Beruflich Dokumente
Kultur Dokumente
Leo Martinez, MD
Faculty Advisor: Patricia Maeso, MD
The University of Texas Medical Branch
Department of Otolaryngology
Grand Rounds Presentation
December 17, 2010
Outline
S History
S Introduction
S Etiology
S Work up
S Treatment
History
and floor, which left the skin covering the posterior table,
which left a cosmetic defect
S Killian in 1904 performed a similar procedure, but left a rim of
supraorbital bone which lessened the cosmetic defect.
S Lynch in 1921 was credited with the first
frontoethmoidectomy leaving the anterior table in place but
removing the frontal sinus floor and ethmoids.
History
History
Introduction
birth
Introduction
Introduction
in 4% of the population.
Introduction
S Anterior table
4.8 mm thick
Introduction
S The sinus has 2 ostia on the posterior floor. They are each
just a foramen
Introduction
supratrochlear vessels.
S Venous drainage is through the facial vein, the ophthalmic
Etiology
S It takes 800-2200 lbs. of force to create a frontal fracture
S They consist of 5-12% of facial fractures
S Incidence is 9 cases per 100,000 adults.
Motor vehicle
4 6
Assults
10
71
Industrial
accidents
Recreational
accidents
Etiology
categories:
S Anterior table fracture
S Posterior table fractures
S Combined fractures
Etiology
S The anterior table also serves as the frontal bar for the
Etiology
Etiology
Etiology
S Chronic complication
S Chronic frontal headaches
S Forehead depression
S Mucocele/mucopyocele
S Delay CSF leak
S Brain abscess
S Chronic nasal drainage
S Frontal fullness
S Diplopia
Workup
Workup
triaged appropriately.
S Initial evaluation includes airway, breathing, circulation (ABCs)
S A neurosurgical and ophthalmological consultation should also be
Workup
S After the patient is stabilized, a thorough head and neck examine
is warranted.
Workup
Workup
S Radiographically, plain films may reveal frontal sinus
Workup
S Sagittal views are also helpful in evaluation of nasofrontal
ducts
Treatment
It has also been reported that with patients with CSF leaks, leaks
longer than 8 days increase rate of infection, and therefore early
surgical repair, if indicated, would reduce the rate of infection
Treatment
rest, head of bed elevated, and lumbar drain at 10 ml CSF per hr.
S Surgery is advocated if the posterior table is displaced more than
one table length. Also, surgery is indicated if CSF leak does not
respond to conservative treatment of over 7 days.
Treatment
Treatment
Treatment
rate.
Treatment
Treatment
S Obliteration 8%
Treatment
fracture
S Miniplates are overall best for strength vs midface and microplates
S No difference in bio-absorbable vs titanium except in miniplates
Endoscopic
duct involvement
S One central and two lateral hairline incision are made.
S Soft tissue is elevated by visualization of 30o Scope.
Endoscopy
Endoscopy
Obliteration
Obliteration
Obliteration
S Material include
S Adipose tissue
S Hydroxyapatite
S Pericranium
S Bone chips
S Temporalis fascia
S Calcium phosphate cement
S Glass ionomers
Obliteration
S Hydroxyapatite
S Described Friedman and Costantino (1991)
S 30% of Hydroxyapatite replaced with bone at 12 months, 68%
replaced at 18 months.
S Pericranial flap obliteration
S Vascular but does not rely on sinus wall
S Anterior supraorbital flap, lateral anterior superficial temporal
artery
Obliteration
Obliteration
Obliteration
S Parhiscar, Laryngoscope 2002
S Use of pericranial flap between the posterior frontal sinus and the
morbidity
S Obliterization success depends more on technique than tissue
type, therefore occlusion of nasofrontal duct and complete
removal of mucosal tissue more important than tissue type.
Obliteration
bone.
S However, it is prone to degradation and chronic foreign body
reactions when placed directly over dura, and therefore not
recommended for frontal sinus work.
Obliteration
S Glass ionomer
S Matrix of glass polymer, osteoconductive material
S Better bone fill, faster healing time than hydroxyapatite
S Only commercially available alloplast recommended for
Obliteration
S Fat obliteration
S Weber, Laryngoscope 2000
S
Obliteration
Cranialization
table injury.
S Repair of the dura can be done with 5-0 nylon sutures, with
Cranilization
S Donath Laryngoscope 2006,
S 19 patients underwent pericranial flap with cranialization
S One CSF leak post op with no infection
Treatment
Follow up
repair or obliteration.
S Follow up every week for the first month, then monthly for
early.
S Long term follow up care is mandatory
Follow up
Complications
S Forehead depression 10 %
Complications
be pursued
S This should include a sinusotomy or a modified Lothrop.
Complications
S Draf Procedures
S Type I -Removal of disease inferior to the frontal sinus ostium
S Type IIa Removal of ethmoid cells projecting into the frontal
sinus
S Type IIb Removal of the frontal sinus floor from the lamina
papyracea to the nasal septum
S Type III- Bilateral enlargement with removal of superior nasal
septum and intersinus septum
Complications
Complications
Conclusion
Conclusion
References
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Fracture. Arch Otolaryngol Head Neck Surg.2001;127:665-669
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Curr Opin Otolaryngol Head Neck Surg 12:4648. 2004 Lippincott Williams & Wilkins.
SParhiscar et al. Frontal Sinus Obliteration with the Pericranial Flap. Otolaryngol Head Neck Surg
2001; 124: 304-7.
SDucic, Y et al. Frontal Sinus Obliteration Using a Laterally Based Pedicled Pericranial Flap.
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SDonath, A. Frontal Sinus Cranialization Using the Pericranial Flap: An Added Layer of
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References