Blunt trauma to the frontal bone may result in a depressed frontal sinus fracture. Often, there is an associated laceration. Isolated frontal fractures normally do not have the associated features of massive blunt facial trauma such as seen in LeFort II and III fractures. Careful nasal speculum examination may reveal blood or CSF leak high in the nasal cavity. Posterior table involvement can lead to mucopyocele or epidural empyema as late sequelae. Involvement of the posterior wall of the frontal sinus may occur and result in intracranial injury or dural tear. Frontal fractures may be part of a complex of facial fractures, as seen in frontonasoethmoid fractures, but generally more extensive facial trauma is required.
Frontal Laceration. Any laceration over the frontal sinuses should be explored to rule out a fracture. This laceration was found to have an associated frontal fracture. (Photo contributor: David W. Munter, MD.)
Management and Disposition
Obtain head CT with bone windows on patients suspected of frontal sinus fractures. Fractures involving only the anterior table of the frontal sinus can be treated conservatively with referral to otolaryngology (ENT) or plastic surgery in 1 to 2 days. Fractures involving the posterior table require urgent neurosurgical consultation. Treat frontal sinus fractures with broad-spectrum antibiotics against both skin and sinus flora. ED management also includes control of epistaxis, application of ice packs, and analgesia.
Explore every frontal laceration digitally before repair. Digital palpation is sensitive for identifying frontal fractures, although false positives from lacerations extending through the periosteum can occur.
Communication of irrigating solutions with the nose or mouth indicates a breach in the frontal sinus.
A head CT scan is needed to assess the integrity of the posterior sinus wall and intracranial injury.
Frontal Sinus Fracture. Fracture defect seen at the base of a laceration over the frontal sinus. (Photo contributor: Jeffrey Kuhn, MD.)
Frontal Sinus Fracture. Fracture of the outer table of the frontal sinus is seen under this forehead laceration. (Photo contributor: Lawrence B. Stack, MD.)
Frontal Sinus Fracture. CT of the patient in Fig. 1.8 demonstrating a fracture of the anterior table of the frontal sinus. (Photo contributor: David W. Munter, MD.)
Video 01-01: Relative Afferent Pupillary Defect (rAPD)
An rAPD seen in the left pupil in a patient with a left retroorbital hematoma after traumatic head injury.