ORIGINAL ARTICLE
Changing the surgical dogma in frontal sinus trauma: transnasal
endoscopic repair
Jessica W. Grayson, MD1 , Hari Jeyarajan, MD1 , Elisa A. Illing, MD1 , Do-Yeon Cho, MD1 ,
Kristen O. Riley, MD2 and Bradford A. Woodworth, MD1
Background: Management of frontal sinus trauma includes
coronal or direct open approaches through skin incisions
to either ablate or obliterate the frontal sinus for pos-
terior table fractures and openly reduce/internally fixate
fractured anterior tables. The objective of this prospective
case-series study was to evaluate outcomes of frontal si-
nus anterior and posterior table trauma using endoscopic
techniques.
Methods: Prospective evaluation of patients undergoing
surgery for frontal sinus fractures was performed. Data
were collected regarding demographics, etiology, tech-
nique, operative site, length involving the posterior ta-
ble, size of skull base defects, complications, and clinical
follow-up.
Results: Forty-six patients (average age, 42 years) with
frontal sinus fractures were treated using endoscopic tech-
niques from 2008 to 2016. Mean follow-up was 26 (range,
0.5 to 79) months. Patients were treated primarily with a
Draf IIb frontal sinusotomies. Draf III was used in 8 pa-
tients. Average fracture defect (length vs width) was 17.1 ×
9.1 mm, and the average length involving the posterior table
was 13.1 mm. Skull base defects were covered with either
C lassification of frontal sinus trauma is predicated on
anatomically defining the injury and determining the
1 Department of Otolaryngology–Head and Neck Surgery, University of
Alabama at Birmingham, Birmingham, Alabama; 2 Department of
Neurosurgical Sciences, University of Alabama at Birmingham,
Birmingham, Alabama
Correspondence to: Bradford A. Woodworth, MD, Department of
Otolaryngology–Head and Neck Surgery, University of Alabama at
Birmingham, BDB 563, 1720 2nd Avenue S, Birmingham, AL 35294-0012;
e-mail: bwoodwo@hotmail.com.
Funding source for the study: Cook Medical (to B.A.W.).
Potential conflict of interest: B.A.W.: Olympus and Cook Medical,
consultancy.
Presented at the American Rhinologic Society Annual Meeting, on
September 19, 2016, in San Diego, CA.
Received: 20 August 2016; Revised: 20 October 2016; Accepted:
15 November 2016
DOI: 10.1002/alr.21897
View this article online at wileyonlinelibrary.com.
1 International Forum of Allergy & Rhinology, Vol. 00, No. 0, xxxx 2017
nasoseptal flaps or free tissue gras. One individual re-
quired Draf IIb revision, but all sinuses were patent on fi-
nal examination and all closed reductions of anterior table
defects resulted in cosmetically acceptable outcomes.
Conclusion: Frontal sinus trauma has traditionally been
treated using open approaches. Our findings show that en-
doscopic management should become part of the man-
agement algorithm for frontal sinus trauma, which chal-
lenges current surgical dogma regarding mandatory open
approaches. C 2017 ARS-AAOA, LLC.
Key Words:
anterior table fracture; cerebrospinal fluid leak; CSF leak;
CSF rhinorrhea; endoscopic CSF leak repair; endoscopic
sinus surgery; frontal fracture; frontal sinus trauma;
posterior table fracture; skull base fracture
How to Cite this Article:
Grayson JW, Jeyarajan H, Illing EA, Cho D-Y, Riley KO,
Woodworth BA. Changing the surgical dogma in frontal
sinus trauma: transnasal endoscopic repair. Int Forum
Allergy Rhinol. 2017;XX:1–9.
need for surgical intervention. Although variably described
and anecdotally biased,1–5 most classifications agree on es-
sential anatomic considerations, including anterior and/or
posterior table involvement, fracture depression and com-
minution, and involvement of the frontal sinus drainage
pathway (FSDP). Approximately two thirds of frontal si-
nus fractures consist of both anterior and posterior table
injuries, with isolated anterior table fractures occurring
in one third and isolated posterior table fractures being
less common (reportedly between 7% and 11%).6–11 Fur-
thermore, iatrogenic trauma can occur during various sur-
gical procedures (eg, craniotomies and endoscopic sinus
surgery), resulting in significant injury to the posterior ta-
ble causing leakage of cerebrospinal fluid (CSF).12 FSDP
injuries were underappreciated in early reviews, especially
outside of the otolaryngology literature. Due to a com-
bination of advanced cross-sectional imaging as well as
Grayson et al.
improved endoscopic assessment, the epidemiologic promi-
nence and clinical significance of FSDP injury are becoming
better recognized.11, 13 Functional considerations of these 3
anatomic sites have critical implications for treatment al-
gorithms. Although anterior table injuries confer primarily
aesthetic consequence, posterior table involvement is the
key consideration in isolation of intracranial structures and
control of CSF leakage. FSDP injury is increasingly being
recognized as the decisive factor in preservation of frontal
sinus function and prevention of long-term infectious
sequelae of sinus obstruction.
