An Endonasal Incision Adds a Second Vector of Manipulation During Percutaneous Reduction of Fractures Involving the Frontonasal Region

Abstract

Study Design: A case report. Objective: To describe a modification of percutaneous reduction of frontal sinus and/or naso-orbito-ethmoid (NOE) fractures, adding an endonasal intercartilaginous incision to provide a second vector of manipulation. Methods: Case report with particular attention paid to surgical technique, followed by a brief review of relevant literature. Results: Technique: A Carroll-Girard screw is used to engage the thickest part of the anterior wall of the frontal bone through a stab incision just superior to the frontonasal junction. An endonasal intercartilaginous incision is then made and a Cottle elevator is introduced to manipulate the fracture from the inferior aspect of the frontonasal junction. The percutaneous screw and the endonasal elevator provide perpendicular vectors for manipulation, thereby improving ability to reduce fractures when percutaneous traction alone is not successful. The technique is described here in a patient with anterior table frontal sinus fractures combined with posteriorly displaced Markowitz type 1 NOE fractures. Conclusion: While percutaneous reduction of frontal sinus fractures has been previously described, this report adds a subtle but important modification both in indication and technique for optimizing reduction while maintaining surgical simplicity and minimizing morbidity.

Introduction

Frontal sinus fractures account for about 5-15% of maxillofacial injuries, with isolated anterior table defects making up about one third of those.[1] Naso-orbito-ethmoid (NOE) fractures account for approximately 5% of maxillofacial injuries.[2] Functional deficits are typically not present, but the contour defect can be quite obvious and distressing. Restoring premorbid form and function while minimizing surgical morbidity is the goal of repairing these injuries. The traditional coronal approach[3] to repairing these fractures provides excellent access but carries the very real risks of bleeding, scarring, alopecia, temporal wasting, and facial nerve weakness.[4] Success in treatment of NOE fractures is often described in terms of the reestablishment of the appropriate mediolateral dimension, specifically the intercanthal distance. However, NOE fractures may be displaced in a posterior direction as well, either alone or in combination with frontal sinus fractures.

A critical focus in repairing both these fracture patterns is creating a pleasing contour of the forehead and its transition to the nasofrontal angle, thus influencing the appearance of the nasal root.[5] In this article, we present a modification to the percutaneous technique using a Carroll-Girard screw in the frontal bone, adding an endonasal incision. This is followed by a review of relevant literature.

Methods

This is a case report with particular attention paid to surgical indications and technique. Informed consent was obtained from the patient regarding both surgery and publication of the case report to describe the technique utilized. Our protocol was submitted to our institutional review board and found to be exempt from formal review.

History

The study patient is a 19-year-old male who was referred for management of a direct blow to the frontonasal region by a batted softball. He sustained a posteriorly displaced injury of the anterior table of the frontal sinus, thereby depressing the frontonasal junction. He also had a nondisplaced fracture of the posterior table of the frontal sinus that did not require treatment, a Markowitz type 1 injury to the NOE complex[6] with posterior displacement bilaterally and lateral displacement on the left side, and multiple nasal bone/septum fractures. He was seen for a consultation 9 days after the injury, at which time his exam was notable for marked flattening of his nasal bridge, loss of projection at the nasal root with indentation of the frontonasal region, mild telecanthus primarily involving the left side, and nasal obstruction. His clinical photos are shown in Figure 1 and selected images from his maxillofacial computed tomography (CT) scan in Figure 2.

He was given the options of traditional management (coronal approach), minimally invasive management (percutaneous and endonasal approaches), or observation without immediate treatment. He chose the minimally invasive management, knowing that his telecanthus could not be predictably addressed using this method. He was scheduled for surgery 2 days later.

Percutaneous Use of a Carroll-Girard Screw in Combination With an Endonasal Intercartilaginous Incision

Indications

Indications for treatment of frontal sinus fractures include functional and esthetic considerations. The functional concerns are related to obstruction of outflow of the sinus through the nasofrontal duct/recess or cerebrospinal fluid (CSF) leak concerns related to posterior table fractures. The esthetic concerns are related to the contour of the forehead and root of the nose. Percutaneous reduction of anterior table frontal sinus fractures has been described in multiple series[7,8,9] and appears quite reliable in most cases. Particularly when the frontal sinus fracture is combined with a posteriorly displaced NOE fracture, the technique described in the current article may be most useful. Contraindication for its use would be if either CSF or outflow tract obstruction necessitates open treatment of the frontal sinus with obliteration or cranialization of the sinus, which should be expected in less than half of patients requiring surgery for frontal sinus fractures.[10]

