Management of Upper Third Facial Fractures and Frontal Fractures

Introduction

Anatomy Relevant to Injury

• Anterior table (table): defines the forehead contour; relatively weak
• Posterior table: separates the sinus from the dura of the anterior cranial fossa; dura is tightly adherent here
• Sinus floor / nasofrontal duct (NFD): drains each sinus into the middle meatus; obstruction leads to mucocele, mucopyocele, or infection

Classification of Frontal/Upper Third Fractures

Initial Assessment and Investigations

Clinical Features

• Forehead laceration (typically overlies the fracture)
• Palpable crepitus over the sinus
• Forehead depression or contour deformity (most common = central forehead depression)
• CSF rhinorrhoea: salty nasal drainage; confirm with β2-transferrin assay — this implies posterior table involvement with dural tear until proven otherwise
• Upper eyelid hematoma (may suggest orbital roof injury with decompression of intracranial/intraorbital haemorrhage)
• Forehead hypoesthesia (supraorbital/supratrochlear nerve injury)
• Neurologic deficits

Investigations

• CT scan (non-contrast axial + coronal) is mandatory: assess anterior table, posterior table, NFD, pneumocephalus, intracranial injury
• Pneumocephalus on CT strongly suggests posterior table fracture
• Ophthalmology assessment: visual acuity, extraocular movements, globe injury (afferent pupillary defect in ~10%)
• Neurosurgical consultation for all posterior table/orbital roof fractures

Management Algorithm

STEP 1: Emergent Management

1. Airway — swelling and bleeding may obstruct; consider early intubation/cricothyrotomy/tracheostomy
2. Haemorrhage control — direct pressure, ligation, or selective embolisation (interventional radiology)
3. Intracranial injuries — neurosurgery takes precedence over facial reconstruction
4. Antibiotics: oral first-generation cephalosporins or amoxicillin-clavulanate for all sinus fractures; IV antibiotics for depressed/open fractures

STEP 2: Fracture-Specific Management

A. Anterior Table Fractures (No Posterior Table Involvement)

• Coronal incision (preferred for larger fractures or when no laceration is present) — avoids visible forehead scarring; the brow/gullwing incision is no longer favoured due to unsightly scarring and supraorbital/supratrochlear nerve injury risk
• Small fractures with overlying lacerations may be repaired through the laceration
• Repair uses small titanium plates or mesh screwed in situ to re-establish forehead contour
• Camouflage with alloplastic implant is an alternative for cosmetic deformity if reduction is not chosen; the patient and surgeon may wait to assess extent of developing deformity

B. Posterior Table Fractures

1. Sinus Obliteration
   • Approach: osteoplastic bone flap via coronal incision
   • Complete stripping of all sinus mucosa (including microscopic invaginations — bur the bone)
   • Obliterate the NFD
   • Fill sinus cavity with abdominal fat or cancellous bone graft
   • A pericranial flap (vascularized) is placed as an additional barrier between brain and the cavity — also useful for dural repair and hardware coverage
   • Caveat: meningitis and brain abscess have been reported even after "successful" obliteration
2. Endoscopic Drainage (Draf III / Modified Lothrop Procedure)
   • Increasingly preferred as an alternative to obliteration in selected cases
   • Creates a maximally widened nasofrontal communication
   • Requires confirmed dural integrity and reliable patient follow-up to monitor patency
   • Preserves sinus function while eliminating stagnant mucus
3. Cranialization
   • Reserved for severely comminuted posterior walls
   • Complete removal of the posterior table
   • The frontal sinus is incorporated into the anterior cranial fossa
   • The NFD is obliterated
   • Pericranial flap interposes between brain and frontal bone to prevent direct contact

C. Orbital Roof Fractures

• These almost always require multidisciplinary management (ENT + Neurosurgery + Ophthalmology)
• More common in children (18–35% of paediatric facial fractures vs. 3–9% of adult facial fractures)
• Pure fracture = orbital roof only, rim intact; Impure fracture = roof + rim (impure blow-in is most common)
• Intracranial injury takes precedence, followed by globe injury

• Coronal incision (primary)
• Adjunctive: upper lid crease, Lynch, infrabrow, suprabrow/gullwing incision
• Identify and protect the supraorbital and supratrochlear neurovascular bundles

D. Supraorbital Rim Fractures

• Part of the impure category; treated similarly to frontal fractures
• Displaced fractures with contour deformity: ORIF via coronal approach with titanium miniplates
• Associated with NFD injury or orbital roof disruption — manage accordingly

Timing of Surgery

Complications

Early

• CSF rhinorrhoea (dural tear, posterior table disruption)
• Pneumocephalus
• Meningitis / brain abscess
• Orbital haematoma / visual loss
• Superior orbital fissure syndrome (CN III, IV, VI, V1 compression → ptosis, proptosis, ophthalmoplegia, supraorbital anaesthesia)
• Orbital apex syndrome = superior orbital fissure syndrome + optic nerve compression → blindness (surgical emergency)

Late

• Mucocoele / mucopyocele (blocked NFD with continued mucus secretion → expanding cyst; may erode bone)
• Pott's puffy tumour (frontal osteomyelitis + subperiosteal abscess)
• Forehead contour deformity / hardware palpability
• Enophthalmos / diplopia
• Supraorbital hypoesthesia (nerve injury during surgery)
• Plate migration (especially in children with growth)

Follow-Up

• CT scan at 6 months to 1 year post-operatively to exclude mucocoele, sinus opacification, or other late complications
• Any cloudy or non-draining sinus on follow-up imaging warrants low threshold for intervention
• If Draf III drainage is performed, imaging to confirm patency is mandatory

Summary Points for Exam

1. Anterior table only → ORIF if displaced/deformed; observe if non-displaced. Coronal approach preferred. Titanium miniplates.
2. NFD obstruction → sinus obliteration (mucosa stripping + fat/bone graft) or Draf III endoscopic drainage.
3. Posterior table fracture → β2-transferrin for CSF; involve neurosurgery; explore if displaced or persistent CSF leak; cranialization for severe comminution.
4. "Safe sinus" is the goal — normal function, protected dura, no mucocoele, no meningitis.
5. Gullwing/brow incision is obsolete → coronal incision is standard.
6. Pericranial flap = key reconstructive tool (obliteration, dural repair, hardware coverage).
7. Orbital roof fractures → multidisciplinary; reconstruct (rather than reduce) comminuted fractures with bone graft or titanium mesh.
8. Mucocoele is the most dangerous late complication — can erode bone into orbit/cranium; necessitated long-term imaging follow-up.