Although a recent paradigm shift toward functional sinus
preservation has been described,7, 14–16 the majority of pub-
lished literature continues to promote open approaches.
More recently, the endoscope has been introduced into
many facets of intervention, including endoscopic-assisted
brow incisions for anterior table fractures and endo-
scopic frontal sinusotomies for FSDP obstruction.5, 8, 17–21
Endoscopic-assisted approaches have been shown to re-
duce the associated functional and aesthetic consequences
of traditional open repairs.8, 19, 20, 22–24 The use of the endo-
scope has only recently been described in the management
of posterior table fractures by the senior author (B.A.W.).25
A truly transnasal endoscopic approach to these injuries
is technically feasible and confers a number of advantages,
including optimal posttreatment clinical surveillance,
clearance of the FSDP, and lack of incisions. The objective
of the current study is to evaluate outcomes of frontal
sinus anterior and posterior table trauma using endoscopic
techniques, while also critically assessing the literature
to redefine the management algorithm related to these
injuries.
Methods
Institutional review board approval for prospective eval-
uation and data collection was obtained before initiation
of the study. Data related to 46 operative patients were
collected between 2008 and 2016 at a tertiary level 1
trauma center. Subjects were enrolled for data collection
if requiring operative intervention by the senior author
(B.A.W.) after consultation by the trauma or neurosurgical
service for frontal sinus fractures or after evaluation
for surgical iatrogenic injuries. Data collected included
gender, age, type of fracture, etiology of injury, repair
techniques, size of skull base defects, length involving the
posterior table, and clinical follow-up. Length involving
the posterior table is the measurement corresponding to
the distance from the start of the ethmoid roof/posterior
table to the apex of the fracture within the frontal sinus.
All subjects had this measurement as well as total length
and width of the defect measured with a ruler cut to size
and placed endoscopically. Patients who underwent cran-
iotomy by neurosurgery for other reasons were cranialized
by their service and only included in the study if the senior
author was consulted for CSF leak after failure of the
cranialization.
Surgical technique
Initial patient evaluation was completed with computed
tomography (CT) scan of the facial bones without contrast
along with physical exam to determine fracture patterns,
other involved facial fractures or neurosurgical injuries, and
medical clearance for surgery. All patients in this series with
anterior table fractures were taken to the operating room
within 10 days for endoscopic reduction. In general, we
advocate addressing the anterior table fracture during this
time period as longer duration may lead to fibrosis and
inability to reduce the segments manually. Acute disruption
of the posterior table with presence of CSF leak were usually
repaired within the same time period or when the patient
was stable enough for surgery. However, CSF leaks from
failures of previously cranialized or endoscopic surgeries
were, in some cases, repaired up to several years after the
initial injury. Computer-assisted surgical navigation was
utilized in all cases.
Subjects with isolated anterior or posterior table frac-
tures (or combination fractures) underwent endoscopic si-
nus surgery, including frontal sinusotomy performed on
the side of the injuries. A 70-degree scope was always used
for visualization and dissection of the frontal sinus. This is
absolutely indispensable for this surgical approach because
many fractures extend laterally and it affords the necessary
view for reduction and placement of grafts or flaps.26 A
frontal sinusotomy was completed on the side of the injury
(bilateral if bilateral fractures) and usually extended to a
Draf IIb sinusotomy (or Draf III if required for visualiza-
tion). At the time of the frontal sinusotomy, any frontal
recess debris was removed. If there was an isolated dis-
placed segment of posterior table, mucosa was removed
from the bone and surrounding areas utilizing radiofre-
quency coblation (Coblator R
; Smith and Nephew, London,
UK). Segments were then manually reduced with a curved
suction or frontal curettes. If posterior table injuries were
comminuted, meticulous removal of the fragments from ad-
hered dura was performed after bipolar cauterization with
the Coblator (Figure 1). For linear cracks without signif-
icant displacement, mucosa was removed from the defect
and surrounding area with no manipulation of the bone in
preparation for skull base repair (Figure 2). In the case of
anterior table fractures, reduction of the fracture segments
was accomplished with manual reduction using curved suc-
tion or frontal curettes (Figures 3 and 4).
