CASE The Journal of TRAUMA威 Injury, Infection, and Critical Care

REPORT

Endoscopically Assisted Repair of Frontal Sinus Fracture

Da-Jeng Chen, MD, Chien-Tzung Chen, MD, Yu-Ray Chen, MD, and Guan-Ming Feng, MD

Background: Classic approaches to
frontal sinus fracture involve bicoronal or
direct forehead incisions. However, these
incisions cause paresthesia, scarring, and
even alopecia. In the field of plastic and
reconstructive surgery, endoscopically as-
sisted surgery is now widely accepted,
particularly for esthetic surgery. It also is
applied for the management of midface
and lower-face fractures, but rarely for
treatment of the frontal area. The authors
present their experience with the repair of
frontal sinus fractures using the endoscop-
ically assisted method.
Methods: The surgery was per-
formed with the patients under general
anesthesia. Two slit incisions were placed
in the hair-bearing area, through which a
4-mm 30° endoscope was inserted. The
subperiosteal dissection was performed
toward the fracture site using an endo-
scopic periosteal elevator. The depressed
fracture segments of the anterior table of
the frontal sinus were reduced and fixed
with microplates to restore the contour of
the forehead. Seven consecutive patients
received endoscopic correction of frontal
sinus depressed fractures.
Results: No patients required con-
version conventional bicoronal incisions.
Good anatomic reduction of the fracture
sites, acceptable surgical scar, and esthetic
recontour were obtained in all the pa-
tients. The postoperative course was un-
eventful, without any complications.
Conclusion: The endoscopically as-
sisted method allows feasible reduction
and fixation of a frontal sinus fracture. It
avoids the complications of traditional
methods and yields improved convales-
cence and esthetic results. It also helps in
the diagnosis of unsuspected cerebrospi-
nal fluid leaks. Thus, for anterior table
fractures with an intact nasofrontal duct,
endoscopically assisted surgery provides
an alternative option of treatment.
Key Words: Endoscopically assisted
surgery, Frontal sinus fracture.
J Trauma. 2003;55:378 –382.

A
s a result of improvements in endoscopic instruments
and techniques, endoscopically assisted surgery has be-
come more popular in recent years. It provides not only
superior visualization with a less invasive approach, but also
a good aesthetic result with less scarring and a more rapid
convalescence. Although commonly used in general, tho-
racic, and gynecologic surgery, it recently has been used in
plastic surgery, including that performed for forehead and
face lift,1,2 breast reconstruction,3 rhinoplasty,4 carpal tunnel
release,5 free flap harvesting,6 and even reconstruction of
facial fractures.7 In the repair of facial fractures, the endo-
scopically assisted method is applied most often to the mid-
face and lower face for zygomatic, orbital, and subcondylar
fractures,8 –12 but seldom to the forehead area.13–15
The traditional treatments for frontal sinus fractures in-
clude bicoronal incisions, eyebrow incisions, or even direct
forehead incisions. Unfortunately, these methods may in-
volve some complications. To minimize scarring, an endo-
scopically assisted method was developed to achieve the
same purpose. The authors present their experience with the
repair of frontal sinus fractures using an endoscopically as-
Copyright © 2003 by Lippincott Williams & Wilkins, Inc.
From the Department of Trauma and Emergency Surgery (D-J.C.,
C-T.C.), the Craniofacial Center, Department of Plastic and Reconstruction
Surgery (Y-R.C.), Chang Gung Memorial Hospital and Chang Gung Uni-
versity, Taipei, Taiwan, and the Division of Plastic Surgery, Army Force
KuoHsiung General Hospital, Taiwan (G-M.F.).
Address for reprints: Chien-Tzung Chen, MD, Department of Trauma
and Emergency Surgery, Chang Gung Memorial Hospital, Taipei, Taiwan;
5, Fu-Shing Street, Kuei-Shan, Taoyuan 333, Taiwan; email:
ctchenap@adm.cgmh.com.tw.
DOI: 10.1097/01.TA.0000083333.93868.AB
sisted method and discuss the role of endoscopy in the man-
agement of frontal sinus fracture.
MATERIALS AND METHODS
From June of 1999 to February of 2001, seven patients
with displaced anterior table fractures of the frontal sinus
were selected for repair using the endoscopically assisted
technique in the Trauma Center of Chang Gang Memorial
Hospital (Table 1). All these patients were men whose aver-
age age was 29 years (range, 20 –57 years). The mechanisms
of injury were either a motorcycle accident (n ⫽ 5) or an
assault (n ⫽ 2).
Physical examination found that six of the men had
obvious forehead depressions and three had paraesthesia of
supraorbital or infraorbital nerves. Malocclusion resulting
from LeFort fracture was found in two of the men. All the
men underwent a preoperative facial skeleton computed to-
mography (CT) scan examination, which showed anterior
table simple depressed or comminuted (⬎3 fracture seg-
ments) fractures. Six of the men had associated facial frac-
tures including nasal bone fractures (n ⫽ 4), orbital wall
fractures (n ⫽ 4), LeFort fractures (n ⫽ 2), and anterior
maxillary wall fractures (n ⫽ 1). No nasofrontal duct injuries
or posterior table comminuted fractures were found. If the
patient had involvement of the nasofrontal duct, displaced
posterior table fractures with cerebrospinal fluid (CSF) leak-
age, or extensive frontoparietal depressed fractures, the en-
doscopically assisted method was not considered. The other
associated injuries included neurosurgical (n ⫽ 4), extremity
(n ⫽ 4), ocular (n ⫽ 2), and trunk (n ⫽ 1) injuries. In the
patients whose injuries had resulted from road traffic acci-

