PEDIATRIC/CRANIOFACIAL

Twenty-Six–Year Experience Treating Frontal

Sinus Fractures: A Novel Algorithm Based on
Anatomical Fracture Pattern and Failure of
Conventional Techniques
Eduardo D. Rodriguez, M.D.,
D.D.S.
Matthew G. Stanwix, M.D.
Arthur J. Nam, M.D.
Hugo St. Hilaire, M.D.
Oliver P. Simmons, M.D.
Michael R. Christy, M.D.
Michael P. Grant, M.D.
Paul N. Manson, M.D.
Baltimore, Md.
Background: Frontal sinus fracture treatment strategies lack statistical power.
The authors propose statistically valid treatment protocols for frontal sinus
fracture based on injury pattern, nasofrontal outflow tract injury, and
complication(s).
Methods: An institutional review board–approved retrospective review was
conducted on frontal sinus fracture patients from 1979 to 2005. Fractures
were categorized by location, displacement, comminution, and nasofrontal
outflow tract injury. Demographic data, treatment, and complications were
compiled.
Results: One thousand ninety-seven frontal sinus fracture patients were
identified; 87 died and 153 were excluded because of insufficient data,
leaving a cohort of 857 patients. The most common injury was simultaneous
displaced anteroposterior walls (38.4 percent). Nasofrontal outflow tract
injury constituted the majority (70.7 percent), with 67 percent having a
diagnosis of obstruction. Of the 857 patients, 504 (58.8 percent) underwent
surgery, with a 10.4 percent complication rate; and 353 were observed, with
a 3.1 percent complication rate. All complications except one involved
nasofrontal outflow tract injury (98.5 percent). Nasofrontal outflow tract
injuries with obstruction were best managed by obliteration or cranialization
(complication rates: 9 and 10 percent, respectively). Fat obliteration and
osteoneogenesis had the highest complication rates (22 and 42.9 percent,
respectively). The authors’ treatment algorithm provides a receiver operat-
ing characteristic area under the curve of 0.8621.
Conclusions: A frontal sinus fracture treatment algorithm is proposed and
statistically validated. Nasofrontal outflow tract involvement with obstruction
is best managed by obliteration or cranialization. Osteoneogenesis and fat
obliteration are associated with unacceptable complication rates. Observa-
tion is safe when the nasofrontal outflow tract is intact. (Plast. Reconstr.
Surg. 122: 1850, 2008.)

F
rontal sinus fracture management has
evolved with greater emphasis on nasofrontal
outflow tract injury.1–20 Complications are de-
scribed; however, series have insufficient power to
From the R Adams Cowley Shock Trauma Center, University
of Maryland School of Medicine, Johns Hopkins School of
Medicine.
Received for publication April 4, 2008; accepted May 6,
2008.
Presented at the 87th Annual Meeting of the American
Association of Plastic Surgeons, in Boston, Massachusetts,
April 5 through 8, 2008.
Copyright ©2008 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0b013e31818d58ba
allow significant conclusions to be drawn regard-
ing treatment effectiveness based on fracture pat-
terns with consideration for nasofrontal outflow
tract injury. These fractures represent 5 to 15
percent of all craniomaxillofacial fractures, with
high-velocity blunt force representing the
majority.1,3,21–23 Concomitant facial fractures along
with associated intracranial and bodily injuries
confirm their severity.5–7,24
Disclosure: None of the authors has a financial
interest in any of the products, devices, or drugs
mentioned in this article.

1850 www.PRSJournal.com
Volume 122, Number 6 • Frontal Sinus Fracture Treatment
Historically, plain radiographs were diagnos-
tic, but surgery provided definitive evaluation of
the extent of injury and nasofrontal outflow tract
involvement.25–27 Computed tomographic scans
improved assessment of posterior wall and naso-
frontal outflow tract injury, but some uncertainty
still exists. Function is difficult to predict based on
radiographic or clinical fracture patterns alone.
Nasofrontal outflow tract patency has served as the
clinical substitute for determining frontal sinus
function. With nasofrontal outflow tract injury
noted as 13 to 55 percent,8,10 preoperative deter-
mination of patency is crucial to management.
Computed tomographic scans often delineate
fracture involvement and injury but are unable to
predict function. Preoperative nasofrontal out-
flow tract computed tomographic assessment var-
ies between providers, but there are three indica-
tors of injury: gross outflow tract obstruction,
frontal sinus floor fracture, and anterior table me-
dial wall fracture.28 –30 One indicator is sufficient to
diagnose nasofrontal outflow tract injury, but to
date no one has described the importance of one,
two, or all criteria, or the significance of one over
the others. Thus, although nasofrontal outflow
tract injury has become the cornerstone of treat-
ment algorithms, its degree of injury in relation to
complications has not been well established.
Treatment strategies stem from Rohrich and
Hollier’s landmark 1992 article and our descrip-
tion of panfacial fracture management.3,31–33 Roh-
rich provided insight into fracture pattern, extent
of injury, and nasofrontal duct involvement. Ulti-
mately, treatment decisions depend on fracture
type, comminution, degree of posterior table frac-
ture, nasofrontal duct injury, neurologic status,
and cerebrospinal fluid leak.1,3,10,21,22,34 –37
EXISTING TREATMENT OPTIONS
1. Observation by serial computed tomography
and/or clinical evaluation.
2. Reconstruction implies duct and mucosal preser-
vation with anterior wall reconstruction. This
may include in situ fragment elevation or micro-
plating of a comminuted fracture. Recently, en-
doscopic management has been used; however,
there are few data to support its benefit.38 – 40
3. Obliteration involves complete removal of sinus
mucosa; burring the sinus walls to eliminate
mucosal invaginations; plugging the nasal
frontal ducts; and filling the sinus cavity of the
sinus with fat, muscle, bone, or alloplasts.
4. Osteoneogenesis in which the sinus cavity is
stripped of mucosa by burring the walls, the
ducts are sealed, and the cavity is preserved.
Spontaneous obliteration occurs in a delayed
fashion by the slow process of scar tissue and
bone formation in the empty cavity.
5. Ablation (or exenteration), as Reidel described
in 1898, with removal of the anterior wall,
mucosa, supraorbital rims, and proximal nasal
bones to allow skin involution against the pos-
terior wall or dura.41 The subsequent delayed
reconstruction is difficult because of commu-
nication with the nasal cavity and a significant
cosmetic defect. Presently, the only potential
indication for the Reidel procedure is severe
acute infection, where collapse of the dead
space, removal of infected, nonvascularized
bone, and protection from both mucocele and
infection is provided.
6. Cranialization removes the ducts, posterior sinus
wall, and mucosa; the nasofrontal outflow tract is
blocked with bone, creating a partition between
the intracranial and nasal cavities. The area oc-
cupied by the sinus, in fact, becomes a portion of
the intracranial cavity and becomes occupied by
the expanding brain after several months.42
Each treatment method has its proponents,
and there is much controversy regarding indica-
tions, applications, and ultimate success in given
situations. Although observation is pursued fre-
quently, complication rates related to fracture pat-
terns have not been recognized. We propose a
statistically validated treatment algorithm for fron-
tal sinus fractures based on fracture pattern, de-
gree of nasofrontal outflow tract involvement, and
complications (Fig. 1).
PATIENTS AND METHODS
An institutional review board–approved retro-
spective study of patients with frontal sinus frac-
tures admitted to the R Adams Cowley Shock
Trauma Center from 1979 to 2005 was conducted.
Associated injuries, demographics, Injury Severity
Score, Glasgow Coma Scale score, and mechanism
of injury were evaluated. Computed tomographic
scans were reviewed and categorized. Nasofrontal
outflow tract injury was defined by one or more of
the following: outflow tract/ductal “obstruction,”
frontal sinus floor fracture, or fracture of the medial
aspect of the anterior table (Fig. 2). Coronal and
sagittal views were inspected before axial cuts to
avoid bias of nasofrontal outflow tract injury based
on fracture patterns. Treatments included observa-
tion, reconstruction with outflow tract and mu-
cosal preservation, obliteration, osteoneogen-
esis, and cranialization.
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 Plastic and Reconstructive Surgery • December 2008

Fig. 1. Frontal sinus fracture treatment algorithm. NFOT, nasofrontal outflow tract.

