Over half of all patients hospitalized with severe brain injuries and cervical spinal cord injuries following high-velocity accidents have associated facial fractures. Frontal sinus fractures are not uncommon since this structure is located in the forehead, an area at risk to direct blunt trauma. Sinus fractures complicate the care of the catastrophically injured patient both acutely and chronically. Initial treatment of fractures may simply require observation while others need urgent surgical intervention. Acute medical problems following fractures to the sinuses may include CSF leaks and acute sinusitis, which is an infection of the sinuses. Potential long-term complications include chronic sinusitis, meningitis, mucocele, and brain abscesses. Academic Physician Life Care Planners must have a trauma otolaryngologist, an ear, nose, and throat doctor, as part of their team to provide the foundation for the future care necessary for the diverse injuries to the sinuses that may result from motorcycle, bicycle, and motor vehicle accidents.

Acute CSF may occur in facial fractures and skull fractures. The clinical sign in a majority of trauma related CSF leaks is clear drainage from the nose or ear following initial trauma, but in some cases be delayed for several weeks. CSF rhinorrhea is the situation where the CSF fluid that surrounds the brain leaks through the nostrils. This is potentially a very serious problem because there is a 10% a year risk of developing a brain infection (meningitis) from bacterial seeding to the brain. Most CSF leaks heal spontaneously within 10 days of injury so operative closure generally isn’t attempted until waiting seven days when the risk of meningitis has been shown to increase. With the advent of endoscopic sinus surgery the management of CSF leaks has drastically changed for the better over the past 15 years. Historically, CSF leaks needed a major neurosurgical procedure to open the skull and fix the defect from the inside. Now most frontal sinus CSF leaks, except the most complicated, can be repaired with an endoscope by a trauma otolaryngologist. Ninety percent of facial trauma related CSF leaks that involve the sinuses are successfully repaired on the first attempt using tiny incisions coupled with an endoscope.

The treatment goals for management of frontal sinus fractures are aimed at diminishing short and long-term complications, establish a reasonable facial appearance, and provide for as normal sinus function as possible. Recommended treatments are dependent on the location of the fracture, if the fracture involves the inner or outer layer of bone that comprises the sinus cavity, and if the nasal portion of the frontal sinus is involved. Options include observation, endoscopic repair, open surgery utilizing plates, screws, and mesh, or surgical obliteration of a sinus that is deemed too injured to salvage.

Life Care Planners and Case Managers must understand that the lifetime care for management of sinus fractures vary significantly across the catastrophically injured population. Studies indicate that merely having a sinus fractures does not alone increase the risk of developing long-term complications such as chronic sinusitis, mucocele, meningitis, and brain abscess.

Therefore, a trauma otolaryngologist is a necessary component of the Academic Physician Life Care Planning team because they bring the experience and knowledge to understand patient specific factors that may predispose the injured person to complications such as chronic rhinitis and chronic sinusitis.

The trauma otolaryngologists understand the issues related to alterations in the functional anatomy caused by the fractures and specific patient characteristics that will impact future care. They bring unique insight to the team to identify patients at risk of recurrent sinusitis such as those on ventilators from spinal cord injuries and severe traumatic brain injury, and those with swallowing dysfunction and feeding tubes.

Academic Physician Life Care Plans for a patient with sinus fractures may include coned beam CT scans, MRI of the sinuses, fiberoptic evaluations, antihistamines, decongestants, nasal steroids, antibiotics, laboratory testing, and surgical procedures to the injured person’s life expectancy. Future care needs will be based not only on the trauma otolaryngologist knowledge and experience but on published studies related to cost analysis among those with various radiologic determined grades of sinusitis.

Sinusitis from fractures may have significant lifetime cost that must be accounted for by the life care plan to prevent complications and improve the psychosocial function of the injured understanding that cost not only include medical care but potentially lost days at work, and associated depression.

http://www.medicinaoral.com/medoralfree01/v12i5/medoralv12i5p397.pdf

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3052655/

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1876155/

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1876155/

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