Frontal Sinus Obliteration During Surgical Management of its Fractures. A Comparative Pilot Study of Possible Used Autogenous Grafts

Abstract Background: Frontal sinus fractures can result as sequelae of head trauma with mismanagement can lead to structural complication and serious infections sometimes with nasofrontal outflow tract obstructions, if the surgical management was decided, then it should apply control of associated CSF leakage with prevention of late frontal sinus complications, it should also provide a good correction of aesthetic deformity. Aim of Study: The aim of this study is to address the efficacy of 3 common autogenous grafts (pericranium, muscle and fat grafts), used in obliteration of frontal sinus in cases of frontal sinus fracture with CSF rhinorrhea, and assess their success rate in sealing the nasofrontal duct and cessation of CSF leak. Patients and Methods: This study was done prospectively in the Cairo University Hospitals, on patients suffering from traumatic frontal sinus fracture with CSF rhinorrhea treated surgically including 30 patients treated between July 2017 and December 2018, Patients were randomized into 3 groups each containing 10 patients according to the autogenous material used in the closure of the sinus outflow whether muscle, pericranium or fat. Results: In our series, we had 25 males, 5 females with male to female ratio 5:1. Age ranged between 19 and 45, with mean age 32 years. Mechanisms of injury was variable, Motor vehicle accident in 8 patients (27%), Motor cycle accidents 11 (37%), Fall from height 6 patients (20%), Blunt facial injuries (e.g assault) 5 (16%). Associated injuries in the form of frontal contusion in 14 cases (47%), extradural hematomas in 11 cases (37%). Nasofrontal duct fractures or obliteration was detected in (50%) of cases in the preoperative CT. None of the operated cases developed mucocele formation or delayed abscess formation, frontal bone osteomyelitis, hematomas, gross contour deformities, or fatalities. With fat graft, only one case (10%) had transient leakage for one day stopped spontaneously, while 4 (40%) out of 10 cases packed with temporalis muscle developed CSF leak that was managed conservatively, then one of them required redo surgery after late CSF recuurent leak, two cases (20%) out of 10 packed with pericranial graft developed early postoperative CSF leak stopped by conservative treatment. Conclusion: Despite the wide variation in the plugging materials usage which is mostly attributed to the surgeon preference, we found a relative advantage and superiority of fat graft as a plugging material over both muscular and pericranial grafts. Careful handling during fat graft harvest can guard against wound complications eventhough it has a separate abdominal wound. Early surgical intervention is highly recommended as it eliminates any potential sources of infection and was associated with good outcome and minimzing infection rate to the least.