Letters to the Editor
To the Editor:
Frontal sinus fractures represent 2% to 12% of facial trauma,1 and most frontal sinus fractures are sustained by young male adults involved in vehicle accidents.2 Devastating complications of frontal sinus fractures such as meningitis, encephalitis, or brain abscess are quite uncommon and potentially avoidable.2 A 36-year-old man, 1 month back, sustained internally compound right frontal sinus fracture in a road traffic accident (Fig. 1). He had cerebrospinal fluid leak from the nose intermittently. For these complaints, he was managed conservatively at many remote rural peripheral health centers. Now, he presented with high-grade fever and altered sensorium of 1-day duration. At the time of admission, the patient was febrile (103°F); pulse rate was 98/min. There was no active cerebrospinal fluid rhinorrhea. Neurologically, his Glasgow Coma Scale was eye-opening to pain, localizing to pain, and incomprehensible sound to pain (GCS-E1V1M4). Pupils were bilaterally equal and reacting to light. He was moving all 4 limbs equally, and there was no facial asymmetry. Urgent plain and contrast computed tomographic scan, in addition to frontal sinus fracture, also showed an abscess in the right frontal lobe with an air fluid level and diffuse cerebral edema (Fig. 2). The patient underwent bicoronal scalp flap, bifrontal craniotomy, evacuation of abscess, exteriorization of frontal sinus, and extradural repair of anterior cranial fossa base (because the brain was very tense and edematous). There was foul-smelling pus in the abscess cavity, and also, there was yellowish pus flakes in the frontal sinus cavity. The patient was started on broad-spectrum antibiotics (ceftriaxone, amikacin, and metronidazole), antiedema measures, and antiepileptics. The patient responded well to surgical drainage and antibiotics. He became conscious and oriented for the next 24 hours and was doing well at follow-up without any neurological deficits.
Because of the location of the frontal sinus and its proximity to numerous intracranial structures, inadequate treatment of frontal sinus fracture may lead to life-threatening intracranial infectious complications that can result in devastating neurological sequelae.1,3 These infective complications include recurrent frontal sinusitis, osteomyelitis, meningitis, epidural abscess, and frontal sinus abscesses.3,4 Because of frontal sinus anatomical relationship with the brain, the earliest treatment of these fractures is of paramount importance.2
In the present case, reasons to treat the fracture conservatively may include lack or unavailability of neurosurgical facilities in remote rural areas, still a major challenge in developing countries. The most important aspect of frontal sinus fracture management is to create a safe sinus as early as possible after trauma.2,3 It can be achieved by reestablishing the frontal bony contour to its premorbid state, by restoring normal sinus mucosa with a patent drainage system, by eradicating the sinus cavity if the normal mucosa or drainage system cannot be reestablished, and by creating a permanent barrier between the intracranial and extracranial systems to prevent overwhelming infectious complications.1-4 Because of its life-threatening nature, and once developed, the intracranial abscess must be managed as a medical and surgical emergency.4 As in the present case when the posterior wall is involved, there may be concomitant dural tear, and the main goal in such cases is the restoration of the dural integrity and the isolation of the intracranial contents from the outer environment.2 It is recommended that, unless anaerobes can be specifically excluded, all paranasal sinus infections failing to respond promptly or developing complications should be treated with metronidazole in addition to the normal therapeutic regimen.5 In the present case, initial inadequate management of frontal sinus fracture resulted in the development of intracranial complications. All the personnel dealing in the management of such cases, particularly in rural and remote areas of developing countries, need to be aware of these complications because early interventions will avoid such devastating consequences.
Amit Agrawal, MCh*
Sudhakar R. Joharapurkar, MS†
*Department of Surgery
and †Datta Meghe Department of
Postgraduate Medical Education and
Research Datta Meghe Institute of
Medical Sciences Sawangi (Meghe)
Wardha Maharashtra, India
1. El Khatib K, Danino A, Malka G. The frontal sinus: a culprit or a victim? A review of 40 cases. J Craniomaxillofac Surg
2. Kalavrezos N. Current trends in the management of frontal sinus fractures. Injury
3. Metzinger SE, Guerra AB, Garcia RE. Frontal sinus fractures: management guidelines. Facial Plast Surg
4. Larrabee WF Jr, Travis LW, Tabb HG. Frontal sinus fractures-their suppurative complications and surgical management. Laryngoscope
. 1980;90(11 Pt 1):1810-1813.
© 2008 Lippincott Williams & Wilkins, Inc.
5. Grace A, Drake-Lee A. Role of anaerobes in cerebral abscesses of sinus origin. Br Med J (Clin Res Ed)