For posterior table defects, skull base repair was per-
formed in several different ways. Overlay grafts or na-
soseptal flaps (NSF) were used without underlay repairs
for simple cracks or when an isolated telescoped segment
of posterior table had been manually reduced. If fragments
were removed and defects were larger than approximately
5 mm, an underlay epidural repair with porcine small in-
testine submucosal (SIS) graft (Biodesign R
, Cook Medical,
Bloomington, IN) was included prior to overlay graft or
flap placement.27 Nasoseptal flaps were harvested as pre-
viously described and can cover up to 3 cm of ipsilateral
posterior table defects.28
International Forum of Allergy & Rhinology, Vol. 00, No. 0, xxxx 2017 2
Endoscopic Repair of Frontal Sinus Trauma

FIGURE 1. Preoperative CT scans of patients with various types of posterior table fractures (A-C) with corresponding postoperative scans after repair (D-F).
Note either telescoped fracture segment with reduction (A, D), comminuted segments requiring removal (B, E), or combinations of both (C, F), showing
reduction of right posterior table segment and removal of comminuted left posterior table segments.

FIGURE 2. (A) Coronal computed tomography of a linear posterior table fracture (arrow). (B) Measurement of fracture 5 cm up the posterior table with
70-degree endoscopy. (C) SIS graft placed in overlay fashion. (D) Gelfoam packing for support with 0.5-mm-thick silastic stent in place. (E) Endoscopic view of
left functional frontal sinus at 2 years after Draf IIB frontal sinusotomy.

3 International Forum of Allergy & Rhinology, Vol. 00, No. 0, xxxx 2017
Grayson et al.
FIGURE 3. (A) Preoperative axial CT scan showing displaced anterior table fracture. (B) A curved suction is placed on the inferior segment through a
Draf IIB frontal sinusotomy. (C) The inferior segment has been reduced (arrow). (D) A frontal curette is positioned on the apex of the superior segment. (E)
Both fractures are in alignment after reduction of the superior fragment. (F) Postoperative axial CT scan revealing complete reduction of the fracture. CT =
computed tomography.
FIGURE 4. (A) Preoperative indentation of the forehead from the anterior
table fracture. (B) Postoperative image reveals no cosmetic deformity.
Supportive packing was utilized in all cases, including gel
foam and rolled stent(s) carved to fit from 0.5-mm silas-
tic sheeting. If a Draf III was completed, mucosal grafts
were placed on the drilled-out nasofrontal area, as previ-
ously described.26, 29 A polyvinyl alcohol sponge inside a
sterile nonlatex glove finger was positioned within the mid-
dle meatus in apposition to the frontal recess and sutured
via a 2-0 Prolene suture to the anterior septum. Patients
received 3 weeks of antibiotics as part of our standard post-
functional endoscopic sinus surgery treatment. Spacers and
frontal sinus stents were removed approximately 11 to 13
days postoperatively.
Results
During the period from 2008 to 2016, a total of 46
patients with frontal sinus trauma were approached us-
ing transnasal endoscopic techniques (see demographics in
Table 1). Mechanisms of injury included motor vehicle col-
lisions (MVC) (n = 19, 41.3%), iatrogenic injuries (n =
13, 28%), gunshot wounds (GSW) (n = 6, 28.3%), falls
(n = 5, 10.9%), and assaults (improvised explosive de-
vice, baseball projectile, and physical assault, n = 3, 6.5%)
(Table 1). Iatrogenic injuries resulted from otolaryngology
(n = 7), neurosurgery (n = 4), and oculoplastics (n = 2).
Most fractures in our study were posterior table (87%),
because the senior author only recently transitioned to per-
forming routine transnasal endoscopic reduction of ante-
rior table fractures within the last year. Intervention for
all posterior table fractures was based on active CSF leak.
Anterior table fractures were isolated in 5 patients and 1
individual had reduction and repair of both anterior and
posterior table fractures. All patients with reduction of the
anterior table were satisfied with the contour of their fore-
head. Thirty-one (73.8%) of the posterior table fractures
also involved the anterior skull base. For posterior table
trauma, the average skull base defect was 17.1 ± 11.4 mm
× 9.1 ± 11.3 mm, with an average length of the posterior
table of 13.1 ± 12.4 mm (± standard deviation).