Fig. 2. Demonstration of computed tomographic diagnosis of nasofrontal outflow tract injury with
(left) fracture of the sinus floor, (middle) fracture of the medial aspect of anterior table, and (right)
frank obstruction.

Exclusion criteria included the following: pa-
tients with incomplete radiographic or clinical
records, patients who died within 48 hours without
treatment, and patients who underwent decom-
pressive craniectomies without subsequent frontal
sinus surgery. Acute major complications were de-
fined as those occurring within 6 months needing
operative management, including cerebrospinal
fluid leak, abscess, sinusitis, meningitis, mucocele,
and persistent pneumocephalus. Minor complica-
tions included wound drainage, infections or cere-
brospinal fluid leak that did not require surgical
treatment, and late contour irregularity or plate re-
moval for palpability or visibility. Unless noted as a
minor complication, the term “complication” in this
article refers to acute major complications only.

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Volume 122, Number 6 • Frontal Sinus Fracture Treatment

Associations were based on Pearson’s correla- Table 2. Patient Averages

tion coefficients, and outcome measures were eval- Value
uated by means of chi-square and Gini-square dis-
ISS 25.3 ⫾ 11.3
tribution, recursive partition tree, and receiver Age (yr) 33.5 ⫾ 17
operator characteristic curve. Chi-square analysis GCS score 12.1 ⫾ 4.7
measured the degree of homogeneity (entropy or LOS (days) 8.8 ⫾ 10.3
Follow-up (mo) 2.8 ⫾ 2.1
classification error), and Gini-square analysis repre- Mortality 7.9%
sented the likelihood ratio (no complication divided ISS, Injury Severity Score; GCS, Glasgow Coma Scale; LOS, length of
by complications). A recursive partition tree is used stay (inpatient).
as a statistical method for the multivariable anal-
ysis of medical diagnostic tests and used in our
analysis to distinguish patients with and without (60 percent) and restrained (22 percent), with 18
complications.43 This separates data into homoge- percent unknown. Ten percent of the patients were
neous groups by creating smaller subsets based on involved in motorcycle collisions, 8 percent were
various frontal sinus variables. Receiver operating pedestrians, 14 percent were victims of assault, and
characteristic area under the curve plots the sensi- 7 percent had ballistic injuries. Environmental acci-
tivity (true classifications) against misclassifications dents accounted for the remaining 19 percent, of
(JMP 7.0.1 software; SAS Institute, Inc., Cary, N.C.). which 70 percent included falls and miscellaneous
The receiver operating characteristic area under the trauma. Associated injuries (Table 3) were divided
curve indicates the diagnostic accuracy of the deci- based on nasofrontal outflow tract injury. Adjacent
sion algorithm of frontal sinus fracture manage- facial fractures are also listed in Table 3, and naso-
ment. In other words, it statistically discriminates frontal outflow tract–injured patients had three
between patients with and without complications times more concomitant facial fractures than those
undergoing treatment (e.g., observation, recon- without. Frontal sinus fractures were highly associ-
struction, obliteration). A receiver operating char- ated with nasoorbitoethmoid and orbital roof inju-
acteristic value of greater than 0.75 indicates diag- ries, and more so with nasofrontal outflow tract in-
nostic accuracy. volvement.
Five hundred four patients (59 percent) under-
went surgery, 94 percent had nasofrontal outflow
RESULTS tract involvement by one or more criteria, 77 percent
One thousand ninety-seven frontal sinus frac- had obstruction as one of the criteria, and 80 percent
tures were evaluated. One hundred fifty-three in- had two or more criteria. Cranialization was the most
dividuals had insufficient data, and there were 87 common treatment, obliteration was second, and
deaths, leaving 857 patients (Table 1). Caucasian reconstruction was third. Most obliterations had
patients constituted 61 percent, African American bone (34 percent), galea (25 percent), fat (23 per-
patients constituted 27 percent, Hispanics pa- cent), or temporoparietal fascia (7 percent). One
tients constituted 11 percent, and Asians patients patient had six procedures, one had five procedures,
constituted 1 percent. The average length of con-
valescence was 114 days before return to function
or work and the average follow-up was 2.8 months Table 3. Associated Injuries in Frontal Sinus
(range, 0 to 66 months) (Table 2). Most patients Fractures with and without Nasofrontal Outflow
had surgery within 24 hours of injury (59 percent) Tract Injury
and only 19 percent had surgery after 72 hours. Without NFOT With NFOT
The most common mechanism of injury was Injury Injury (%) Injury (%)
motor vehicle collision (42 percent), unrestrained Brain 31 76
Cervical spine 7 14
Upper extremity fracture 15 25
Table 1. Total Patient Series with Frontal Lower extremity fracture 13 23
Sinus Fractures Pneumothorax 12 24
Abdominal 7 13
No. % Orbital roof 13 40
Orbital wall 7 13
Total 1097 100 Orbital floor 2 7
Insufficient data 153 13.9 NOE 12 31
Mortality 87 7.9 Zygoma 8 18
Analyzed series 857 78.1 Le Fort 2 17
Surgery 504 45.9 Mandible 3 5
Observation 353 32.2
NOE, nasoorbitoethmoid complex; NFOT, nasofrontal outflow tract.

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 Plastic and Reconstructive Surgery • December 2008

2.6 percent had four procedures, 4.9 percent had
three procedures, and 7.1 percent had two proce-
dures. Thus, a major complication requiring surgery
had a 69 percent chance of having a third operation,
and if so, an additional 53 percent risk of a fourth.
Fracture type, treatment, and complications
are summarized in Tables 4 through 9. The most
common fracture pattern was simultaneous an-
teroposterior displaced (38.4 percent) followed by
anterior nondisplaced (21.6 percent). Side or
comminution did not play a role in any associa-
tions more than displacement alone.
Our series had 61 major complications (7.1
percent), and all except one had nasofrontal out-
flow tract injury (1.6 percent). Likewise, there was
only one complication in the nasofrontal outflow
tract injury group that did not have obstruction by
criteria (1.6 percent). Patients lacking nasofrontal
outflow tract injury had no complications when
observed and those with nasofrontal outflow tract
injury by obstruction had the lowest complication
rates with obliteration or cranialization. Further-
more, patients with nasofrontal outflow tract in-
jury diagnosed by obstruction plus another crite-
rion treated with observation or reconstruction
had a 100 percent complication rate. Likewise,
those managed by osteoneogenesis had a 56 percent
risk of complication compared with obliteration (10
percent) and cranialization (9 percent). Seventy-
one percent of all patients had nasofrontal outflow
tract injury, 26 percent had one criterion, 25 percent
had two criteria, and 49 percent met all criteria.
Overall, 67 percent of those with nasofrontal
outflow tract injury had obstruction according
to criteria, with a 14 percent complication rate.
The receiver operating characteristic area under
the curve of our algorithm equals 0.8621, represent-
ing statistically significant diagnostic accuracy (Fig.
3). Gini-square and chi-square analysis of those with-
out nasofrontal outflow tract injury treated by ob-
servation according to our algorithm was 0, creating
an undefined p value calculation. Those with naso-
frontal outflow tract injury and obstruction treated
by cranialization or obliteration had a Gini-square
and chi-square value equal to 215.97, calculated as
2[32 * ln (32/360) ⫹ 328 * ln (328/360)], and a
corresponding value of p ⬍ 0.0001. Those with na-
sofrontal outflow tract injury but no obstruction
should be treated by reconstruction if the fracture is
displaced (p value undefined, chi-square ⫽ 0) and
observation if the fracture is nondisplaced (p ⫽
0.00124, chi-square ⫽ 7.35).
The frontal sinus fracture groups can be clas-
sified as follows:
1. Anterior wall fractures.
A. Nondisplaced anterior wall fractures
(185 patients) (Table 4).
B. Displaced anterior wall fractures (143
patients) (Table 5).

