Frontal sinus fractures

[EuroOMFS]

How are the OMS guys in here managing frontal sinus fractures? Do you always obliterate the sinus or the ostia? With what? Do you remove the sinus membrane and if so, how?

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[scalpel2008]

We manage frontal sinus fractures. Our tx is as follows. If it's a low velocity injury with minimal displacement of anterior table, then we do nothing. If the mechanism is a relatively high force injury, with displaced anterior wall, then we open it via a coronal approach and evaluate the ostia for patency. If patent and no floor fx, we leave the ostia alone and leave the membrane, reduce the anterior wall into proper anatomic pre trauma form. If ostia are involved then we plug them with autogenous bone and a pericranium flap (some attendings like to just do some bone and abdominal fat, but I think that living pericranium is better and more persistent.) If the posterior wall is fractured and displaced, we evaluate the dura for tears with the help of our NS friends and then cranialize the sinus (after ostia plugging and mucosa removal obviously) .
We remove the sinus membrane with a peripheral ostectomy (round bur) and currettes (esp posterior wall). As far as obliteration goes after membrane removal, I've seen it done both ways i.e some do and some don't. I dont see why it needs to be obliterated if the ostia are obliterated.

 

[IcedOMFS]

We manage frontal sinus fractures. Our tx is as follows. If it's a low velocity injury with minimal displacement of anterior table, then we do nothing. If the mechanism is a relatively high force injury, with displaced anterior wall, then we open it via a coronal approach and evaluate the ostia for patency. If patent and no floor fx, we leave the ostia alone and leave the membrane, reduce the anterior wall into proper anatomic pre trauma form. If ostia are involved then we plug them with autogenous bone and a pericranium flap (some attendings like to just do some bone and abdominal fat, but I think that living pericranium is better and more persistent.) If the posterior wall is fractured and displaced, we evaluate the dura for tears with the help of our NS friends and then cranialize the sinus (after ostia plugging and mucosa removal obviously) .
We remove the sinus membrane with a peripheral ostectomy (round bur) and currettes (esp posterior wall). As far as obliteration goes after membrane removal, I've seen it done both ways i.e some do and some don't. I dont see why it needs to be obliterated if the ostia are obliterated.

We do pretty much the same thing... We usually use tiseel to obliterate the duct, and then a variety of things for the sinus itself, for displaced anterior tables with crummy sinus mucosa or duct involvement in the fracture. Depends on the patient... Sometimes we use hip, sometimes fat, sometimes DFDB paste. Most of our patients are so horrible for compliance and followup, that we have no way of knowing what works... We never see them again.

 

[IcedOMFS]

How are the OMS guys in here managing frontal sinus fractures? Do you always obliterate the sinus or the ostia? With what? Do you remove the sinus membrane and if so, how?

I bet that at Gary Ruska's program, the periodontists do all the frontal sinus fractures. Especially the ones with comminuted, displaced posterior tables.

 

[EuroOMFS]

We manage frontal sinus fractures. Our tx is as follows. If it's a low velocity injury with minimal displacement of anterior table, then we do nothing. If the mechanism is a relatively high force injury, with displaced anterior wall, then we open it via a coronal approach and evaluate the ostia for patency. If patent and no floor fx, we leave the ostia alone and leave the membrane, reduce the anterior wall into proper anatomic pre trauma form. If ostia are involved then we plug them with autogenous bone and a pericranium flap (some attendings like to just do some bone and abdominal fat, but I think that living pericranium is better and more persistent.) If the posterior wall is fractured and displaced, we evaluate the dura for tears with the help of our NS friends and then cranialize the sinus (after ostia plugging and mucosa removal obviously) .
We remove the sinus membrane with a peripheral ostectomy (round bur) and currettes (esp posterior wall). As far as obliteration goes after membrane removal, I've seen it done both ways i.e some do and some don't. I dont see why it needs to be obliterated if the ostia are obliterated.

We do pretty much the same thing, except some of the attendings like to plug the ostia even if they're not involved in the fracture. If we cranialize the sinus, we only obliterate the ostia. Some use temporalis musle, some use bone and some use a galea flap.
I was surprised to recently see one of our attendings not removing the sinus membrane when removing a pretty comminuted posterior wall. He just plugged the ostia with a galea-flap and left it at that. He said there was no need to remove it and I wasn't going to argue with him. Have you ever heard of this?