Of the patients with posterior table fractures, skull base
repair was performed with SIS (n = 25), a combination
of SIS and NSF (n = 14), cadaveric pericardium (n = 1),
and SIS and fat (n = 1). Thirty-seven patients had a Draf
IIb frontal sinusotomy, whereas a Draf III was employed
International Forum of Allergy & Rhinology, Vol. 00, No. 0, xxxx 2017 4
Endoscopic Repair of Frontal Sinus Trauma

TABLE 1. Patients’ demographics and fracture data other patient developed periorbital cellulitis that resolved
with intravenous antibiotics.
Number (%)

Type of fracture
Discussion
Anterior 5 of 46 (10.9%)
Despite numerous case reports and several large case
Posterior 40 of 46 (87%) series, the management of frontal sinus fractures has
Combined anterior and posterior 1 of 46 (2.2%) remained shrouded in controversy for the better part of
the last century. Frontal sinus fractures are associated
Gender
with high-impact trauma and panfacial injuries as well
Male 30 of 46 (65.2%) as close proximity to intracranial and orbital structures,
Female 16 of 46 (34.8%)
and their presence indicates a 42% risk of permanent
neurologic compromise, 59% risk of orbital compromise,
Frontal sinus approach and up to a 25% mortality risk.6, 32 In addition, fractures
Trephine with Draf IIa 1 of 46 (2.2%) of the posterior table are commonly complicated by dural
injury33 with pneumocephalus in 25% to 33%, CSF
Trephine with Draf IIb 37 of 46 (80.4%)
leak in 13% to 25%, and extradural hematoma in 10%
Trephine with Draf III 8 of 46 (17.4%) of patients.8, 25, 34, 35 With such high rates of associated
Mechanism of injury trauma and sequelae, it is not surprising that management
of such injuries is complex and influenced by many factors.
MVC 19 of 46 (41.3%)
Furthermore, there is a lack of uniformity in treatment
Iatrogenic 13 of 46 (28.3%) paradigms due to the retrospective nature of available case
GSW 6 of 46 (13%)
series, difficulty in maintaining long-term follow-up in
trauma patients, variable reporting of complications, and
Falls 5 of 46 (10.9%) differences in technical expertise and philosophy among
Other a
3 of 46 (6.5%) subspecialties charged with management of these entities.
a
Improvised explosive device, or projectile or assault weapon.
GSW = gunshot wound; MVC = motor vehicle collision. Outcomes of ablative/obliterative treatments
for posterior table injuries
Trauma to the frontal sinus anterior and posterior tables
in 8 subjects (17.39%). One individual had a trephine and has historically been managed with open approaches,
Draf IIa (2.17%). The trephine was performed early on in primarily open reduction/internal fixation with either
our experience and has not been used since that time, as we osteoplastic flap with obliteration or cranialization, with
no longer consider this necessary. the premise of preventing early and late complications from
Conservative measures such as bed rest, Valsalva precau- the injuries. However, open approaches have a high rate of
tions, and sometimes lumbar drains or external ventricular complications, many of which are infectious or obstructive
devices were often employed initially. This reflects our ex- in nature and caused by the procedures intended to avoid
perience as a consult service for trauma and neurosurgery, them. Reported complication rates for open fracture repair
although some centers have advocated for early repair of range from 10% to 17%, with chronic headache being the
traumatic CSF leaks due to long-term risk of ascending most common, present in over 50% of trauma patients.36
meningitis even when conservative measures successfully Sinus cranialization has been standard management
seal the leak.30, 31 As is typically the case in severe disrup- for comminuted posterior table fractures, but it carries
tion or iatrogenic injuries, surgery was usually the first-line significant issues with cosmesis,18 resorption of autologous
option. Fourteen patients had diversion of CSF via lumbar fat,3, 37 and re-epithelialization in 50% of cases over time,
drain or ventriculostomy. One of these patients had idio- increasing risk of postoperative mucocele formation.13, 38
pathic intracranial hypertension, whereas the others were This translates to a failure rate of up to 25%.39 Further-
either iatrogenic neurosurgical injuries or a ventriculostomy more, cranialization has been the treatment of choice for
or lumbar drain was placed before our involvement with complicated fractures of the posterior table and, increas-
the patient’s care. ingly, those involving the FSDP. This surgical treatment
Average clinical follow-up was 26 months (range, 2 has also been plagued with high failure rates and long-term
weeks to 79 months) with 2 complications noted in this co- risk of mucocele formation due to inadequate elimina-
hort. Both patients had Draf IIb frontal sinusotomies with tion of all mucosa within the ablated cavity. Although
NSF+SIS for skull base repair. The first had scarring of retrospective reviews have achieved complication rates as
her frontal outflow and was revised with another Draf IIb. low as 9%,13 the true incidence of mucocele formation is
She was followed up for a total of 62 months and did not grossly underestimated, because a follow-up of 16 years is
require further procedures to open her frontal sinus. The required to capture 50% of all posttraumatic mucoceles.40

5 International Forum of Allergy & Rhinology, Vol. 00, No. 0, xxxx 2017
Grayson et al.