Table 4. Nondisplaced Anterior Wall Fractures (21.6 Percent of the Series)

Criteria
Complications Complications Met¶
Complications O and O and Other
Treatment No. No. % O* % O† O (%)‡ Other§ (%)円円 1 2 3
Observation
Without NFOT injury 151 0 0
With NFOT injury 6 1 16.7 0 0 0 6
Reconstruction
(sinus preserved)
Without NFOT injury 1 0 0
With NFOT injury 8 0 0 0 0 0 7 1
Osteoneogenesis
Without NFOT injury 0 0 0
With NFOT injury 2 1 50 2 100 50 1 100 1 1
Obliteration
Without NFOT injury 0 0 0
With NFOT injury 13 1 7.6 12 92 8 8 13 5 7 1
Cranialization
Without NFOT injury 0 0 0
With NFOT injury 4 0 0 4 100 0 4 0 0 4 0
Total 185 3 1.6 18 55 11 13 15 19 13 1
NFOT, nasofrontal outflow tract.
*Obstruction criterion met.
†Number obstructed from all with NFOT injury.
‡Complications resulting from obstruction.
§Patients obstructed with a second or all criteria met (fracture of the frontal sinus floor, fracture of anterior ethmoid cells).
兩兩Percentage of complications arising from this group.
¶One or more of the following: obstruction of nasofrontal outflow tract, fracture of the frontal sinus floor, fracture of anterior ethmoid cells.

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Table 5. Displaced Anterior Wall Fractures (16.7 Percent of the Series)

Complications Complications Criteria Met¶
Complications O and O and other
Treatment No. No. % O* % O† O (%)‡ Other§ (%)円円 1 2 3
Observation
Without NFOT injury 13 0 0
With NFOT injury 14 0 0 1 7 0 0 8 6 0
Reconstruction
(sinus preserved)
Without NFOT injury 14 1 7.1
With NFOT injury 30 1 3.3 2 7 50 0 20 10 0
Osteoneogenesis
Without NFOT injury 1 0 0
With NFOT injury 4 2 50 4 100 50 3 67 1 1 2
Obliteration
Without NFOT injury 7 0 0
With NFOT injury 43 2 4.7 41 95 5 39 5 0 11 32
Cranialization
Without NFOT injury 0 0
With NFOT injury 17 1 5.9 17 100 6 17 6 8 9
Total 143 7 4.9 65 60 9 59 8 29 36 43
NFOT, nasofrontal outflow tract.
*Obstruction criterion met.
†Number obstructed from all with NFOT injury.
‡Complications resulting from obstruction.
§Patients obstructed with a second or all criteria met (fracture of the frontal sinus floor, fracture of anterior ethmoid cells).
兩兩Percentage of complications arising from this group.
¶One or more of the following: obstruction of nasofrontal outflow tract, fracture of the frontal sinus floor, fracture of anterior ethmoid cells.

Table 6. Nondisplaced Posterior Wall Fractures (3.6 Percent of the Series)

Criteria
Complications Met¶
Complications O and Complications
Treatment No. No. % O* % O† % O‡ Other§ O and Other円円 1 2 3
Observation
Without NFOT injury 14 0 0
With NFOT injury 9 3 33.3 3 33 100 3 100 3 4 2
Obliteration
Without NFOT injury
With NFOT injury 5 1 20 5 100 20 4 0 1 1 3
Cranialization
Without NFOT injury
With NFOT injury 3 0 0 3 100 0 3 0 3
Total 31 4 12.9 11 65 36 10 30 4 5 8
NFOT, nasofrontal outflow tract.
*Obstruction criterion met.
†Number obstructed from all with NFOT injury.
‡Complications resulting from obstruction.
§Patients obstructed with a second or all criteria met (fracture of the frontal sinus floor, fracture of anterior ethmoid cells).
兩兩Percentage of complications arising from this group.
¶One or more of the following: obstruction of nasofrontal outflow tract, fracture of the frontal sinus floor, fracture of anterior ethmoid cells.

2. Posterior wall fractures. B. Displaced anteroposterior wall frac-

tures (329 patients) (Table 9).
A. Nondisplaced posterior wall fractures
(31 patients) (Table 6). Treatment effectiveness is summarized in
B. Displaced posterior wall fractures (28 Table 10.
patients) (Table 7).
3. Anteroposterior wall fractures. DISCUSSION
Frontal sinus fractures represent a small por-
A. Nondisplaced anteroposterior wall frac- tion of maxillofacial fractures. Nevertheless, nu-
tures (141 patients) (Table 8). merous classification schemes and treatment al-

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 Plastic and Reconstructive Surgery • December 2008

Table 7. Displaced Posterior Wall Fractures (3.3 Percent of the Series)

Criteria
Complications Complications Met¶
Complications O and O and Other
Treatment No. No. % O* % O† % O‡ Other§ (%)円円 1 2 3
Observation
Without NFOT injury 1 0 0
With NFOT injury 12 0 0 2 16 0 1 0 11 1
Osteoneogenesis
Without NFOT injury
With NFOT injury 1 0 0 1 100 0 1
Obliteration
Without NFOT injury
With NFOT injury 5 0 0 5 100 0 4 0 1 1 3
Cranialization
Without NFOT injury 1 0 0
With NFOT injury 8 1 12.5 8 100 13 7 14 1 3 4
Total 28 1 3.6 16 62 6 12 8 14 4 8
NFOT, nasofrontal outflow tract.
*Obstruction criterion met.
†Number obstructed from all with NFOT injury.
‡Complications resulting from obstruction.
§Patients obstructed with a second or all criteria met (fracture of the frontal sinus floor, fracture of anterior ethmoid cells).
兩兩Percentage of complications arising from this group.
¶One or more of the following: obstruction of nasofrontal outflow tract, fracture of the frontal sinus floor, fracture of anterior ethmoid cells.

Table 8. Nondisplaced Anterior and Posterior Wall Fractures (16.5 Percent of the Series)
Criteria
Complications Complications Met¶
Complications O and O and Other
Treatment No. No. % O* % O† % O‡ Other§ (%)円円 1 2 3
Observation
Without NFOT injury 43 0 0
With NFOT injury 60 3 5 5 8 60 2 100 42 18 0
Reconstruction
(sinus preserved)
Without NFOT injury
With NFOT injury 6 1 16.7 1 16 100 0 6
Obliteration
Without NFOT injury
With NFOT injury 10 0 0 10 100 0 9 0 1 4 5
Cranialization
Without NFOT injury
With NFOT injury 22 1 4.5 20 91 5 18 6 2 9 11
Total 141 5 3.5 36 36 14 27 11 51 31 16
NFOT, nasofrontal outflow tract.
*Obstruction criterion met.
†Number obstructed from all with NFOT injury.
‡Complications resulting from obstruction.
§Patients obstructed with a second or all criteria met (fracture of the frontal sinus floor, fracture of anterior ethmoid cells).
兩兩Percentage of complications arising from this group.
¶One or more of the following: obstruction of nasofrontal outflow tract, fracture of the frontal sinus floor, fracture of anterior ethmoid cells.

gorithms have been presented without statistical
significance. Lack of treatment uniformity con-
tributes to suboptimal care and fails to follow
evidence-based medicine. Unlike most facial
fractures, mismanagement of frontal sinus frac-
tures leads to devastating and potentially fatal
complications.5,44
Regardless of treatment, determination of na-
sofrontal outflow tract obstruction remains the cor-
nerstone of management. Complications arise from
failure of frontal sinus drainage, and recent naso-
frontal outflow tract findings have contributed to
further understanding.3,30,45– 47 Until now, no one
could relate fracture patterns and degree of naso-
frontal outflow tract injury to its complications. We
present a statistically significant treatment algorithm
based on degree of nasofrontal outflow tract injury
and its relationship to fracture patterns (Fig. 1).

