericranial Flap.Laryngoscope 1999; 109 (4), p 54141--55.55.


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Ducic, Y et al. Frontal Sinus Obliteration Using a Laterally Based Pedicled Pericranial Flap. Laryngoscope 1999; 109 (4), p 5Ducic, Y et al. Frontal Sinus Obliteration Using a Laterally Based Pedicled Pericranial Flap. Laryngoscope 1999; 109 (4), p 54141--55.55.


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Fat ObliterationFat Obliteration

Outcome not influenced by degree of survivingOutcome not influenced by degree of surviving

fat.fat.

Post op fat distributionPost op fat distribution < 20%< 20% 53% of cases53% of cases

> 60%> 60% 18% of cases18% of cases

Statistical tests and modelingStatistical tests and modeling

Significant decrease of adipose tissue with timeSignificant decrease of adipose tissue with time

Median halfMedian half--life 15.4 molife 15.4 mo




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Post op scansPost op scans

CTCT

Soft tissue windowsSoft tissue windows

Low attenuation of fat may be confused with airLow attenuation of fat may be confused with air

Range of normal appearancesRange of normal appearances stages of partialstages of partialfibrosis of the obliterating fat.fibrosis of the obliterating fat.




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Post op scansPost op scans

MRIMRI FatFat

High signal intensity (T1)High signal intensity (T1)

Intermediate signal (T2)Intermediate signal (T2)

Fibrotic areasFibrotic areas Low to intermediate signal (T1 and T2)Low to intermediate signal (T1 and T2)

Patients with persistent symptoms had no distinguishing MRI featuresPatients with persistent symptoms had no distinguishing MRI featureswhen compared with asymptomatic patients.when compared with asymptomatic patients.

Appearance of mucoceles.Appearance of mucoceles.

Varies according to the protein concentration of the secretionsVaries according to the protein concentration of the secretions T1T1 -- low, intermediate, or high signallow, intermediate, or high signal

T2T2 -- high signal intensityhigh signal intensity


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Fat ObliterationFat Obliteration

CatalanoCatalano 59 patients (1 to 9 years post op)59 patients (1 to 9 years post op) 8.5% needed revision of osteoplastic flap8.5% needed revision of osteoplastic flap

6.7% required correction of frontal bossing6.7% required correction of frontal bossing

LoevnerLoevner 13 patients (1 to 12 years post op)13 patients (1 to 12 years post op) 3 mucoceles3 mucoceles

Weber, DrafWeber, Draf 59 patients (1 to 12 post op)59 patients (1 to 12 post op)

MucocelesMucoceles 5 of 51 cases5 of 51 cases

1, 3, 4, 8 and 10 years1, 3, 4, 8 and 10 years




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Pericranial Flap Craniali ationPericranial Flap Craniali ation

Donald and Bernstein (1978)Donald and Bernstein (1978)

First report of cranializationFirst report of cranialization

By convention; frontal sinus left as dead space or filled withBy convention; frontal sinus left as dead space or filled with

free adipose tissue.free adipose tissue. Consider with displacement > one table widthConsider with displacement > one table width

Severely comminuted fxSeverely comminuted fx

Donath et al (2006)Donath et al (2006)

19 patients, no reported complications19 patients, no reported complications

One sphenoid CSF leak post opOne sphenoid CSF leak post op

No post op infectionsNo post op infections


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Donath, A. Frontal Sinus Cranialization Using the Pericranial Flap: An Added Layer of Protection.Laryngoscope, 116:15851588, 2006


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What would you do?What would you do?


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ReferencesReferences

1.1. Strong, EB et al. Frontal sinus fractures: A 28Strong, EB et al. Frontal sinus fractures: A 28--year retrospective review. Otolaryngologyyear retrospective review. OtolaryngologyHead and NeckHead and NeckSurgery (2006) 135, 774Surgery (2006) 135, 774--779.779.

2.2. Maladiere et al. Aetiology and Incidence of Facial Fractures Sustained During Sports: A Prospective StudyMaladiere et al. Aetiology and Incidence of Facial Fractures Sustained During Sports: A Prospective Studyof 140 Patients. Int J Oral Maxillofac Surg, 2001: 30; 291of 140 Patients. Int J Oral Maxillofac Surg, 2001: 30; 291--295.295.