FIGURE 5. Anterior table fracture repair algorithm. CSF = cerebrospinal fluid; FSDP = frontal sinus drainage pathway.
Outcomes of transnasal endoscopic management
of posterior table injuries
Mounting evidence supports the validity of transnasal
endoscopic repair of frontal sinus trauma in appropriately
selected patients. The first case series regarding transnasal
endoscopic management of frontal sinus CSF leaks was
reported in 2006.41 Advancements in surgical methods
permitting closure of multi-centimeter defects of the
posterior table of all etiologies,42 including trauma, were
published several years later, but technical aspects related
to repairing severely comminuted posterior table fractures
were developed and reported by the senior author in
2011, after garnering significant clinical experience.25
Although the current study expands on this previous
experience, indications were recently extended to in-
clude transnasal endoscopic reduction of anterior table
fractures.
The functional endonasal approach to frontal sinus
trauma allows for optimal assessment of mucosal injuries
as well as repair of both bony and mucosal disruption with
true preservation of functional sinus drainage. As described
herein, 46 patients with frontal sinus trauma were man-
aged successfully using transnasal endoscopic approaches
without major complications (brain abscess, meningitis, or
mucoceles) and acceptable cosmetic outcomes. All patients
with posterior table fractures in the current series had CSF
leakage. Although the pericranial flap is the workhorse of
open anterior skull base reconstruction, it has a 10% to
17% failure rate in the management of traumatic leaks,43
most likely due to poor visualization at the ethmoid roof.
Importantly, 31 (73.8%) subjects with posterior table frac-
tures in this study also had involvement of the anterior skull
base (ethmoid roof and cribriform). The endoscopic view
can greatly improve characterization of anterior skull base
International Forum of Allergy & Rhinology, Vol. 00, No. 0, xxxx 2017 6
Endoscopic Repair of Frontal Sinus Trauma
FIGURE 6. Posterior table fracture repair algorithm. CSF = cerebrospinal fluid; FSDP = frontal sinus drainage pathway.
fractures. The ability to address complicated posterior table
fractures and dural lacerations with significant involvement
of the ethmoid roof is highlighted by our 0% leak recur-
rence rate. Overall, our complication rate was very low
(4%) and well below the morbidity for both cranialization
and obliteration of the frontal sinus (reported range, 6%
to 71%).3, 13, 16, 34, 44–47 Importantly, subjects maintained
normal postoperative frontal sinus function and drainage,
with the exception of 1 patient who underwent revision
of their Draf IIB frontal sinusotomy. The seminal findings
indicate mandate modifications of previous treatment al-
gorithms related to management of frontal sinus fractures
(Figures 5–7).
Advantages of endoscopic management of
the FSDP
Long-term complications related to open surgical manage-
ment are primarily infectious or obstructive in nature from
inadequate obliteration or ablation of the sinus, which un-
derscores one of the major advantages of the endoscopic
approach. Endoscopic management of the FSDP facilitates
postoperative clinical assessment of the frontal sinus, of-
ten obviating the need for long-term radiologic follow-up
and precluding the risk of long-term mucocele. In previous
treatment algorithms, the FSDP was critical in determining
surgical intervention. However, FSDP involvement is not
a major consideration if endoscopic repair is indicated for
7 International Forum of Allergy & Rhinology, Vol. 00, No. 0, xxxx 2017
anterior or posterior table fractures, because the frontal si-
nus is opened in this approach, with an emphasis on main-
taining functional physiology. Poor patient follow-up in
this population is often cited as the reason to obliterate or
ablate a frontal sinus so that the risk of infectious complica-
tions from FSDP obstruction is lowered. This argument is
counterintuitive because mucoceles develop at such a high
rate, despite attempts to eliminate the sinus cavity. In con-
trast, current Draf IIB and III techniques have such high
rates of success for maintaining a patent FSDP that, even
with short-term follow-up, the likelihood of frontal sinus
closure long-term is much lower than the risk of mucocele
formation with open procedures. 29, 48
FSDP obstruction can also be managed expectantly if no
surgical intervention for the anterior or posterior tables is
necessary. It is important to note that these injuries have
been difficult to assess clinically.47, 49, 50 In a series of 857
patients, careful radiographic assessment with multiplanar
reformatted CT images identified FSDP injury in 70.7% of
patients.11 Smith et al.15 demonstrated that spontaneous
ventilation of the frontal sinus after expectant manage-
ment and medical therapy, including 4 weeks of antibi-
otics, topical nasal steroids, and oral corticosteroids occurs
in 71.4% of these patients. Follow-up CT scans should be
completed at 8 weeks for evaluation of spontaneous ven-
tilation. If there is spontaneous ventilation at 8 weeks on
CT scan, patients can be followed symptomatically. Further
Grayson et al.