378 August 2003

 Frontal Sinus Fracture

dents, more comminuted facial fractures and associated inju-

Follow-up Period
ries were found (Table 1).
(months)
All the patients with neurosurgical problems accepted
15

20
16
28

23

4
7
conservative treatment and intensive monitoring of the coma
scale. No patients needed emergent neurosurgical interven-
tion. After the general condition of the patient had stabilized

fx, fracture; CT, computed tomography; MCA, motorcycle accident; SAH, subarachnoid hemorrhage; EDH, epidural hemorrhage; SDH, subdural hemorrhage
and swelling of the soft tissue of the frontal area had receded,
reduction

reduction
reduction
reduction

Adequate reduction

Adequate reduction
Adequate reduction
Postoperative CT

the facial fractures were approached. The frontal sinus frac-

Examination

tures and associated facial fractures, if present, were managed

in the same operation, during which the buccogingival, sub-
Adequate

Adequate
Adequate
Adequate

ciliary incisions, or both were used to approach midfacial

fractures. After surgery, five patients were discharged un-
eventfully within 4 days, and the others were hospitalized
Right orbital floor blowout

longer because of other associated injuries. All the patients

were followed up regularly in the outpatient clinic after dis-
Medial orbital wall fx
Nasal bone, LeFort I

Nasal bone, LeFort I

Facial Fracture

Maxilla, orbital roof

Associated

charge. The outcome was assessed in terms of patient satis-

Right orbital floor

faction, esthetic improvement, complications, and adequacy

Nasal bone

Nasal bone

of fracture reduction.

Surgical Techniques
Under general anesthesia, the patients were placed in the
supine position. Two 2-cm longitudinal incisions were made
Left 5th metacarpal bone fx

Bilateral ocular blunt injury

Left femoral, tibia–fibula fx

behind the anterior hairline: the one over the midline of the
Liver laceration, ribs fx
Left lower leg avulsion

scalp and the other on the injury site. The incisions were
Right leg laceration
Associated

Ocular blunt injury

deepened into the subperiosteal layer. A regular periosteal

Right hemothorax
Injury

Brain contusion

elevator was inserted first to create an optical cavity. Then a

4-mm 30° endoscope (Karl Stors, Germany) was introduced
EDH, SDH

through the midline incision to assist the subperiosteal dis-

section. The endoscopic dissector and scissors were inserted
SAH

SAH

through the other port for further downward subperiosteal

dissection to approach the fracture site. The boundary of the
Time of Repair

frontal sinus fracture was clearly defined under the control of

(days)

7
23
7

18

6
25

the endoscope (Fig. 1A and B). A stab incision was made just
above the fracture sites, through which a small elevator was
inserted to facilitate reduction of the fracture fragments. After
Right side, simple depressed

the depressed bony fragments had been reduced, they were

Left side, simple depressed

removed through the scalp wound by an endoscopic grasper

Right side, comminuted

Right side, comminuted

Location/Severity of

Left side, comminuted

Left side, comminuted

Left side, comminuted

and used as free grafts. These fragments were assembled and

Frontal Sinus fx

fixed with microplates (Leibinger) on the side table (Fig. 1C).

