How Do You Repair The Bone Around The Frontal Sinus If There's A Hole In It

one. Introduction

Severe injuries which upshot in disruption of greater than 25% of the posterior table should be considered for cranialization. This involves exposure of the entire sinus, meticulous removal of all sinus mucosa, and removal of the posterior table bone. The anterior table bone is replaced to reconstitute the brow contour.

Important: Consummate removal of the posterior wall and obstruction of the sinus outflow tract is essential to create a "safe sinus".

2. Approach

For this procedure the coronal approach is normally used. However, if present, lacerations tin be used to straight admission fracture sites for fracture managment.

3. Exposure

While elevating the coronal flap, it is disquisitional to maintain the integrity of the pericranial flap. It may exist necessary for repair of dural lacerations.

Pearl: identification of explanted bone fragments
Last orientation of any removed os fragments can exist challenging. Placing the explanted segments on a rough sketch of the skull made with a sterile pen will maintain orientation until re-implantation. Outline each segment and the overall shape of the defect.

The bone fragments should be kept moist until they are re-placed.

4. Defining the sinus margin

The margins of the frontal sinus are irregular and may non be visible through the fracture.

It is yet disquisitional to determine the precise margins of the sinus to allow for an accurate osteotomy and consummate exposure of the sinus. There are several ways to achieve this:

• Bayonet forceps
• Transillumination
• half-dozen-foot (one.83 m) Caldwell x-ray with coin reference
• Intraoperative navigation

Bayonet forceps

One tine of the bayonet forceps (or bipolar cautery) can exist inserted into the defect. The other tine spans the anterior table. The internal tine is so "walked" around the periphery of the sinus. The external tine is then used to guide markings which will outline the periphery of the sinus on the outer table os. The outline tin be marked with ink or electrocautery (the electrocautery should be placed at a low setting to coagulate overlying blood and avoid excessive bone injury).

Transillumination

Alternatively, a light source (such as an endoscope) can be inserted through the anterior table bone defect. The light will transilluminate the sinus and delineate its margins.
Beware of pitfalls such every bit soft-tissue and blood present in the sinus.

6-foot (1.83 m) Caldwell x-ray with coin reference

A 6-foot (ane.83 m) Caldwell x-ray with (anterior-posterior Caldwell x-ray with the patient placed 6 feet from the 10-ray tube) can be used to delineate the margins of the sinus. The 6-human foot penny Caldwell generates a "life-size" representation of the sinus crenel. It is imperative that the orientation (ie, right and left) is clearly documented on the 10-ray.

Scissors are and so used to cut along the margins of the sinus. Lateral "wings" that projection along the orbital rims are too cutting out to help with orientation. A 2nd copy of the sinus template is generated from the outset in instance ane is contaminated during the procedure. An "R" is scratched into the right side of both templates to record orientation. Both copies are sterilized and brought onto the surgical field.

The template is then placed over the sinus using the orbital rim "wings" to assistance with orientation. The template is held in place. The sinus periphery can then be outlined using ink or electrocautery as previously described.

Intraoperative navigation

Intraoperative navigation can exist used to outline the periphery of the sinuses using the preoperative CT scan. A reference assortment must be fixed to the skull (or Mayfield head holder) to allow for accurate navigation.

The navigation system is used to guide the probe along the periphery of the sinus.

Ink or electrocautery tin can be used to mark the outline.

5. Osteotomy

Plate application

After the proposed osteotomy has been marked at the periphery of the sinus, thin plates are applied spanning the sinus margin. An adequate number of plates should be applied to provide stability when the anterior table segment is osteotomized. The plates should be pre-practical prior to the osteotomy. This allows for accurate repositioning of the anterior tabular array bone.

Each plate should exist rotated away from the proposed osteotomy line. This tin be accomplished by removal all merely ane spiral located on stable bone exterior the sinus. The plate can then be rotated away from the sinus.