FIGURE 7. Expectant management algorithm. CSF = cerebrospinal fluid; CT = computed tomography; FDSP = frontal sinus drainage pathway.
radiographic and clinical follow-up is required in the ab-
sence of ventilation according to this protocol, but timing
of endoscopic intervention depends on a number of fac-
tors, including presence of symptoms, patient preference,
and the surgeon’s discretion.
Transnasal endoscopic reduction of anterior table
fractures
Previously, anterior table fractures were thought to pre-
clude endoscopic repair of posterior table fractures, be-
cause an open approach was necessary to perform open
reduction and internal fixation. Based on the success of
endoscopic manual reduction of telescoped posterior table
segments, the present investigators transitioned to routine
reduction of anterior table fractures within the last year.
Although transnasal endoscopic reduction of the anterior
table has been described previously by Steiger et al.,39 there
are distinct differences in management. Their algorithm is
based on location (medial vs lateral) of the fracture and
presence of comminuted segments, yet only 1 in 5 fractures
were reduced through a frontal sinusotomy. The remain-
ing patients were reduced through a trephine rather than
transnasal and, in 3 cases, fixed with miniplates. However,
displaced anterior table fractures can now be reduced com-
pletely through the frontal sinusotomy as described in this
study. If unable to reduce a lateral fracture through a Draf
IIB, the approach can be converted to a Draf III procedure,
allowing excellent access to laterally based fractures.
Timing of repair
Timing of the repair within 10 days was considered cru-
cial for anterior table fractures because the indications
were purely cosmetic and required repositioning of the seg-
ments in every case. Fibrosis and healing of the segments in
their fractured position for an extended duration should be
International Forum of Allergy & Rhinology, Vol. 00, No. 0, xxxx 2017 8
Endoscopic Repair of Frontal Sinus Trauma

considered a contraindication to transnasal endoscopic re-
pair. In the event of delayed evaluation of an anterior table
fracture, the endoscopic brow-assisted approaches could
be used for camouflage techniques. On the other hand, the
goals of closure of posterior table fractures include cessa-
tion of leak and prevention of intracranial infection. Skull
base reconstruction is performed, regardless whether seg-
ments are reduced or removed. As such, skull base repair
can be performed on late CSF leak presentations years after
injury. Posterior table fractures without CSF leaks do not
require repair but rather close monitoring and endoscopic
closure in the event of a delayed leak.
Limitations
In patients who require a craniotomy, there is limited role
for endoscopic repair of frontal sinus injury, except in
the case of frontal sinus drainage pathway injury alone.
Cranialization is performed at the time of the craniotomy
and endoscopic routes would be considered relatively con-
traindicated. However, it should be noted that 3 subjects
in the current study were successfully repaired endoscopi-
cally after failure of a cranialization procedure. Such evi-
dence underscores the utility of experience with transnasal
endoscopic techniques even when open procedures are
performed first.
Conclusion
Endoscopic endonasal approaches to repair frontal sinus
fractures are not only feasible, but also preferred in se-
lected patients for maintaining both the structure and func-
tion of the sinus and minimizing early and late complica-
tions. The accrued experience reported here with excellent
outcomes should encourage experienced endoscopic sur-
geons to include transnasal endoscopic management in the
armamentarium of approaches to these injuries.

References
1. Luce EA. Frontal sinus fractures: guidelines to man-
agement. Plast Reconstr Surg. 1987;80:500–508.
2. Sailer HF, Gratz KW, Kalavrezos N. Frontal sinus
fractures: principles of treatment and long term results
after sinus obliteration with the use of lyophilized car-
tilage. J Craniomaxillofac Surg. 1998;26:235–242.
3. Gonty AA, Marciani RD, Adornato DC. Management
of frontal sinus fractures: a review of 33 Cases J Cran-
iomaxillofac Surg. 1999;57:372–379.
4. Ioannides C, Freihofer HP. Fractures of the frontal
sinus: classification and its implications for surgical
treatment. Am J Otolaryngol. 1999;20:273–280.