The contused mucosa of the frontal sinus was stripped off,
and the nasofrontal duct was examined under endoscope
visualization. After this, the fragments with microplates were
reinserted through the scalp wound and fixed to the intact,
stable frontal bone with microscrews percutaneously (Fig.
1D). The stability of the plate fixations and the contour of the
Mechanism

reduced frontal bone could be checked under direct endo-

Assault
Assault

scopic vision (Fig. 1E). After irrigation of the wound and

Table 1 Patients’ Data

MCA

MCA

MCA

MCA
MCA

checking of the bleeder under endoscopic visualization, the

wounds were closed in two layers without any drainage.
Gender

Postoperative facial bone CT examination was performed to

M

M
M
M

M
M

confirm the adequacy of the fracture reduction (Fig. 1F).

Age

24

20
36
57

25

23
20

RESULTS
Case

None of the patients needed to undergo conversion to

No.

2
3
4

6
7

traditional incision techniques. The follow-up period for

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 The Journal of TRAUMA威 Injury, Infection, and Critical Care

Fig. 1. (A) Preoperative computed tomography (CT) showing right frontal bone depressed fractures with central depression (arrow). (B)
Endoscopic view showing depressed fractures (arrow) of the right frontal bone corresponding to the preoperative CT finding. Arrowhead:
superior orbital rim. Upper part of the figure: periosteum and soft tissue. (C) Two bony fragments removed and fixed with microplates on
the side table. (D) Operative schema illustrating fracture fragments fixed to the stable frontal bone with a percutaneous microscrew under
endoscopic visualization. (E) Endoscopic view showing the depressed bony fragments well reduced and fixed with microplates. (F)
Postoperative CT showing adequate reduction of the fracture site.

these patients ranged from 4 to 28 months (average, 16
months). Two patients had transient anterior scalp numbness,
but recovered within 1 month. Permanent scalp numbness,
wound infection, apparent incisional alopecia, and temporal
hollowing were not observed in these patients. To date, there
have been no complications of mucocele or mucopyocele. All
the patients are satisfied with the healing of their incisions
and their forehead contour. The postoperative CT examina-
tion confirmed adequate anatomic reduction of the frontal
sinus fractures in all the patients.
CASE REPORT
Case 3
A 36-year-old man sustained an assault injury directly to
his right frontal area. He did not pay too much attention to it
because of frontal swelling. After the swelling had subsided
3 weeks later, he found a depressed deformity over his right
frontal area (Fig. 2A). The preoperative CT examination
showed right anterior table fractures of the frontal sinus, an
intact nasofrontal duct, and right orbital medial wall fractures
(Fig. 2B).
Surgery was performed using the endoscopically assisted
method. The frontal sinus fractures were corrected under
endoscopic control and fixed with a microplate using hairline
incisions. The orbital medial wall fractures also were repaired
through a medial transconjunctival incision with the aid of a
2.7-mm, 0° endoscope. At 6 weeks after the surgery, the right
previously depressed frontal area and the orbital medial wall
were well recontoured (Fig. 2C). The follow-up CT exami-
nation showed complete anatomic reduction of the fracture
sites and bone healing (Fig. 2D). No evidence of mucocele or
mucopyocele was found 28 months later.
DISCUSSION
The incidence of frontal sinus fractures is approximately
5% to 12% of all maxillofacial fractures.16 Most of these
fractures are caused by high-velocity injuries and usually
involve associated facial and neurosurgical injuries. The ap-
propriate management for a frontal sinus fracture is a matter
of debate, but most surgeons agree that surgical operative
exploration is necessary for anterior table displacement with
esthetic forehead deformity, nasofrontal duct involvement or
obstruction, and displacement of posterior table with dura
tear and CSF leakage.16 –18 Conventional approaches for fron-
tal sinus fractures include transverse forehead and vertical
corrugator crease incisions directly through a laceration
wound, bilateral brow– glabella or butterfly incision, and bi-
coronal incision.
The approach depends on the type (closed or open) or
severity of the fractures.16 The former three methods involve
obvious unsightly scars and a high risk of injury to the
neurovascular bundle of the forehead region. The bicoronal