Perforating the inductive tabular array

A sagittal saw tin can exist used to perform the osteotomy. However, a side-cutting burr (as illustrated) is more controlled and authentic. The bit is used to drill sequential holes along the superior border of the sinus. Individual holes are separated by several millimeters.

The handpiece should be angled approximately 45° towards the sinus and away from the cranial vault to avert violation of the posterior table.

Completion of superior osteotomy

The holes are then connected to create a single osteotomy on the superior margin of the sinus.

Osteotomizing the orbital rims/glabella

Next, the drill is used to osteotomize the orbital rims and glabella in a similar fashion. Care should be taken to protect the orbital contents and supratrochlear/supraorbital neurovascular pedicles.

Intersinus septum osteotomy

If the intersinus septum is intact, information technology may be necessary to insert a curved osteotome through the superior osteotomy site and fracture the intersinus septum but deep to the anterior table bone. Care must be used to avert injuring the posterior table.

Bone removal

A curved osteotome is so inserted through the superior osteotomy to cantilever the anterior tabular array and generate a controlled fracture of any remaining attached bone. A clench should be used to control the inductive bone fragment as the osteotomy fracture is completed.

Mucosa removal

The sinus cavity is then suctioned costless of any blood or mucous. An elevator and/or forceps are used to remove any bone or mucosa that has been displaced into the sinus cavity. Meticulous dissection technique should be used to avert iatrogenic injury of the dura.

These injuries tin can result in severe disruption or even loss of anterior table bone. Therefore, larger os fragments from the posterior table should be maintained for possible use with reconstruction of the inductive table or obliteration of the frontal recess.

6. Posterior table removal

An elevator is used to separate the dura from the posterior tabular array forth the entire margin of the defect.

The dura should be elevated from the posterior sinus wall prior to bone removal.

A Kerrison rongeur is and so used to initiate the removal of the posterior wall.

The process of dural elevation and bone removal should so be repeated. As the defect gets larger, it is possible to employ a double activity rongeur to remove the rest of the posterior wall.

A diamond drill should be used to make a smooth contour between the sinus and intracranial cavities. A malleable retractor is used to retract and protect the brain while drilling. When drilling is complete, there should be a smoothen contour between the cranial vault and the sinus.

Item attention must be paid to the scalloped areas at the periphery of the sinus.

7. Mucosa removal

A clamp is used to stabilize the gratuitous anterior bone segment(due south) that were previously removed. A big diamond burr is then used to remove the mucosa from the inner surface. The mucosa should also be stripped of whatever posterior tabular array bone fragments to be used for reconstruction of the anterior wall.

eight. Closure of the recess

An elevator is so used to circumferentially elevate the mucosa in the frontal recess bilaterally. The mucosa is and so inverted and pushed inferiorly to obstruct the outflow tract. Free fascia is used for obliteration of the outflow tract.

Alternatively, a sharp i-2 cm straight osteotome can exist used to harvest a thin layer of outer layer calvarial bone. If the graft can be harvested from a region with Intact periosteum, this will help maintain the integrity of the graft. If posterior tabular array bone fragments are available, these can also exist used to plug the outflow tract.

9. Closure of sinus ostia

Each bone graft is trimmed to fit into the frontal sinus infundibulum using a fine bone rongeur.

The graft is then wedged into identify to obstruct the sinus outflow tract.

x. Anterior table repair

The inductive table os fragments are then repositioned and the pre-applied plates are rotated back into position to fixate the fragments. Replace whatever remaining fragments and fix them with pocket-sized plates.
With fourth dimension, the brain will expand into the cranialized sinus.

xi. Aftercare following management of frontal sinus fractures

Evaluation of the patient's vision

Evaluation of the patient'south vision is performed as before long as they are awakened from anesthesia and and then at regular intervals until they are discharged from the infirmary.
A swinging flashlight test may serve in the unconscious and/or noncooperative patient; alternatively electrophysiological examination has to be performed but is dependent on the appropriate equipment visual evoked potential (VEP).

