Early combined management of frontal sinus and orbital and facial fractures.

BACKGROUND: Historically, frontal sinus fractures and associated maxillofacial fractures were addressed at different times. We retrospectively reviewed our experience with a series of 79 consecutive patients with bitable frontal sinus fractures, most with associated facial fractures, who underwent early combined cranial and maxillofacial procedures.

METHODS: The operations were performed emergently for patients with open or depressed skull fractures and hematomas with mass effect, and electively within 2 weeks for those with closed fractures. The cranial procedures were performed first. The nasofrontal ducts were packed with "cigars" of bacitracin powder wrapped in Surgicel. All patients received antibiotics for 2 weeks.

RESULTS: Postoperatively, good subjective cosmetic results were obtained except in one patient. Eight patients with lumbar drains had expected temporary cerebrospinal fluid (CSF) leaks of less than 72 hours duration. Six postoperative intracranial infections (four cases of meningitis, one epidural empyema, and one intracerebral abscess) were detected; five of these occurred in patients with open depressed fractures. Patients with preoperative CSF leaks (p = 0.0039, Fisher's exact test) and open fractures (p = 0.065, Fisher's exact test) were more likely to develop intracranial infections.

CONCLUSION: The combined neurosurgical and maxillofacial repairs achieved good cosmetic outcomes, with relatively low morbidity. By combining the two-stage procedure into one stage, standard surgical and anesthetic risks could potentially be reduced. Preoperative CSF leaks and open fractures were associated with a higher incidence of postoperative central nervous system infection. Early operations did not appear to be associated with a higher complication rate.