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Severe Infectious Complications following Frontal Sinus Fracture: The Impact of Operative Delay and Perioperative Antibiotic Use

Bellamy, Justin L. B.S.; Molendijk, Josher B.S.; Reddy, Sashank K. M.D., Ph.D.; Flores, José M. M.P.H.; Mundinger, Gerhard S. M.D.; Manson, Paul N. M.D.; Rodriguez, Eduardo D. M.D., D.D.S.; Dorafshar, Amir H. M.B.Ch.B.

Plastic and Reconstructive Surgery: July 2013 - Volume 132 - Issue 1 - p 154–162
doi: 10.1097/PRS.0b013e3182910b9b
Pediatric/Craniofacial: Original Articles

Background: The purpose of this study was to investigate whether a delay in operative management of frontal sinus fractures is associated with increased risk of serious infections.

Methods: Retrospective chart review was performed of 242 consecutive patients with surgically managed frontal sinus fractures who presented to the R Adams Cowley Shock Trauma Center between 1996 and 2011. Collected patient characteristics included demographics, surgical management, hospital course, and complications. All computed tomographic imaging was reviewed to evaluate involvement of the posterior table and nasofrontal outflow tract. Serious infections included meningitis, encephalitis, brain abscess, frontal sinus abscess, and osteomyelitis. Delayed operative interventions were defined as procedures performed more than 48 hours after admission. Adjusted relative risk estimates were obtained using multivariable regression.

Results: There were 14 serious infections (5.8 percent). All patients with serious infections had both involvement of the posterior table and nasofrontal outflow tract injury. The cumulative incidence of serious infection in these patients was 10.8 percent. After adjustments for confounding, multivariable regression showed that operative delay beyond 48 hours was independently associated with a 4.03-fold (p < 0.05) increased risk for serious infection; external cerebrospinal fluid drainage catheter use and local soft-tissue infection conferred a 4.09-fold (p < 0.05) and 5.10-fold (p < 0.001) increased risk, respectively. Antibiotic use beyond 48 hours postoperatively was not associated with fewer infections.

Conclusions: Delay in operative management of frontal sinus fractures in patients requiring operative intervention is associated with an increased risk for serious infections. Continued antibiotic prophylaxis beyond the perioperative period provides little benefit in preventing serious infections.


Baltimore, Md.

From the Johns Hopkins School of Medicine; the Division of Plastic and Reconstructive Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine; and the Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University.

Received for publication December 24, 2012; accepted January 28, 2013.

The first two authors contributed equally to this investigation.

Disclosure:The authors have no financial interest to declare in relation to the content of this article. No external funding was received.

Presented at the 58th Annual Meeting of the Plastic Surgery Research Council, May 2, 2013, in Santa Monica, California.

Amir H. Dorafshar, M.B.Ch.B., Plastic, Reconstructive, and Maxillofacial Surgery, R Adams Cowley Shock Trauma Center, 22 South Greene Street, Room P1G04K, Baltimore, Md. 21201,

©2013American Society of Plastic Surgeons