380 August 2003

 Frontal Sinus Fracture

Fig. 2. (A) Adult male patient with depressed deformity (arrowhead) over the right frontal area caused by assault injury. (B) Preoperative
computed tomography (CT) showing right frontal anterior table simple depressed fractures. (C) Postoperative frontal view showing good
contour of the right forehead. (D) Postoperative CT scan showing well-reduced frontal fracture.

approach, with its well-hidden incision and excellent expo-
sure to the fracture site, has become a standard method for
frontal sinus fracture repair. Although bicoronal incision is a
widely accepted method of approach to the frontal sinus
fracture, it has some disadvantages including a long scalp
scar, alopecia, scalp paraesthesia, increased blood loss, and
temporal hollowing caused by extensive surgical dissection.
These disadvantages have drawbacks for patients with simple
forehead depressed fractures.
With the endoscopically assisted method, only two small
incisions are required to achieve the same results as bicoronal
incision gives. This method provides magnified direct visu-
alization, avoidance of neurovascular injury, minimal tissue
manipulation, and superior esthetic outcome, especially for

Volume 55 • Number 2 381

 The Journal of TRAUMA威 Injury, Infection, and Critical Care
bald patients. This approach also can help clinicians assess
for CSF leaks in otherwise unsuspected patients. With this
minimal invasive method, patients may have a short hospital
stay because of the smaller incision and better convalescence.
In the forehead region, endoscopically assisted surgery
has been applied for facial rejuvenation, tumor excision, and
even bony recontouring. The endoscopically assisted method
was first used for frontal sinus fractures by Graham and
Spring13 in 1996. These authors performed fracture reduction
only without internal fixation, but this was not stable enough
in cases of comminuted fractures. The report of Onishi et al.14
described the in situ reduction of a large displaced fragment
by attaching it to a microscrew and stabilizing it with a
microplate. However, adequate reduction could not be
achieved for the rest of the small or comminuted fragments.
In contrast, the current authors removed the bony fragments
as free grafts and fixed them at the side table. This method
was similar to the open approach and facilitated the operative
procedure.
Nevertheless, not all the frontal sinus fractures are suit-
able for this method. Displaced posterior table fracture with
evidence of dura tear, associated orbital roof blow-in fracture,
and extensive skull bone fractures are not appropriate for
endoscopically assisted surgery. In these situations, repair of
dura and reduction of impacted cranial fracture by craniot-
omy and even cranialization require more complicated pro-
cedures, which are better provided by conventional bicoronal
incision. Thus, preoperative evaluation is important for se-
lection of the treatment method. In the authors’ experience,
the best candidate for the endoscopically assisted method has
been the obvious anterior table fracture of the frontal sinus
with an intact nasofrontal duct.
For endoscopically assisted surgery, several limiting fac-
tors are encountered including more complicated fracture
reduction and plate fixation and a steep learning curve for the
endoscopic skills. If the surgeon has experience with endo-
brow lifting surgery, the operative time will be shorter than
for those who have no experience with endoscopic surgery.
Besides, the operative time is shorter than for the conven-
tional bicoronal method because of the limited incision re-
quired for endoscopic surgery.
CONCLUSION
The endoscopically assisted techniques are reliable for
frontal sinus fractures. They can avoid bicoronal or direct
382
forehead incisions, resulting in better and quicker postoper-
ative recovery, shorter hospitalization, and better esthetic
results. Widening scalp scar, alopecia, increasing blood loss,
scalp numbness, and temporal hollowing resulting from con-
ventional bicoronal approach can be prevented. This proce-
dure remains a viable alternative for the repair of anterior
table fractures of the frontal sinus that do not involve the
nasofrontal ducts.
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