Resident Manual of Trauma to the Face, Head and Neck

CHAPTER 3: Upper Facial Trauma

3. Frontonasal Duct Fractures Fractures of the frontonasal duct have no particularly distinguishing clinical diagnostic features and are usually picked up on a CT scan. Though the actual fracture may not be seen, an opacified frontal sinus that does not clear in 2 weeks raises a strong suspicion of disruption of the duct. The duct is often fractured as part of a Le Fort III maxillary fracture. If at 2 weeks the sinus does not clear, a test can be done to establish patency of the duct. A small trephine hole in the floor of the sinus is made through a small incision in or just below the brow. The sinus is irrigated through the trephine with a saline solution containing cocaine or epinephrine. A solution containing methylene blue is instilled in the sinus, and the appearance of the dye in the middle meatus of the nose is observed with a sinus endoscope. The appearance of the dye indi- cates duct patency; the dye’s absence is an indication for surgery. 4. Corner Fractures A corner fracture is usually not displaced. The anterior wall, floor, and posterior wall are fractured, and the corner fracture is normally in continuity with a more extensive fracture to the frontal bone. Corner

fractures usually require no treatment. 5. Through-and-Through Fractures

The through-and-through fracture is the most serious of all frontal sinus fractures. It is a compound comminuted fracture involving the anterior and posterior walls, entering the anterior cranial fossa (Figure 3.2). The skin is torn—often extensively, the dura is ripped, and the frontal lobes

Figure 3.2 Endoscopic inspection of the frontonasal duct. View through fractured anterior wall of trephine.

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