Management of frontal sinus fractures: a comprehensive review and treatment algorithm from Sapienza university of Rome

Frontal sinus (FS) fractures are uncommon and depending on the impact's force the fracture may involve the anterior table, the adjacent skull, the posterior table and the frontal sinus outflow tract (FSOT). The treatment is based on correcting anti-aesthetic alteration, avoiding the complications, protecting intracranial structures and treating cerebrospinal fluid (CSF) leak. However, the indication and type of treatment of FS fractures is still controversial. The purpose of this study is to evaluate and to propose a surgical algorithm for FS fractures treatment based on relevant data found in current literature. A comprehensive Literature review on FS fractures management was performed to define the most used treatment approaches. In this review, we sought in the Medical Literature for patterns that describe injuries of the FS and evaluated the quality of the classification schemes in terms of validity and reliability, severity assessment, treatment guidance and prognosis estimation. We identified 705 articles on the topic and after the screening process, we included 4 documents. In this 4 papers, the four most used classifications in the modern Literature were proposed. Therefore, we analyzed and discussed these main four classifications and, consequentially, we developed an algorithm that represents an attempt to provide a general guideline for the management of FS injuries. Here an intuitive multidisciplinary algorithm based on both radiological and clinical presentation of the fracture is proposed, trying to guide the surgeon in the correct treatment choice. We believe that a complete classification system must take into account not only the different involvement between anterior and posterior table fractures, but also the involvement of the FSOT and define for each type a therapeutic combined approach between neurosurgeons and maxillofacial surgeons.