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Table 9. Displaced Anterior and Posterior Wall Fractures (38.4 Percent of the Series)
Complications Complications Criteria Met¶
Complications O and O and Other
Treatment No. No. % O* % O† % O‡ Other§ (%)円円 1 2 3
Observation
Without NFOT injury
With NFOT injury 30 4 13.3 5 17 80 3 100 17 10 3
Reconstruction
(sinus preserved)
Without NFOT injury
With NFOT injury 39 6 15.4 8 21 75 6 100 15 19 5
Osteoneogenesis
Without NFOT injury
With NFOT injury 14 6 42.8 13 93 46 12 50 1 2 11
Obliteration
Without NFOT injury
With NFOT injury 93 11 11.8 87 94 13 87 13 12 81
Cranialization
Without NFOT injury 5 0 0
With NFOT injury 148 14 9.5 144 97 10 137 10 7 21 120
Total 329 41 257 79 16 245 16 40 64 220
NFOT, nasofrontal outflow tract.
*Obstruction criterion met.
†Number obstructed from all with NFOT injury.
‡Complications resulting from obstruction.
§Patients obstructed with a second or all criteria met (fracture of the frontal sinus floor, fracture of anterior ethmoid cells).
兩兩Percentage of complications arising from this group.
¶One or more of the following: obstruction of nasofrontal outflow tract, fracture of the frontal sinus floor, fracture of anterior ethmoid cells.

The unique experience with high-energy fa-
cial injuries at the R Adams Cowley Shock Trauma
Center allows one to evaluate options of frontal
sinus fracture treatment. There was no particular
surgeon who had more complications if success of
a single treatment option was evaluated among all
groups. The treatment choice for a particular frac-
ture pattern did not relate to personal surgical
judgment or results achieved. Most patients were
managed within 72 hours, because early treatment
reduces complications.10,16,48 Although we do not
describe late complications because of their low
incidence, we do make inferences regarding in-
dolent infections.
Plain radiographs do not adequately character-
ize frontal sinus fractures and therefore have been
largely supplanted by computed tomography.49 –51
Importantly, one cannot assess nasofrontal outflow
tract involvement from plain films alone. Nasofron-
tal outflow tract involvement can be defined by com-
puted tomography: obstruction, associated anterior
ethmoid complex fracture, and frontal sinus floor
fracture.28,29 Computed tomography is therefore
mandatory for adequately assessing frontal sinus
fracture and nasofrontal outflow tract function and
for planning surgery.
Most series report motor vehicle collisions as
the primary injury mechanism and our data con-
firm this.5,7,12 The next most common mechanisms
are assault and accidental injuries, confirming high-
energy trauma as the common denominator. The
rarity with lower energy trauma reflects the struc-
tural ability of the skull and face to absorb and dis-
tribute forces along the stress-bearing framework,
reducing the incidence of skull and brain damage
despite extensive facial fractures.52,53
Concomitant facial fractures were found in
over 75 percent of patients. Interestingly, those
with nasofrontal outflow tract involvement were
almost three times more likely to have other facial
fractures than those without. Orbital floor, naso-
orbitoethmoid complex, zygoma, and Le Fort frac-
tures were most commonly associated. Similarly,
intracranial injuries (epidural and subdural he-
matomas) were over twice as likely with nasofrontal
outflow tract injury (76 percent). Studies have shown
intracranial involvement (33 to 70 percent) with
frontal sinus fractures,5,12,16,52 confirming the rela-
tionship of the nasofrontal outflow tract with the
cranial base and injury severity. Rohrich and Hollier
presented a diagnostic and therapeutic algorithm
establishing a major emphasis on nasofrontal out-
flow tract anatomy and drainage.2,3,45,46,54 A true duct
may be identified in only 15 percent of humans,3 and
for this reason, the term “nasofrontal outflow tract”
was defined. Although the nasofrontal outflow tract
anatomy was established, its relationship to injury
and complications was missing.
Some authors have argued that patients lacking
nasofrontal outflow tract injury with isolated ante-

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 Plastic and Reconstructive Surgery • December 2008
Fig. 3. Receiver operating characteristic area under the curve
(AUC) plots the sensitivity (true-positives) against false-positives
(1 – specificity). The straight black line represents results if left to
“chance alone.” The receiver operating characteristic area under
the curve indicates the diagnostic accuracy of the decision algo-
rithm for frontal sinus fractures. In other words, it describes how
well the algorithm discriminates between patients with and
without complications who underwent treatments (observa-
tion, reconstruction, osteoneogenesis, cranialization, and
obliteration) with regard to fracture pattern, displacement,
obstruction, and nasofrontal outflow tract injury. Our receiver
operating characteristic area under the curve of 0.8621 indi-
cates that the decision algorithm provides a diagnostic accu-
racy of over 86 percent, which is regarded as statistically sig-
nificant diagnostic accuracy.
rior wall fractures can be safely observed because
they rarely have complications.1–5,9,10,17,18,47,55,56 Fur-
thermore, some hypothesize that complications
were attributed to invasive operations. El Khatib et
al. questioned whether the frontal sinus was a “vic-
tim” or a “culprit.”56 A literature-based search an-
swered the safety of observation.57 The authors con-
cluded that most articles constituted level 4 evidence
(poor), with an average complication rate of 9 per-
cent (3 percent for those observed). However, the
role of nasofrontal outflow tract involvement was not
defined. The authors ultimately concluded that
those with more severe injuries benefit from surgery
with fewer short-term sequelae. They note that a
1858
prospective randomized study could compare non-
surgical to surgical treatment but is neither feasible
nor ethical.
The decision accuracy of our algorithm is rep-
resented by the receiver operating characteristic
area under the curve of 0.8621 (Fig. 3). Receiver
operating characteristic curves are used extensively
in medical research and frequently mentioned in
conjunction with evidence-based medicine.58 – 61 Fur-
thermore, these curves are beneficial at decision
analysis with binomial outcomes (complication or
no complication).60,62,63 The receiver operating char-
acteristic area under the curve based on our decision
algorithm of 0.8621 is quite good; it is close to the
ideal value of 1.0 and much larger than the worst-
case value58; p values in recursive partition analysis
(decision tree analysis) are weak measures of statis-
tical significance.43,64 This is especially true in frontal
sinus fractures because of the ratio of uncomplicated
to complicated cases. The underrepresentation of
complicated cases leads to Gini-square and chi-
square values of 0 in two of our arms, creating an
undefined p value. A p value is the probability of
finding a chi-square value that is as large as or larger
than what we computed. Therefore, a receiver op-
erating curve provides a better statistical metric for
evaluating the most appropriate treatment algo-
rithm for frontal sinus fractures.
Observation in patients who lack nasofrontal
outflow tract involvement is definitely safe as
noted by 222 patients with zero complications. In
fact, there was only one complication among all
those without radiographic evidence of nasofron-
tal outflow tract involvement (0.4 percent). This
patient underwent anterior table reconstruction
with nasofrontal outflow tract stenting because of
a questionable intraoperative finding. Perhaps
this patient may have avoided a complication if
they had been observed or not stented. Although
some advocate nasofrontal outflow tract recon-
struction and stenting,65,66 it is plagued with failure
and a high restenosis rate.3,15 One may say that
patients with anterior table displacement who lack
nasofrontal outflow tract injury still need opera-
tive fixation for proper contouring. However, we
found that patients who had displaced anterior
tables without nasofrontal outflow tract involve-
ment were minimally displaced. Nasofrontal out-
flow tract injury with obstruction is highly asso-
ciated with worsening fracture type (Fig. 4).
Ninety-two percent of patients with any form of
anterior displacement and 88 percent of poste-
rior wall fractures (98 percent displaced) had
nasofrontal outflow tract involvement. Commi-
nution played no role in our algorithm but was
 Table 10. Frontal Sinus Treatment Effectiveness
Complications Complications Criteria Met¶
Complications O and O and Other
Treatment No. No. % O* % O† % O‡ Other§ (%)円円 1 2 3 >1 (%)
Observation
Without NFOT injury 222 0 0
With NFOT injury 131 11 8.4 16 12 63 9 100 87 38 6 34
Reconstruction
(sinus preserved)
Without NFOT injury 15 1 6.7
With NFOT injury 83 8 9.6 11 13 73 6 100 48 30 5 42
Osteoneogenesis
Without NFOT injury 1 0 0
With NFOT injury 21 9 42.9 20 95 45 16 56 4 4 13 81
Obliteration
Without NFOT injury 7 0 0
With NFOT injury 169 15# 8.9** 164 97 9 151 10 8 36 125 95
Cranialization
Without NFOT injury 6 0 0
With NFOT injury 202 17 8.4 196 97 9 186 9 10 45 147 95
Without NFOT injury 251 (29.30%) 1 0.4
With NFOT injury 606 (70.70%) 60 9.9 407 67 14 368 15 157 153 296 74
Total 857 61 7.1
Volume 122, Number 6 • Frontal Sinus Fracture Treatment

