Choice of Material for Nasofrontal Duct Obliteration in Frontal Sinus Fracture

Introduction: Within the surgical management algorithm for frontal sinus fracture (FSF), the choice of material for nasofrontal duct (NFD) obliteration is controversial, and a multitude of materials have been described in the literature. The present study aims to perform a systematic review to determine postoperative outcomes associated with various NFD obliteration materials. Methods: Two independent reviewers identified studies to be included based on inclusion and exclusion criteria. Odds ratios and Fisher’s Exact Tests were then used to compare outcomes between cohorts based on the material used for NFD obliteration. Complications under review included donor site complications, reoperations, frontal sinus infections, cerebrospinal fluid leaks, cosmetic defects, persistent pain and/or headaches, and mucocele formation. Results: Twenty-nine studies met inclusion criteria. The use of a vascularized flap was associated with a reduced risk of reoperation and postoperative frontal sinus infection compared with non-flap materials (OR = 0.23 (CI: 0.05, 1.04), P = .05. The use of avascular bone graft was associated with an increased risk of reoperation (OR = 8.89 (CI: 2.24, 29.94), P < .001. Use of bone graft was associated with increased postoperative frontal sinus infection compared with non-bone materials (OR = 3.92 (CI: 1.28, 11.96)), P = .017 and postoperative mucocele formation, P = .0035. The use of bone graft was associated with increased risk of total postoperative complications (OR = 2.68 (CI: 1.41, 5.11), P < .01. Use of autologous materials was associated with decreased number of total complications when compared with non-autologous materials (OR = 0.13 (CI: 0.02, 0.99), P = .02. Conclusions: Avascular grafts, such as bone grafts, for NFD obliteration may be associated with an increased risk of reoperation. In particular, bone grafts are associated with higher rates of reoperation, postoperative infection and mucocele formation. Vascularized flaps appear to offer excellent postoperative outcomes with minimal operative morbidity. This systematic review may be useful in further refining the roles of certain materials in NFD obliteration for FSF surgery.

Repair of frontal sinus fractures: clinical and radiological long-term outcomes

Objective The long-term clinical and radiological outcomes of patients surgically treated for frontal sinus fracture were assessed. Methods A retrospective, single-centre analysis was conducted of patients treated for frontal sinus fracture in a tertiary trauma centre between 2000 and 2017. Patients who underwent surgical repair for frontal sinus fracture followed by clinical and radiographical evaluation for at least six months were included. Results Of 338 patients admitted with frontal sinus fracture, 77 were treated surgically. Thirty patients met the inclusion criteria for long-term follow-up. The average follow-up duration was 37 months (range, 6–132 months). Reconstruction, obliteration and cranialisation of the frontal sinus fracture were performed in 14, 9 and 7 patients, respectively. Two patients with a reconstructed frontal sinus and one with an obliterated frontal sinus developed mucoceles. One patient developed forehead disfigurement following obliteration. Conclusion Long-term complications of frontal sinus repair using the chosen repair techniques are rare, but patients need to be made aware of these potential complications.

Tratamento cirúrgico de fratura do seio frontal utilizando enxerto de pericrânio para obliteração de ducto nasofrontal: relato de caso