3.3. Friedman, JA et al. Persistent Posttraumatic Cerebrospinal Fluid Leakage. Neurosurg Focus. 2000 (9), 1Friedman, JA et al. Persistent Posttraumatic Cerebrospinal Fluid Leakage. Neurosurg Focus. 2000 (9), 1--5.5.4.4. Weber, R, Draf, W et al. Osteoplastic Frontal Sinus Surgery With Fat Obliteration: Technique and LongWeber, R, Draf, W et al. Osteoplastic Frontal Sinus Surgery With Fat Obliteration: Technique andLong--

Term Results Using Magnetic Resonance Imaging in 82 Operations. Laryngoscope. 2000. 1037Term Results Using Magnetic Resonance Imaging in 82 Operations. Laryngoscope. 2000. 1037--44.44.5.5. Fattahi et al. Comparison of 2 Preferred Methods Used for Frontal Sinus Obliteration. J Oral MaxillofacFattahi et al. Comparison of 2 Preferred Methods Used for Frontal Sinus Obliteration. J Oral Maxillofac

Surg 63; 487Surg 63; 487--91, 2005.91, 2005.6.6. Gossman et Laryngoscope al. Management of Frontal Sinus Fractures: A Review of 96 Cases., 116: 1357Gossman et Laryngoscope al. Management of Frontal Sinus Fractures: A Review of 96 Cases., 116: 1357--

136, 2006.136, 2006.7.7. Hwang et al. Closed Reduction of Fractured Anterior Wall of the Frontal bone. Journal of CraniofacialHwang et al. Closed Reduction of Fractured Anterior Wall of the Frontal bone. Journal of Craniofacial

Surgery. 2005 (16); 120Surgery. 2005 (16); 120--122.122.8.8. Pham, A and Strong, EB. Endoscopic management of facial fractures. Curr Opin Otolaryngol Head NeckPham, A and Strong, EB. Endoscopic management of facial fractures. Curr Opin Otolaryngol Head Neck

Surg 14:234Surg 14:234241. 2006 Lippincott Williams & Wilkins.241. 2006 Lippincott Williams & Wilkins.9.9. Friedman, C et al. Reconstruction of the Frontal Sinus and Frontofacial Skeleton With HydroxyapatiteFriedman, C et al. Reconstruction of the Frontal Sinus and Frontofacial Skeleton With Hydroxyapatite

Cement. Arch Facial Plast Surg.2000;2:124Cement. Arch Facial Plast Surg.2000;2:124--12912910.10. Lakhani, Raam S. MD et al. Titanium Mesh Repair of the Severely Comminuted Frontal Sinus Fracture.Lakhani, Raam S. MD et al. Titanium Mesh Repair of the Severely Comminuted Frontal Sinus Fracture.

Arch Otolaryngol Head Neck Surg.2001;127:665Arch Otolaryngol Head Neck Surg.2001;127:665--66966911.11. Rice, DH. Management of Frontal Sinus Fractures. Curr Opin Otolaryngol Head Neck Surg. Curr OpinRice, DH. Management of Frontal Sinus Fractures. Curr Opin Otolaryngol Head Neck Surg. Curr OpinOtolaryngol Head Neck Surg 12:46Otolaryngol Head Neck Surg 12:4648. 2004 Lippincott Williams & Wilkins.48. 2004 Lippincott Williams & Wilkins.

12.12. Parhiscar et al. Frontal Sinus Obliteration with the Pericranial Flap. Otolaryngol Head Neck Surg 2001;Parhiscar et al. Frontal Sinus Obliteration with the Pericranial Flap. Otolaryngol Head Neck Surg 2001;124: 304124: 304--7.7.

13.13. Ducic, Y et al. Frontal Sinus Obliteration Using a Laterally Based Pedicled Pericranial Flap. LaryngoscopeDucic, Y et al. Frontal Sinus Obliteration Using a Laterally Based Pedicled Pericranial Flap. Laryngoscope1999; 109 (4), p 5411999; 109 (4), p 541--55.55.

14.14. Donath, A. Frontal Sinus Cranialization Using the Pericranial Flap: An Added Layer of Protection.Donath, A. Frontal Sinus Cranialization Using the Pericranial Flap: An Added Layer of Protection.Laryngoscope, 116:1585Laryngoscope, 116:15851588, 20061588, 2006

15.15. Chen et al. Frontal Sinus Fractures: A Treatment Algorithm and Assessment of Outcomes Based on 78Chen et al. Frontal Sinus Fractures: A Treatment Algorithm and Assessment of Outcomes Based on 78

Clinical Cases. Plast. Reconstr. Surg. 118: 457, 2006.Clinical Cases. Plast. Reconstr. Surg. 118: 457, 2006.

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Frontal Sinus Fx Slides 070117