NFOT, nasofrontal outflow tract.

*Obstruction criterion met.
†Number obstructed from all with NFOT injury.
‡Complications resulting from obstruction.
§Patients obstructed with a second or all criteria met (fracture of the frontal sinus floor, fracture of anterior ethmoid cells).
兩兩Percentage of complications arising from this group.
¶One or more of the following: obstruction of nasofrontal outflow tract, fracture of the frontal sinus floor, fracture of anterior ethmoid cells.
#Obliteration with fat: nine complications 41 (22%).
**Obliteration complications without fat: six of 128 (4.7%).

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 Plastic and Reconstructive Surgery • December 2008

Fig. 4. Images of a frontal sinus fracture caused by a motor vehicle injury. This patient has a simultaneous
anteroposterior displaced fracture seen on the axial cut (above, left) and a three-dimensional reconstruction
(above, right). The fracture meets all criteria for nasofrontal outflow tract injury: fracture of the medial aspect
of the anterior table, sinus floor fracture (f ), and outflow tract obstruction (o) (below, left). (Below, right)
Photograph obtained intraoperatively showing comminution and obstruction around the nasofrontal out-
flow tract.

always associated with nasofrontal outflow tract
injury (100 percent) and highly associated with
obstruction (97 percent). However, definition
of nasofrontal outflow tract injury depends not
only on fracture pattern and severity but also on
degree of injury.
Radiographic evidence of nasofrontal outflow
tract injury (Fig. 2) was documented by specific
criteria (obstruction, anterior ethmoid cell frac-
ture, or frontal sinus floor fracture). By evaluating
which criterion, combination of criteria, or num-
ber of criteria were involved, a statistically signif-
icant relationship with complications was found.
Ninety-eight percent of complications in patients
with nasofrontal outflow tract injury had obstruc-
tion as a criterion. The only complication without
obstruction was a patient who was observed with an
anterior nondisplaced fracture and resulting si-
nusitis. No specific details of this patient’s hospital
course could explain this complication. The num-
ber of criteria met did not play a role; however, 56
of 59 complications with obstruction had frank
obstruction with at least another criterion (95 per-
cent). Overall, obstruction was found in 75 per-
cent of anterior displaced fractures with nasofron-
tal outflow tract involvement, in contrast to 59
percent anterior nondisplaced and 78 percent
posterior displaced versus 59 percent posterior

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Volume 122, Number 6 • Frontal Sinus Fracture Treatment

nondisplaced fractures. Ultimately, the finding of
obstruction in association with a frontal sinus frac-
ture must persuade the provider toward oblitera-
tion or cranialization.
Cranialization and obliteration have a 9 percent
complication rate for any fracture with nasofrontal
outflow tract injury caused by obstruction (Table
10). This is compared with complication rates of 63
percent for observation, 73 percent for recon-
struction, and 45 percent for osteoneogenesis. If
one evaluates obstruction plus a second or third
criterion, then obliteration and cranialization stay
constant at complication rates of 10 percent and
9 percent, whereas observation and reconstruc-
tion increase to 100 percent and osteoneogenesis
to 56 percent. After individual review of each an-
atomical fracture pattern, cranialization and oblit-
eration were comparable to the least complica-
tions, whereas the other management strategies
were problematic. The only exception was a pa-
tient with an anterior displaced fracture who was
observed despite a diagnosis of obstruction but did
not have a complication. Therefore, a patient with
nasofrontal outflow tract involvement caused by
obstruction merits defunctionalizing to avoid se-
rious sequelae. Importantly, the combination of
another criterion in addition to obstruction
should drive the provider even further toward cra-
nialization or obliteration.
Cranialization has several distinct advantages:
wide exposure of the injured area allows assess-
ment and repair of dural injury, access to the
cranial base for complex facial fracture repair, and
elimination of the sinus with its propensity for
infection and mucocele formation in a single
stage. Cranialization had formerly been reserved
for more serious injuries26,67,68 characterized by
grossly comminuted fractures with open skin and
those with fragments insufficient for reconstruct-
ing the posterior wall. Some authors feel that cra-
nialization is highly morbid; however, they did not
mention the meticulous burring of the mucosa,
careful plugging of the nasofrontal outflow tract,
or reconstruction of the cranial base as prerequi-
sites for success.37,44,69,70 Donald has been a major
proponent of cranialization26,44,67,68,71,72 and cites
several advantages: immediate frontal contour res-
toration, elimination of sinus and subsequent risk
for infection and mucocele, and the fact that there
is no need to rely on the variable take of a fat graft
as a barrier between the central nervous system
and the sinonasal cavity.44 Its success relies on
meticulous mucosa removal and obliteration of
the nasal communication. The frontal sinus lining
is a tenacious mucoperiosteum that regenerates
from residual basilar mucosal cells if simple strip-
ping alone is used.44 To eliminate the mucosa, the
walls must be burred to remove mucosal tails along

Fig. 5. Computed tomographic scans showing the sequelae of improper frontal sinus frac-
ture management. This patient underwent management of panfacial fractures after a motor
vehicle collision 4 years previously, which included obliteration of the frontal sinus with bone
graft. She presented to our clinic with months of progressive frontal pressure, headaches, and
throbbing. A mucopyocele formed after inadequate occlusion of the nasofrontal outflow tract
(left). The direct sinonasal communication seen in the axial cut (right) resulted in persistent air
and an indolent infection.