5. Guy WM, Brissett AE. Contemporary management of
traumatic fractures of the frontal sinus. Otolaryngol
Clin North Am. 2013;46:733–748.
6. Kountakis SE, Senior BA, Draf W, eds. The Frontal
Sinus. Berlin: Springer; 2016:469–484.
7. Pawar SS, Rhee JS. Frontal sinus and naso-
orbital-ethmoid fractures. JAMA Facial Plast Surg.
2014;16:284–289.
8. Strong EB, Pahlavan N, Saito D. Frontal sinus frac-
tures: a 28-year retrospective review. Otolaryngol
Head Neck Surg. 2006;135:774–779.
9. Delaney SW. Treatment strategies for frontal sinus an-
terior table fractures and contour deformities. J Plast
Reconstr Aesthet Surg. 2016;69:1037–1045.
10. Rice DH. Management of frontal sinus fractures. Curr
Opin Otolaryngol Head Neck Surg. 2004;12:46–48.
11. Stanwix MG, Nam AJ, Manson PN, Mirvis S,
Rodriguez ED. Critical computed tomographic diag-
nostic criteria for frontal sinus fractures. J Oral Max-
illofac Surg. 2010;68:2714–2722.
12. Illing EA, Woodworth BA. Management of frontal si-
nus cerebrospinal fluid leaks and encephaloceles. Oto-
laryngol Clin North Am. 2016;49:1035–1050.
13. Rodriguez ED, Stanwix MG, Nam AJ, et al. Twenty-
six year experience treating frontal sinus fractures: a
novel algorithm based upon anatomical fracture pat-
tern and failure of conventional techniques. Plast Re-
constr Surg. 2008;122:1850–1866.
14. Thong JF, Lee J. Single-stage strategy for manage-
ment of anterior table frontal sinus fractures involv-
ing the frontal sinus outflow tract. Eur J Plast Surg.
2011;34:299–303.
15. Smith TL, Han JK, Loerl TA, Rhee JS. endoscopic
management of the frontal recess in frontal sinus
fractures: a shift in the paradigm? Laryngoscope.
2002;112:784–790.
16. Bell RB, Dierks EJ, Brar P, Potter JK, Potter BE. A
protocol for the management of frontal sinus frac-
tures emphasizing sinus preservation. J Oral Maxillo-
fac Surg. 2007;65:825–839.
17. Shumrick KA. Endoscopic management of frontal
sinus fractures. Otolaryngol Clin North Am.
2007;40:329–336.
18. Emara TA, Elnashar IS, Omara TA, Basha WM,
Anany AM. Frontal sinus fractures with suspected
outflow tract obstruction: a new approach for sinus
preservation. J Craniomaxillofac Surg. 2015;43:1–6.
19. Kim KK, Mueller R, Huang F, Strong EB. Endoscopic
repair of anterior table: frontal sinus fractures with
a Medpor implant. Otolaryngol Head Neck Surg.
2007;136:568–572.
20. Strong EB, Buchalter GM, Moulthop HM. Endoscopic
repair of isolated anterior frontal sinus fractures. Arch
Facial Plast Surg. 2003;5:514–521.
21. Mensink G, Zweers A, van Merkesteyn JP. Endoscop-
ically assisted reduction of anterior table frontal sinus
fractures. J Craniomaxillofac Surg. 2009;37:225–228.
22. Strong EB. Frontal sinus fractures: current concepts.
Craniomaxillofac Trauma Reconstr. 2009;2:161–
175.
23. Pham AM, Strong EB. Endoscopic management of
facial fractures. Curr Opin Otolaryngol Head Neck
Surg. 2006;14:234–241.
24. Strong EB. Frontal sinus fractures. Oper Techn Oto-
laryngol Head Neck Surg. 2008;19:151–160.
25. Chaaban MR, Conger BT, Riley K, Woodworth BA.
Transnasal endoscopic repair of posterior table frac-
tures. Otolaryngol Head Neck Surg. 2012;147:1142–
1147.
26. Conger BT, Riley KO, Woodworth BW. The Draf
III mucosal grafting technique: a prospective study.
Otolaryngol Head Neck Surg. 2010;146:664–668.
27. Illing E, Chaaban MR, Riley KO, Woodworth BA.
Porcine small intestine submucosal graft for endo-
scopic skull base reconstruction. Int Forum Allergy
Rhinol. 2013;3:928–932.
28. Virgin F, Baranano CF, Riley K, Woodworth BA.
Frontal sinus skull base defect repair using the pedi-
cled nasoseptal flap. Otolaryngol Head Neck Surg.