Postoperative positioning

Keeping the patient'southward head in a raised position both preoperatively and postoperatively may significantly amend edema and pain.

Nose-blowing

Nose-blowing should be avoided for at least iii weeks following frontal sinus and skull base repair.

Medication

The employ of the post-obit perioperative medication is controversial. There is little evidence to make strong recommendations for postoperative intendance.

• No aspirin for 7 days (nonsteroidal antiinflammatory drugs (NSAIDs) use is controversial)
• Analgesia as necessary
• Antibiotics (many surgeons use perioperative antibiotics. In that location is no clear advantage of any ane antibiotic, and the recommended duration of treatment is debatable.)
• Nasal decongestant may be helpful for symptomatic improvement in some patients.
• Steroids, in cases of severe orbital trauma, may help with postoperative edema. Some surgeons have noted increased complications with perioperative steroids.
• Ophthalmic ointment should follow local and approved protocol. This is not generally required in case of periorbital edema. Some surgeons prefer it. Some ointments have been found to cause significant conjunctival irritation.

Ophthalmological exam

Postoperative test by an ophthalmologist may be requested. The following signs and symptoms are normally evaluated:

• Vision
• Extraocular motion (motility)
• Diplopia
• Globe position
• Visual field test
• Lid position
• If the patient complains of epiphora (tear overflow), the lacrimal duct must be checked
• If the patient complains of eye hurting, evaluate for corneal abrasion

Note: In case of postoperative diplopia, ophthalmological assessment is needed to identify the cause. Hess-chart testing should be performed if diplopia persists.

Postoperative imaging

Postoperative imaging has to be performed within the first days after surgery. three-D imaging (CT, cone axle) is recommended to assess complex fracture reductions. In centers where intraoperative imaging is available postoperative imaging tin can be performed at a delayed time.

For skull base of operations and frontal sinus fractures postoperative imaging should be performed when indicated. If the frontal sinus is preserved, perform a follow up scan in three-6 months to ensure that it is aerated.

Wound care

The scalp tin can generally be washed at 5 days postoperatively.

Suture removal from scalp is performed at 7-10 days postoperatively.

Avoid sun exposure and tanning to pare incisions for several months.

Diet

Diet depends on the fracture pattern and patients status but there are usually no limitations.

Clinical follow-upwards

Patients should be counseled that frontal sinusitis, mucocele formation, or whatsoever other signs of intracranial infection can occur years after the injury. The symptoms should exist discussed with the patient including

• Headache
• Erythema
• Mucopurulent nasal drainage
• Frontal bone deformity
• Orbital edema/displacement

Clinical follow-up depends on the complexity of the surgery, and the patient'south postoperative form.

• Other problems to consider are:
• Cranial vault contour deformity
• Sensory nerve compromise
• Problems of scar formation
• Alopecia
• Postoperative headache
• Anosmia
• Dizziness
• Airsickness
• Meningitis (can occur years subsequently injury)
• Mucocele formation (can occur years later injury)

Implant removal

Implant removal is rarely required. It is possible that this may be requested by patients if the implant becomes palpable or visible. In some countries it will be more normally requested. In that location have been cases where patients have complained of cold sensitivity in areas of plate placement. Information technology is controversial whether this common cold sensitivity is a result of the plate, a result of nerve injury from the original trauma, or from nerve injury due to trauma of the surgery. Issues of common cold sensitivity generally improve or resolve with time without removal of the hardware.

Special considerations

Travel in pressurized aircraft is permitted 4 – 6 weeks postoperatively. Mild pain on descent may be noticed. However, flying in not-pressurized aircraft should be avoided for a minimum of 12 weeks.

No scuba diving should be permitted for at least 12 weeks. Additionally, the patient should be warned of long term potential risks.

How Do You Repair The Bone Around The Frontal Sinus If There's A Hole In It,

Source: https://surgeryreference.aofoundation.org/cmf/trauma/skull-base-cranial-vault/frontal-sinus-posterior-table/cranialization

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