Technique

Our study patient was taken to the operating room and placed under a general anesthetic with orotracheal intubation. A Carroll-Girard screw was placed through a stab incision just superior to the frontonasal junction to engage the anterior table of the frontal sinus. The area with the thickest bone was chosen to allow optimal control of the fractured segment. Tractional force was applied, but this was not adequate to reduce the fractures. An endonasal intercartilaginous incision was then made and supraperichondrial dissection was taken superiorly along the upper lateral cartilage with a Cottle elevator until the nasal bones were reached. At this time, the dissection was transitioned to a subperiosteal plane to reach the frontonasal junction. The inferior aspect of the fracture was manipulated with the elevator while simultaneously holding anterior and superior tractional force with the Carroll-Girard screw until a satisfactory contour of the forehead and nasofrontal junction was achieved. No internal fixation was applied. Intraoperative and immediate postreduction views are shown in Figure 3. The nasal septal deformity was treated in standard fashion with septoplasty, followed by stabilization with Doyle splints and a thermoplastic external splint. His 9-week postoperative outcome is shown in Figure 4, with successful restoration of physiologic contours of the forehead and nose. He now has unobstructed nasal breathing and no diplopia, although his left-sided mild telecanthus remains.

Discussion

This article is a case report describing the use of an endonasal incision to add a second vector of manipulation in percutaneous reduction of fractures involving the frontonasal region. The fractures treated may involve anterior table of the frontal sinus, the NOE complex, or both. This technique is effective in addressing anteroposterior defects often seen in blunt injuries to the forehead and nose.

Various approaches and treatment algorithms to frontal sinus fractures have been described in the literature. Bell et al[10] helped reject the controversial belief that all fractured frontal sinuses needed to be surgically rendered nonfunctional. Techniques using endoscopes have been described by authors including Strong and Kellman[11] and Steiger et al,[12] which aim to maximize the ratio of visualization to morbidity. Jin et al[8] demonstrated how using small incisions with bony trephinations provided better traction compared to the endoscopic approaches with shorter operation times and minimal scarring.

Other minimally invasive approaches that have been described include percutaneous screws with external fixation[13] and transcutaneous reduction with a periosteal elevator.[9] The use of an external screw handle (such as the Carroll-Girard screw) for reduction of the frontal sinus has previously been described by Yoo et al.[7] They were able to obtain adequate reduction on all the patients in their series of 13 cases, but they do not specifically address what to do if this technique is not successful with tractional force alone.

Our method adds an additional vector for reduction of fracture segments through an intranasal intercartilaginous approach. Surgeons treating maxillofacial injuries have varying degrees of comfort and experience with endonasal incisions. While basic steps can be found in surgical atlases, the current authors prefer the technique of pinching the lower lateral cartilage between the thumb (endonasal) and index finger (extranasal). While pushing superomedially with this grip, the thumb contacts the inferior aspect of the upper lateral cartilage, which is then visualized and marked (Figure 5). The incision is then made and the upper lateral cartilage located. Dissection can proceed superiorly in a supraperichondrial or subperichondrial plane. We prefer the supraperichondrial plane to maintain blood supply to the cartilage, and oxymetazoline pledgets help minimize bleeding. The transition to the subperiosteal plane is not difficult typically because of the periosteal disruption from the fracture. We advocate for the use of the intercartilaginous incision over other endonasal incisions because of its easy access to the nasal dorsum without changes to the domes, tip, or columella.

We believe this is the first description of this maneuver in the literature, providing two perpendicular vectors for reduction at the frontonasal junction, applicable to anterior table frontal sinus fractures, Markowitz type 1 NOE fractures with posterior displacement, or a combination of the two. This may prove advantageous when fractures are older or when geometry prevents reduction in a single vector. As seen in this case, limitations to the technique are the inability to address the horizontal component of the NOE fracture and inability to fixate the fractures. These were deemed acceptable in this case, still allowing for a meaningful improvement in this patient’s facial contour. The short operating time, predictable outcome, and minimization of complications make this an attractive technique to be considered by maxillofacial trauma surgeons when tractional force with the Carroll-Girard screw alone is not sufficient for reduction.