2011;145:338–340.
29. Illing EA, Cho Do Y, Riley KO, Woodworth BA.
Draf III mucosal graft technique: long-term results. Int
Forum Allergy Rhinol. 2016;6:514–517.
30. Bernal-Sprekelson M, Alobid I, Mullol J, Trobat F,
Tomas-Barberan M. Closure of cerebrospinal fluid
leaks prevents ascending bacterial meningitis. Rhinol-
ogy. 2005;43:277–281.
31. Bernal-Sprekelson M, Bleda-Vazquez C, Carrau RL.
Ascending meningitis secondray to traumatic cere-
brospinal fluid leaks. Am J Rhinol. 2000;14:257–259.
32. Manolidis S. Frontal sinus injuries: associated injuries
and surgical management of 93 patients. J Oral Max-
illofac Surg. 2004;62:882–891.
33. Sataloff RT, Sariego J, Myers DL, Richter HJ. Surgi-
cal management of the frontal sinus. Neurosurgery.
1984;15:593–596.
34. Gossman DG, Archer SM, Arosarena O. Management
of frontal sinus fractures: a review of 96 cases. Laryn-
goscope. 2006;116:1357–1362.
35. Kountakis SE, Önerci TM, eds. Rhinologic and
Sleep Apnea Surgical Techniques. Berlin: Springer;
2007:149–158.
36. Adelson RT, Wei C, Palmer JN. Frontal sinus frac-
tures. In: Palmer JN, Chiu AG, Adappa ND, eds.
Atlas of Endoscopic and Sinonasal Skull Base Surgery.
Philadelphia: Elsevier; 2013:337–356.
37. Dolan RW. Facial Plastic, Reconstructive, and
Trauma Surgery. New York: Marcel Dekker; 2004:
549–596.
38. Poetker DM, Smith TL. Endoscopic treatment of
the frontal sinus outflow tract in frontal sinus
trauma. Oper Techn Otolaryngol Head Neck Surg.
2006;17:66–72.
39. Steiger JD, Chiu AG, Francis DO, Palmer JN.
Endoscopic-assisted reduction of anterior table frontal
sinus fractures. Laryngoscope. 2006;116:1936–
1939.
40. Koudstaal MJ, van der Wal KG, Bijvoet HW, Vincent
AJ, Poublon RM. Post-trauma mucocele formation in
the frontal sinus; a rationale of follow-up. Int J Oral
Maxillofac Surg. 2004;33:751–764.
41. Woodworth BA, Schlosser RJ, Palmer JN. Endo-
scopic repair of frontal sinus cerebrospinal fluid leaks.
J Laryngol Otol. 2005;119:709–713.
42. Jones V, Virgin F, Riley K, Woodworth BA. Chang-
ing paradigms in frontal sinus cerebrospinal fluid
leak repair. Int Forum Allergy Rhinol. 2012;2:227–
232.
43. Archer JB, Sun H, Bonney PA, et al. Extensive trau-
matic anterior skull base fractures with cerebrospinal
fluid leak: classification and repair techniques us-
ing combined vascularlized tissue flaps. J Neurosurg.
2016;124:647–656.
44. Gerbino G, Roccia F, Benech A, Caldarelli C. Analysis
of 158 frontal sinus fractures: current surgical man-
agement and complications. J Craniomaxillofac Surg.
2000;28:133–139.
45. Chen KT, Chen CT, Mardini S, Tsay PK, Chen YR.
Frontal sinus fractures: a treatment algorithm and as-
sessment of outcomes based on 78 clinical cases. Plast
Reconstr Surg. 2006;118:457–468.
46. Pollock RA, Hill JL Jr, Davenport DL, Snow DC, Vas-
conez HC. Cranialization in a cohort of 154 consecu-
tive patients with frontal sinus fractures (1987-2007):
review and update of a compelling procedure in the
selected patient. Ann Plast Surg. 2013;71:54–59.
47. Wilson BC, Davidson B, Corey JP, Haydon RC.
Comparison of complications following frontal sinus
fractures managed with exploration with or without
obliteration over 10 years. Laryngoscope.
1988;98:516–520.
48. Conger BT, Illing E, Bush B, Woodworth BA.
Management of lateral frontal sinus pathology in
the endoscopic era. Otolaryngol Head Neck Surg.
2014;15:159–163.
49. Thaller S, McDonald WS, Facial trauma. Boca Raton,
FL: CRC Press; 2004:289–330.
50. Wallis A, Donald PJ. Frontal sinus fractures: a review
of 72 cases. Laryngoscope. 1988;98:593–598.

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