Orbital complications following the use of bone substitutes in frontal sinus trauma

Abstract

Objectives: To explore a serious orbital complication that may result from the use of bone substitutes in the management of frontal sinus fractures. We will also review recent trends in the management of complex frontal trauma and proposed mechanisms for failure. Methods: We describe 2 cases of delayed orbital mucocele following the use of bone substitutes for frontal sinus obliteration following trauma. Results: Patient 1 had comminuted frontal sinus fractures following a motor vehicle accident and was obliterated using hydroxyappetite. Patient 2 had a complex frontal fracture following a tire explosion and was repaired with methylmethacrylate. Both patients presented years later with marked proptosis, diplopia, and pain. Patient 1 also had reduced visual acuity. In both cases, imaging studies (CT and MRI) reveled a cystic mass within the orbital cone, while the frontal sinus contained bone substitute. Patient 1 was managed by mucocele excision via an upper lid blepharoplasty incision. Patient 2 was managed by cyst marsupialization through a combined transorbital/endoscopic ethmoidectomy approach. Although visual symptoms have improved markedly in both patients, each has suffered further recurrence of the cyst. Conclusion: The use of bone substitutes in frontal sinus fracture repair may have ophthalmologic sequellae that pose significant management dilemmas. The role of these materials in the management of complex frontal sinus fractures should be revisited, particularly as advances in endoscopic technique has inspired evolution in the indications for obliteration.