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CHAPTER 3: Upper Facial Trauma

Resident Manual of Trauma to the Face, Head, and Neck

The sinus can be managed either endoscopically or by an open opera-

tion. The reestablishment of ductal patency has thwarted frontal sinus

surgeons for over 100 years.

All methods of opening the frontal sinus

floor to the nasal cavity have been attempted with varying degrees of

success. Currently, the use of the Draf III endoscopic version of the

Lothrop operation

has become very popular. The two classic open

techniques are the Lynch operation using the Sewell-Boyden flap to line

the widely open tract, and the osteoplastic flap procedure with fat

obliteration.

The Draf III uses classical fiberoptic endoscopic evaluation of swallow-

ing (FESS) techniques to remove the frontal sinus floor, the superior

part of the nasal septum and the so-called “beak” area of the anterior

frontal sinus floor. Because the technique causes a minimum amount of

trauma in the resection area, theoretically, the opening is more likely to

stay open.

The Lynch operation uses a curvilinear incision starting in the medial

brow, and courses through the so-called “nasojugal area,” half way

between the medial canthus of the eye and the mid-line of the nasal

dorsum. The ethmoid sinuses and the entire area of the frontonasal

duct, as well as the floor of the frontal sinus, are removed. The Sewell-

Boyden flap is constructed from the nasal septum medially or the lateral

nasal wall anterior to the turbinates. The flap is then used to line the

opening in the frontal sinus floor. The most reliable way to repair a duct

fracture is to eliminate the frontal sinus entirely with the osteoplastic

flap and fat obliteration procedure.

4. Through-and-Through Fractures

This devastating injury was formerly managed by the neurosurgeon by

craniectomy, often discarding the skull fragments because of their

contamination at the scene of the accident, and not cleansing them and

restoration of the cranial vault because of the concern of brain swelling.

The otolaryngologist classically did a Riedel ablation, with the two

procedures leaving the patient with unprotected brain as well as a

significant cosmetic defect.

In 1975, Donald and Bernstein

and Derome and Merville

described the

cranialization procedure for these through-and-through fractures. The

neurosurgeon controls the intracranial problems by stopping the

intracranial bleeding, debriding necrotic brain, and providing a water-

tight dural repair.