Introdução: Dentre as fraturas em face destacam-se as fraturas em seio frontal, que podem resultar em dano estético. Essas fraturas podem acometer a parede anterior isoladamente ou em associação à parede posterior. A integridade do seio frontal tem importância para o paciente do ponto de vista estético e funcional. Objetivo: Este estudo tem por finalidade apresentar um caso clínico de uma vítima de acidente motociclístico, que resultou em fratura de osso frontal, associada à fratura naso-órbito-etmoidal. Relato De Caso: O paciente, do gênero masculino, 20 anos de idade, deu entrada em um Hospital de Emergência, em Pernambuco, após trauma em face. Ao exame físico observou-se afundamento em região frontal, aumento da distância intercantal e desvio nasal. Ao exame tomográfico notou-se fratura naso-órbito-etmoidal associada à fratura de osso frontal, havendo deslocamento da parede anterior do seio frontal, com preservação da parede posterior. Optou-se por intervenção cirúrgica, através de acesso coronal e realizou-se a obliteração do ducto nasofrontal com enxerto livre de pericrânio e fixação da parede anterior do seio frontal; além de redução dos ossos próprios do nariz. No pós-operatório, observou-se projeção anteroposterior em região frontal adequada, melhora da distância intercantal e da arquitetura nasal. O paciente continuou sendo acompanhado durante um mês em ambulatório, evoluindo sem intercorrências. Conclusão: Pode-se concluir que o tratamento de fraturas em terços superior e médio de face constitui um desafio ao cirurgião buco-maxilo-facial, mas que um plano de tratamento adequado resulta em bons resultados para o paciente.Descritores: Seio Frontal; Face; Fraturas Ósseas.ReferênciasSilva JJ, Neto AR, Pereira AM, Correia V, Lira AA. Fratura tardia de seio frontal: relato de caso. Rev Cir Traumatol buco-maxilo-fac. 2005; 5(3):51-6.Montovani JC, Nogueira EA, Ferreira FD, Lima Neto AC, Nakajima V. Cirurgia das fraturas do seio frontal: estudo epidemiológico e análise de técnicas. Rev Bras Otorrinolaringol. 2006; 72(2):204-9.Conci RA, Martins JRP, Tomazi FH, Sbardelotto BM, Sirena Neto L, Oliveira GR. Tratamento Cirúrgico de fratura de seio frontal. Surgical Treatment of Frontal Sinus Fracture. Rev Cir Traumatol Buco-Maxilo-Fac. 2012;(12):31-36.Lessa ES, Cruz RL, Costa MJM, Magalhaes GE, Braune AS. Fraturas do seio frontal: conduta em relação ao ducto nasofrontal. Rev Bras Cir Plást. 2010;25(supl):1-102.Melo, RB, Hage CA, Carneiro NCM, Xavier TB, Fonseca WLM, Ferreira DP. Tratamento cirúrgico de fratura de parede anterior de seio frontal decorrente de acidente desportivo: relato de caso clínico. Rev Odontol Bras Central 2016;25(72).Doonquah L, Brown P, Mullings W. Management of frontal sinus fractures. Oral Maxillofac Surg Clin North Am. 2012;24(2):265-74.Melo MFS, Zanettini LMS, Lukschal LF, Silveira RL, Amaral MBF. Correção de fratura fronto-naso-órbito-etmoidal: passos cirúrgicos para resultado estético. Cir Traumatol Buco-Maxilo-Fac. 2015;15(1):33-40.Silva JR, Mourão CFAB, Rocha Júnior HV, Magacho LF, Moraes GFD, Homsi N. Inversão do segmento fraturado para tratamento das sequelas de fratura do seio frontal. Rev Col Bras Cir 2016; 43(6):472-75.Macedo TFO, Lima RFF, Toledo IC, Cavalcante WC, Santos JN. Tratamento de fratura da parede anterior do seio frontal com técnica minimamente invasiva: relato de caso clínico. Rev Bras Cir Cabeça Pescoço. 2017;46(3):105-8.Fernandes BDR, Mandarino S, Gomes-Ferreira PHS, Palin LP, Zorzi Coléte J, Ribeiro J, et al. Tratamento de fratura do seio frontal, por meio de cranialização, obliteração, redução e fixação das fraturas: relato de caso clínico. Arch Health Invest. 2018;7(Spec Iss 3):451.Santos MBP, Cavalieri I, Araújo MM, Vale DS, Breda Júnior, MA. Inversão do segmento fraturado para tratamento das sequelas de fratura do seio frontal. Rev Col Bras Cir. 2016; 43(6):472-75.Jardim EC, Santiago Júnior JF, Guastaldi FPS, Magro Filho O, Jardim Júnior, EG. Fratura do seio frontal: relato de caso. Rev Odontol Araçatuba 2010;31(2):35-39.

Asystole due to stimulation of the supraorbital nerve: abrupt and potentially fatal presentation of the trigeminocardiac reflex

We present a case of sudden asystole that was elicited via the trigeminocardiac reflex in a patient undergoing surgery for a frontal sinus fracture. Asystole occurred after mild stimulation of the supraorbital nerve during dissection along the superior orbital rim. Anticholinergics were administered and lidocaine-soaked gauze was applied to the exposed wound. The patient was an athlete and had pre-existing sinus bradycardia. We hypothesise that the severe reflex response was associated with his underlying increased vagal tone. When performing surgery in patients with increased vagal tone, preventative measures to diminish the trigeminocardiac reflex are recommended. Further studies are needed.