1861
 Plastic and Reconstructive Surgery • December 2008

the diploic veins of Breschet. Attention is then
turned to the anterior wall fragments and oblit-
eration of the sinus. For less serious (nondisplaced
or minimally displaced) anterior and posterior
wall fractures, obliteration may be used with a
more limited exposure with equal success.
The choice of obliteration material is widely vari-
able. Autogenous materials including fat, muscle,
and bone have been used for decades.5,15,22,34,44,68–70,73–75
Alloplastic biomaterials including hydroxyapatite,
bioactive glass, methylmethacrylate, calcium phos-
phate bone cement, and oxidized regenerated cel-
lulose have also been used.36,76 – 82 Supporters of
alloplastic materials note their possible antibacte-
rial properties, lack of donor morbidity, and un-
ending supply. Rohrich and Mickel70 and Wolfe
and Johnson37 have separately addressed this con-
troversy, and both advocate use of autogenous
materials. Local flaps provide a vascularized
source to the injury site,1,83,84 and cancellous bone
grafts force the sinus to undergo ossification.85
Controversy has arisen over the use of fat for oblit-
eration which, although proven safe for chronic
sinusitis, is not safe or efficacious in sinuses with
fractured walls.
Fat grafts have been less supported, as they rely
on the viability where the damaged bony walls are
poorly vascularized. Although Montgomery notes
that fat is resistant to infection,35 our series indi-
cates that fat obliteration results in high compli-
cation rates. Overall, 41 fat obliterations were per-
formed with nine complications (22 percent), and
obliteration without fat had only six complications
(5 percent). The degree of fat graft vascularization
depends on the vascular bed; in comminuted frac-
tures, there is a decreased blood supply, resulting

Fig. 6. Images of a 30-year-old patient treated 1 month previously with obliteration of the frontal sinus after sustaining
a simultaneous anteroposterior fracture with nasofrontal outflow tract injury. Pus (arrows) is expressed from the
superior orbital rim and left medial canthus (above, left). Complete removal of previous hardware and anterior table along
with extensive burring of the sinus was performed (above, right). A vascularized free fibula osteomyocutaneous flap was
used to construct the frontal buttress and external contour, and the muscular segment obliterates the sinonasal com-
munication (below, left). (Below, right) A lateral sinus view showing complete separation of the nasal cavity and frontal
sinus after properly occluding the nasofrontal outflow tract.