 

[scalpel2008]

We do pretty much the same thing, except some of the attendings like to plug the ostia even if they're not involved in the fracture. If we cranialize the sinus, we only obliterate the ostia. Some use temporalis musle, some use bone and some use a galea flap.
I was surprised to recently see one of our attendings not removing the sinus membrane when removing a pretty comminuted posterior wall. He just plugged the ostia with a galea-flap and left it at that. He said there was no need to remove it and I wasn't going to argue with him. Have you ever heard of this?

never heard of plugging the ostia and leaving the mucosa. if you have mucosa you need a drainage mechanism. otherwise a mucopyocele is possible down the road. also it sounds like you cranialized the sinus if you removed the posterior wall which means that you have dura in contact with sinus membrane. and if the dura has tears (which it likely has small tears in a communited wall) you have brain in communication with nasty sinus membrane. i don't think that's a very good idea and you were right in asking him about it, even though the ostia are plugged.

 

[EuroOMFS]

never heard of plugging the ostia and leaving the mucosa. if you have mucosa you need a drainage mechanism. otherwise a mucopyocele is possible down the road. also it sounds like you cranialized the sinus if you removed the posterior wall which means that you have dura in contact with sinus membrane. and if the dura has tears (which it likely has small tears in a communited wall) you have brain in communication with nasty sinus membrane. i don't think that's a very good idea and you were right in asking him about it, even though the ostia are plugged.

Yep, it struck me as a strange way of cranializing the sinus. The NS put some sort of a fibrine glue (thats what he called it) to cover the area where he had sutured the dura, so there shouldn´t have been any direct brain communication.

 

[IcedOMFS]

Yep, it struck me as a strange way of cranializing the sinus. The NS put some sort of a fibrine glue (thats what he called it) to cover the area where he had sutured the dura, so there shouldn´t have been any direct brain communication.

Fonseca prefers the term 'Fibrin sealant' because of some FDA concern...

Tiseel = Fibrin Sealant. Or Fibrin glue, if you are a Swede or Dane, I guess.

Sweden has produced some pretty good things... Ikea, Branemark, Markus Naslund...

 

[scalpel2008]

when i did my craniofacial rotation, we used a ton of tisseal on our craniosynostoses and frontal-orbital advancements prior to reorganizing the cranial vault. I believe its a bovine thrombin human fibrinogen mixture. Duraseal is another product that the NS use.

 

[EuroOMFS]

when i did my craniofacial rotation, we used a ton of tisseal on our craniosynostoses and frontal-orbital advancements prior to reorganizing the cranial vault. I believe its a bovine thrombin human fibrinogen mixture. Duraseal is another product that the NS use.

It was Duraseal he used. Expensive stuff I was told.

 

[IcedOMFS]

It was Duraseal he used. Expensive stuff I was told.

Duraseal isn't fibrin sealant... It's a polyethylene glycol derivative... ALSO found in many sexual lubricants, toothpaste, antifreeze, and Dr. Pepper!

Not sure how much it costs, but Tiseel is like $500-600 per 2.5 cc syringe. Reminds me of epoxy from Home Depot.

 

[toofache32]

Fonseca prefers the term 'Fibrin sealant' because of some FDA concern...

Tiseel = Fibrin Sealant. Or Fibrin glue, if you are a Swede or Dane, I guess.

Sweden has produced some pretty good things... Ikea, Branemark, Markus Naslund...

...that bikini team....

 

[scalpel2008]

did a nice little frontal sinus fx today. have you guys used stryker's HA bone paste, Hydroset? Man, that stuff is very easy to work with and it was a breeze to contour (much better than Norion). Although I think think sticking something with a vascular supply (galea-frontalis flap) in the sinus is ideal for obliteration, this stuff is pretty cool after plugging the duct with some pericranium. One downside is cost.

 

[tx oms]

Not sure how much it costs, but Tiseel is like $500-600 per 2.5 cc syringe. Reminds me of epoxy from Home Depot.

Aint' that the truth.

 

[IcedOMFS]

did a nice little frontal sinus fx today. have you guys used stryker's HA bone paste, Hydroset? Man, that stuff is very easy to work with and it was a breeze to contour (much better than Norion). Although I think think sticking something with a vascular supply (galea-frontalis flap) in the sinus is ideal for obliteration, this stuff is pretty cool after plugging the duct with some pericranium. One downside is cost.

No, but have tried DBX bone paste. It's pretty nice too. You can irrigate over it and everything without it washing away.

I agree that a vascularized wad of something helps one to feel better after the case, at least as far as potential for infection goes... But, spare no expense, as they say! Can you really put a price-tag on fricking cool-ness? I think not...