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Volume 122, Number 6 • Frontal Sinus Fracture Treatment
in resorption and fibrous replacement of the graft.
Donald and Klotch offer experimental evidence
that fractures with significant bone loss that un-
dergo sinus obliteration with fat result in up to 50
percent reepithelialization with the risk of infec-
tion and mucocele.26,44,67,68,86 Donald also related
prevention of complications to the percentage of
posterior wall removed. The necessity of meticu-
lous mucosal removal in obliteration techniques
has been emphasized by Bergara and Itoiz, who
described successful fat grafting despite introduc-
tion into septic cavities.25 Mucosal invaginations
along the veins of Breschet constitute a source of
mucocele and abscess formation. Plugging the
ducts with bone seems important, as mucosa may
travel up the duct to reepithelialize the sinus after
simple mucosal stripping.
Nadell and Kline have shown that contami-
nated cranial vault and sinus fragments could be
returned to the wound if thoroughly debrided,
without risk of infection.87 If the tenets of careful
mucosa removal, bone graft plugging of the na-
sofrontal ducts, surgical debridement of involved
areas of the ethmoid sinus, and attention to dural
integrity are followed, cranialization is a suitable
Fig. 7. Treatment algorithm for indolent infectious complications following frontal sinus fractures.
alternative to obliteration, with a lower risk in
anteroposterior displaced fractures. Although
data are not available to justify the use of crani-
alization over other techniques, in simpler frontal
sinus injuries, obliteration and cranialization have
the least morbidity when used according to our
algorithm.
Isolated posterior wall fractures are rare, and
our series does not have statistical power to de-
lineate management. Some authors support ob-
servation of nondisplaced posterior wall fractures,
but Donald26,67,68 cites higher morbidity and ad-
vocates obliteration.26,67,68 Some authors also note
that surgical management depends on posterior
table displacement of more than one table
width3,72 or cerebrospinal fluid involvement.8 –10
Hybels and Newman evaluated 26 posterior table
fractures in a cat model and found that no com-
plications arose unless the nasofrontal outflow
tract was injured.86 We hypothesize that those who
lack nasofrontal outflow tract involvement should
be observed (0 percent complications) and those
with nasofrontal outflow tract injury should be
cranialized or obliterated regardless of displace-
ment. We had three complications from observing
1863
 Plastic and Reconstructive Surgery • December 2008
those with nasofrontal outflow tract injury. How-
ever, all three were nondisplaced fractures with
outflow obstruction. We can strongly conclude
that one must use caution observing patients with
isolated nondisplaced posterior wall fracture if ob-
struction is present.
Chronic complications were not documented in
our series, but some important findings must be
addressed. Although early diagnosis seems critical,
patients often fail to return for follow-up before clin-
ical manifestations of a missed nasofrontal outflow
tract obstruction manifests. These injuries precipi-
tate frontal sinusitis and mucocele formation.3,55,88
Both of these have indolent courses that create sim-
ilar problems. In the face of inadequate sinus drain-
age, mucous is produced continuously, resulting ul-
timately in infection (Fig. 5).37,69,70
Mucoceles have an insidious course and usually
result from the regrowth of sinus mucosa in poorly
managed frontal sinus fractures. Mucoceles usually
present years after the initial injury as an infection
with pressure or mass-like symptoms.3,55,88 The indo-
lent symptoms may begin late with visual distur-
bances, nasal obstruction, and pain or may be oc-
casioned by bone destruction and erosion;
treatment is complicated and requires intracranial-
extracranial approaches.72,89,90
We had a series of five patients who had per-
sistent infection despite numerous treatments.
The patients had sequelae of a slow indolent pro-
cess noted by frontal bone resorption, eczematous
skin changes, and cutaneous fistulas (Fig. 6). All
five patients were managed successfully by means
of a novel strategy including a single-stage de-
bridement and free vascularized tissue transfer for
final obliteration.91 Therefore, persistent frontal
sinus fracture infections that fail conventional sal-
vage techniques can be treated according to our
supplementary algorithm (Fig. 7).
CONCLUSIONS
We developed a statistically significant treat-
ment algorithm for frontal sinus fractures. Pa-
tients without radiographic evidence of nasofron-
tal outflow tract involvement may be observed,
whereas those with nasofrontal outflow tract injury
with obstruction must be treated by either oblit-
eration or cranialization. There is no role for oblit-
eration with fat or osteoneogenesis. Finally, a sin-
gle-stage vascularized free tissue transfer holds
promise for treating persistent indolent infectious
complications.
1864
Eduardo D. Rodriguez, M.D., D.D.S.
R Adams Cowley Shock Trauma Center
22 South Greene Street
Baltimore, Md. 21201
erodriguez@umm.edu
REFERENCES
1. Gerbino, G., Roccia, F., Benech, A., and Caldarelli, C. Anal-
ysis of 158 frontal sinus fractures: Current surgical manage-
ment and complications. J. Craniomaxillofac. Surg. 28: 133,
2000.
2. Rohrich, R. J., and Hollier, L. The role of the nasofrontal
duct in frontal sinus fracture management. J. Craniomaxillo-
fac. Trauma 2: 31, 1996.
3. Rohrich, R. J., and Hollier, L. H. Management of frontal
sinus fractures: Changing concepts. Clin. Plast. Surg. 19: 219,
1992.
4. Stanley, R. B., Jr., and Becker, T. S. Injuries of the nasofrontal
orifices in frontal sinus fractures. Laryngoscope 97: 728, 1987.
5. Wallis, A., and Donald, P. J. Frontal sinus fractures: A review
of 72 cases. Laryngoscope 98: 593, 1988.
6. Nahum, A. M. The biomechanics of maxillofacial trauma.
Clin. Plast. Surg. 2: 59, 1975.
7. Nahum, A. M. The biomechanics of facial bone fracture.
Laryngoscope 85: 140, 1975.
8. Yavuzer, R., Sari, A., Kelly, C. P., et al. Management of frontal
sinus fractures. Plast. Reconstr. Surg. 115: 79e, 2005.
9. Bell, R. B., Dierks, E. J., Brar, P., Potter, J. K., and Potter, B. E.
A protocol for the management of frontal sinus fractures em-
phasizing sinus preservation. J. Oral Maxillofac. Surg. 65: 825,
2007.
10. Chen, K. T., Chen, C. T., Mardini, S., Tsay, P. K., and Chen,
Y. R. Frontal sinus fractures: A treatment algorithm and
assessment of outcomes based on 78 clinical cases. Plast.
Reconstr. Surg. 118: 457, 2006.
11. Dickenson, J. T. C. J., and Kameron, D. B. Principles of
frontal sinus reconstruction. Laryngoscope 98: 593, 1988.
12. Gonty, A. A., Marciani, R. D., and Adornato, D. C. Manage-
ment of frontal sinus fractures: A review of 33 cases. J. Oral
Maxillofac. Surg. 57: 372, 1999.
13. Ioannides, C., and Freihofer, H. P. Fractures of the frontal
sinus: Classification and its implications for surgical treat-
ment. Am. J. Otolaryngol. 20: 273, 1999.
14. Ioannides, C., Freihofer, H. P., Vrieus, J., and Friens, J. Frac-
tures of the frontal sinus: A rationale of treatment. Br. J. Plast.
Surg. 46: 208, 1993.
15. Luce, E. A. Frontal sinus fractures: Guidelines to manage-
ment. Plast. Reconstr. Surg. 80: 500, 1987.
16. Shen, B. H. F. R. H., and Lin, J. T. Management of frontal
sinus fractures. J. Plast. Reconstr. Surg. Assoc. R.O.C. 6: 25,
1997.
17. Stanley, R. B., Jr. Management of frontal sinus fractures.
Facial Plast. Surg. 5: 231, 1988.
18. Tiwari, P., Higuera, S., Thornton, J., and Hollier, L. H. The
management of frontal sinus fractures. J. Oral Maxillofac.
Surg. 63: 1354, 2005.
19. Weber, S. C., and Cohn, A. M. Fracture of the frontal sinus
in children. Arch. Otolaryngol. 103: 241, 1977.
20. Xie, C., Mehendale, N., Barrett, D., Bui, C. J., and Metzinger,
S. E. 30-year retrospective review of frontal sinus fractures:
The Charity Hospital experience. J. Craniomaxillofac. Trauma
6: 7, 2000.
21. Schultz, R. C., and de Camara, D. L. Athletic facial injuries.
J.A.M.A. 252: 3395, 1984.
Volume 122, Number 6 • Frontal Sinus Fracture Treatment
22. Wilson, B. C., Davidson, B., Corey, J. P., and Haydon, R. C.,
III. Comparison of complications following frontal sinus frac-
tures managed with exploration with or without obliteration
over 10 years. Laryngoscope 98: 516, 1988.
23. Raveh, J., Laedrach, K., Vuillemin, T., and Zingg, M. Man-
agement of combined frontonaso-orbital/skull base frac-
tures and telecanthus in 355 cases. Arch. Otolaryngol. Head
Neck Surg. 118: 605, 1992.
24. Duvall, A. J., III, Porto, D. P., Lyons, D., and Boies, L. R., Jr.
Frontal sinus fractures: Analysis of treatment results. Arch.
Otolaryngol. Head Neck Surg. 113: 933, 1987.
25. Bergara, A. R., and Itoiz, A. O. Present state of the surgical
treatment of chronic frontal sinusitis. A.M.A. Arch. Otolaryn-
gol. 61: 616, 1955.
26. Donald, P. J., and Bernstein, L. Compound frontal sinus
injuries with intracranial penetration. Laryngoscope 88: 225,
1978.
27. Lynch, R. C. The technique of radical frontal sinus operation
which has given me the best results. Laryngoscope 31: 1, 1921.
28. Harris, L., Marano, G. D., and McCorkle, D. Nasofrontal
duct: CT in frontal sinus trauma. Radiology 165: 195, 1987.
29. Heller, E. M., Jacobs, J. B., and Holliday, R. A. Evaluation of
the frontonasal duct in frontal sinus fractures. Head Neck 11:
46, 1989.
30. Landsberg, R., and Friedman, M. A computer-assisted ana-
tomical study of the nasofrontal region. Laryngoscope 111:
2125, 2001.
31. Kelly, K. J., Manson, P. N., Vander Kolk, C. A., et al. Se-
quencing LeFort fracture treatment (organization of treat-
ment for a panfacial fracture). J. Craniofac. Surg. 1: 168, 1990.
32. Manson, P. N., Crawley, W. A., and Hoopes, J. E. Frontal
cranioplasty: Risk factors and choice of cranial vault recon-
structive material. Plast. Reconstr. Surg. 77: 888, 1986.
33. Manson, P. N., Markowitz, B., Mirvis, S., Dunham, M., and
Yaremchuk, M. Toward CT-based facial fracture treatment.
Plast. Reconstr. Surg. 85: 202, 1990.
34. Larrabee, W. F., Jr., Travis, L. W., and Tabb, H. G. Frontal
sinus fractures: Their suppurative complications and surgical
management. Laryngoscope 90: 1810, 1980.
35. Montgomery, W. W. Surgery of the frontal sinuses. Otolaryn-
gol. Clin. North Am. 4: 97, 1971.
36. Snyderman, C. H., Scioscia, K., Carrau, R. L., and Weissman,
J. L. Hydroxyapatite: An alternative method of frontal sinus
obliteration. Otolaryngol. Clin. North Am. 34: 179, 2001.
37. Wolfe, S. A., and Johnson, P. Frontal sinus injuries: Primary
care and management of late complications. Plast. Reconstr.
Surg. 82: 781, 1988.
38. Barone, C. M., Boschert, M. T., and Jimenez, D. F. Usefulness
of endoscopy in craniofacial trauma. J. Craniomaxillofac.
Trauma 4: 36, 1998.
39. Forrest, C. R. Application of endoscope-assisted minimal-
access techniques in orbitozygomatic complex, orbital floor,
and frontal sinus fractures. J. Craniomaxillofac. Trauma 5: 7,
1999.
40. Shumrick, K. A. Endoscopic management of frontal sinus
fractures. Facial Plast. Surg. Clin. North Am. 14: 31, 2006.
41. Reidel, R., and Schenke, H. Ueber die Stimhohlen und ihre
Erkrankungen (inaugural dissertation). Jena, Germany,
1898.
42. Spinelli, H. M., Irizarry, D., McCarthy, J. G., Cutting, C. B.,
and Noz, M. E. An analysis of extradural dead space after
fronto-orbital surgery. Plast. Reconstr. Surg. 93: 1372, 1994.
43. Breiman, L. Classification and Regression Trees. Boca Raton,
Fla.: Chapman & Hall/CRC, 1984.
44. Donald, P. J., and Ettin, M. The safety of frontal sinus fat
obliteration when sinus walls are missing. Laryngoscope 96:
190, 1986.
45. Lee, D., Brody, R., and Har-El, G. Frontal sinus outflow
anatomy. Am. J. Rhinol. 11: 283, 1997.
46. McLaughlin, R. B., Jr., Rehl, R. M., and Lanza, D. C. Clinically
relevant frontal sinus anatomy and physiology. Otolaryngol.
Clin. North Am. 34: 1, 2001.
47. Turgut, S., Ercan, I., Sayin, I., and Basak, M. The relationship
between frontal sinusitis and localization of the frontal sinus
outflow tract: A computer-assisted anatomical and clinical
study. Arch. Otolaryngol. Head Neck Surg. 131: 518, 2005.
48. Lee, T. T., Ratzker, P. A., Galarza, M., and Villanueva, P. A.
Early combined management of frontal sinus and orbital and
facial fractures. J. Trauma 44: 665, 1998.
49. Kreipke, D. L., Moss, J. J., Franco, J. M., Maves, M. D., and
Smith, D. J. Computed tomography and thin-section tomog-
raphy in facial trauma. A.J.R. Am. J. Roentgenol. 142: 1041,
1984.
50. Nahser, H. C., and Lohr, E. Possibilities of high resolution
computer tomography in the diagnosis of injuries of the
facial skull (in German). Radiologe 26: 412, 1986.
51. Rowe, L. D., Miller, E., and Brandt-Zawadzki, M. Computed
tomography in maxillofacial trauma. Laryngoscope 91: 745,
1981.
52. Olson, E. M., Wright, D. L., Hoffman, H. T., Hoyt, D. B., and
Tien, R. D. Frontal sinus fractures: Evaluation of CT scans in
132 patients. A.J.N.R. Am. J. Neuroradiol. 13: 897, 1992.
53. Wright, D. L., Hoffman, H. T., and Hoyt, D. B. Frontal sinus
fractures in the pediatric population. Laryngoscope 102: 1215,
1992.
54. Kennedy, D. W., and Senior, B. A. Endoscopic sinus surgery:
A review. Otolaryngol. Clin. North Am. 30: 313, 1997.
55. Manolidis, S., and Hollier, L. H. Management of frontal sinus
fractures. Plast. Reconstr. Surg. 120: 32S, 2007.
56. El Khatib, K., Danino, A., and Malka, G. The frontal sinus:
A culprit or a victim? A review of 40 cases. J. Craniomaxillofac.
Surg. 32: 314, 2004.
57. Chuang, S. K., and Dodson, T. B. Evaluation and manage-
ment of frontal sinus injuries. In R. J. Fonseca, R. Walker, N.
Betts, M. P. Powers, and H. D Barber (Eds.), Oral and Max-
illofacial Trauma, Vol. 2. Philadelphia: Saunders, 2004. P. 721.
58. Simon, S. STATS: Steve’s attempt to teach statistics (web
page). Available at: http://www.childrensmercy.org/stats/
ask/roc.asp. Accessed February 21, 2008.
59. Lasko, T. A., Bhagwat, J. G., Zou, K. H., and Ohno-Machado,
L. The use of receiver operating characteristic curves in
biomedical informatics. J. Biomed. Inform. 38: 404, 2005.
60. Obuchowski, N. A. Receiver operating characteristic curves
and their use in radiology. Radiology 229: 3, 2003.
61. Zweig, M. H., and Campbell, G. Receiver-operating charac-
teristic (ROC) plots: A fundamental evaluation tool in clin-
ical medicine. Clin. Chem. 39: 561, 1993.
62. Pepe, M. S. The Statistical Evaluation of Medical Tests for Clas-
sification and Prediction. New York: Oxford University Press,
2003.
63. Spackman, K. A. Signal detection theory: Valuable tools for
evaluating inductive learning. In Proceedings of the Sixth Inter-
national Workshop on Machine Learning. San Francisco: Calif.,
Morgan Kaufman, 1989.
64. Metz, C. E. Basic principles of ROC analysis. Semin. Nucl. Med.
8: 283, 1978.
65. Dedo, H. H., Broberg, T. G., and Murr, A. H. Frontoeth-
moidectomy with Sewall-Boyden reconstruction: Alive and
well, a 25-year experience. Am. J. Rhinol. 12: 191, 1998.
1865
 Plastic and Reconstructive Surgery • December 2008
66. Romain, P., Legros, M., Hannion, X., Schmidt, P.,
Chalumeau, F., and Bazin, A. Frontal sinus injuries: Apropos
of 67 cases. Rev. Laryngol. Otol. Rhinol. (Bord.) 111: 5, 1990.
67. Donald, P. J. Frontal sinus ablation by cranialization: Report
of 21 cases. Arch. Otolaryngol. 108: 142, 1982.
68. Donald, P. J. Obliteration of compressed frontal sinus. Plast.
Reconstr. Surg. 78: 832, 1986.
69. Mickel, T. J., Rohrich, R. J., and Robinson, J. B., Jr. Frontal
sinus obliteration: A comparison of fat, muscle, bone, and
spontaneous osteoneogenesis in the cat model. Plast. Recon-
str. Surg. 95: 586, 1995.
70. Rohrich, R. J., and Mickel, T. J. Frontal sinus obliteration: In
search of the ideal autogenous material. Plast. Reconstr. Surg.
95: 580, 1995.
71. Donald, P. J. Frontobasal approach for trauma and tumor.
Minim. Invasive Neurosurg. 37: 37, 1994.
72. Donald, P. J., Montgomery, W. W., and Calcaterra, T. Frontal
bone defect with frontal sinus mucopyocele. Head Neck Surg.
10: 59, 1987.
73. Goodale, R. L. Obliteration of the frontal sinus. Ann. Otol.
Rhinol. Laryngol. 74: 831, 1965.
74. Mosher, H. A method of obliterating the naso-frontal duct
and catheterizing the frontal sinus. Laryngoscope 21: 946,
1911.
75. Weber, R., Draf, W., Keerl, R., et al. Osteoplastic frontal sinus
surgery with fat obliteration: Technique and long-term re-
sults using magnetic resonance imaging in 82 operations.
Laryngoscope 110: 1037, 2000.
76. Baker, S. B., Weinzweig, J., Kirschner, R. E., and Bartlett,
S. P. Applications of a new carbonated calcium phosphate
bone cement: Early experience in pediatric and adult cranio-
facial reconstruction. Plast. Reconstr. Surg. 109: 1789, 2002.
77. Kalavrezos, N. D., Gratz, K. W., Oechslin, C. K., and Sailer, H.
F. Obliteration of the frontal sinus with lyophilized cartilage in
frontal fractures. Mund. Kiefer. Gesichtschir. 2(Suppl. 1): S66,
1998.
78. Kalavrezos, N. D., Gratz, K. W., Warnke, T., and Sailer, H. F.
Frontal sinus fractures: Computed tomography evaluation of
sinus obliteration with lyophilized cartilage. J. Craniomaxil-
lofac. Surg. 27: 20, 1999.
1866
79. Peltola, M., Aitasalo, K., Suonpaa, J., Varpula, M., and
Yli-Urpo, A. Bioactive glass S53P4 in frontal sinus oblitera-
tion: A long-term clinical experience. Head Neck 28: 834,
2006.
80. Petruzzelli, G. J., and Stankiewicz, J. A. Frontal sinus oblit-
eration with hydroxyapatite cement. Laryngoscope 112: 32,
2002.
81. Verret, D. J., Ducic, Y., Oxford, L., and Smith, J. Hydroxy-
apatite cement in craniofacial reconstruction. Otolaryngol.
Head Neck Surg. 133: 897, 2005.
82. Weber, R., Draf, W., Kahle, G., and Kind, M. Obliteration of
the frontal sinus: State of the art and reflections on new
materials. Rhinology 37: 1, 1999.
83. Parhiscar, A., and Har-El, G. Frontal sinus obliteration with
the pericranial flap. Otolaryngol. Head Neck Surg. 124: 304,
2001.
84. Thaller, S. R., and Donald, P. The use of pericranial flaps in
frontal sinus fractures. Ann. Plast. Surg. 32: 284, 1994.
85. Grahne, B. Chronic frontal sinusitis treated by autogenous
osteoplasty. Acta Otolaryngol. 72: 215, 1971.
86. Hybels, R. L., and Newman, M. H. Posterior table fractures
of the frontal sinus: I. An experimental study. Laryngoscope
87: 171, 1977.
87. Nadell, J., and Kline, D. G. Primary reconstruction of de-
pressed frontal skull fractures including those involving the
sinus, orbit, and cribriform plate. J. Neurosurg. 41: 200, 1974.
88. Weitzel, E. K., Hollier, L. H., Calzada, G., and Manolidis, S.
Single stage management of complex fronto-orbital muco-
celes. J. Craniofac. Surg. 13: 739, 2002.
89. Abrahamson, I. A., Jr., Baluyot, S. T., Tew, J. M., Jr., and
Scioville, G., Jr. Frontal sinus mucocele. Ann. Ophthalmol. 11:
173, 1979.
90. LaRossa, D. D., Noone, R. B., and Jackson, P. Facial deformity
from frontal sinus mucocele: Single stage surgical correction.
Case report. Plast. Reconstr. Surg. 60: 917, 1977.
91. Bluebond-Langner, R., Jackowe, D., and Rodriguez, E. D.
Simultaneous obliteration and treatment of infected frontal
sinus fractures: Novel use of the fibula flap. J. Craniofac. Surg.
18: 680, 2007.