Anterior Table Research Articles

EComment. Efforts to further enhance the safety of sternal re-opening in the paediatric age group

We thank Gandolfo et al. for their effective and easy reproducible technique for managing major vessel injuries during chest re-entry in children [1]. As diagnostic and therapeutic interventions in congenital heart diseases advance progressively, cardiac surgeons have begun to deal with chest re-opening more frequently. Although major venous damages like innominate vein can be managed by a Fogarty catheter, cardiac surgeons are still facing challenging problems, such as damage of cardiac chambers, retrosternal right ventricle to pulmonary artery conduits and ascending aortic aneurysms during the re-sternotomy procedures performed in children. In such cases, we believe that the inflation of Fogarty catheters may even enlarge the defect and make it more uncontrollable in an incomplete sternotomy. In our practice, patients with a sternotomy history are carefully evaluated before the operation. Although the best option in imaging work-up is computed tomography, its routine usage is avoided so as not to increase the exposure of ionizing radiation in the paediatric age group. In most of the patients with redo cardiac surgery, magnetic resonance angiography or lateral projection of cardiac cine-angiography studies demonstrate the potential adhesions of the anatomic structures to the posterior part of the sternum. At the operation, we regularly mark the femoral vessels with Doppler ultrasonography and prepare a cardiopulmonary bypass (CPB) set-up before initiating the incision. The skin incision is performed subsequently, the sternal wires are untwisted and an oscillating saw is used to open the anterior table of the sternum until contact with the sternal wires at the posterior side is felt. The untwisted wires are held with clamps and the sides of the sternum are pulled upwards in which a lateral retraction force is strictly avoided. Afterwards, the posterior table of the sternum is carefully opened starting with xiphoid process towards the jugular fossa with the aid of Mayo scissors. We believe hyperinflation of the lungs, which decompresses the right atrium and ventricle, is a safe and easy measure during this part of the re-entry process [2]. We neither use electrocautery nor blunt digital manipulation for the dissection of the mediastinum. As described by Holst et al. we can clinically group cardiac injuries during sternal re-entry procedures into two categories [3]. A cardiac injury in re-sternotomy is an anticipated (i.e. expected) injury when there is a conduit, an aortic aneurysm, an enlarged right atrium or ventricle which is adherent to the posterior surface of the sternum. In such cases, we prefer to initiate CPB with femoral arterial and venous cannulation before sternal re-entry. This provides us with a safer re-entry process in the mediastinum with decompressed cardiac chambers. The main disadvantage of initiating CPB at the early stage of surgery is the prolonged duration of CPB and uneasiness of controlling the haemostasis in a heparinized patient. CPB may be discontinued after the safe entry to the mediastinum and dissection may be completed off-pump in order to shorten the CPB time. In unanticipated injuries, when a massive bleeding occurs, we discontinue the re-sternotomy and join the two sides of the sternum with two towel clamps. The femoral artery and vein are then promptly cannulated before further dissection at the mediastinum after which CPB is initiated. As a result, besides meticulous surgical technique and judicious usage of CPB, we believe that simple and easily applicable precautions can decrease the incidence of cardiac injuries being encountered during sternal re-opening procedures. These precautions will obviously stipulate a prudent, safe and bloodless operative field for the surgical team. Conflict of interest: none declared.

A Novel Approach to Frontal Sinus Surgery

Access to the frontal sinus remains a challenging problem for the craniofacial surgeon. A wide array of techniques including minimally invasive endoscopic approaches have been described. Here we present our technique using medical modeling to gain fast and safe access for multiple indications. Computer-aided surgery involves several distinct phases: planning, modeling, surgery, and evaluation. Computer-aided, precise cutting guides are designed preoperatively and allowed to perfectly outline and then cut the anterior table of the frontal sinus at its junction to the surrounding frontal bone. The outcomes are evaluated by postoperative three-dimensional computed tomography scan. Eight patients sustaining frontal sinus fractures were treated with the aid of medical modeling. Three patients (37.5%) had isolated anterior table fractures, and 4 (50%) had combined anterior and posterior table fractures, whereas 1 patient (12.5%) sustained isolated posterior table fractures. Operative times were significantly shorter using the cutting guides, and fracture reduction was more precise. There was no statistically significant difference in complication rates or overall patient satisfaction. The surgical approach to the frontal sinus can be made more efficient, safe, and precise when using computer-aided medical modeling to create customized cutting guides.

Management of Frontal Sinus Fracture

One-third of frontal sinus fractures are isolated to the anterior table. Accurate reduction and stable fixation are important in the treatment of frontal sinus fracture. Traditional approaches to the reduction of an isolated anterior table fracture include the coronal incision, the bilateral brow incision, an endoscopic brow lift with an incision either directly over the fracture or in the brow, and delayed repair with a camouflaging implant. In our experience, autogenous bone graft is considered to be the best grafting material. It has the less short-term or long-term complications, and the donor site morbidity is insignificant. We describe a case involving a 45-year-old man with a depressed anterior table fracture that we successfully treated using an iliac bone graft.

Anterior table remodeling after treatment for Pott's Puffy Tumor

We report a case of near-complete remodeling of the anterior table of the frontal sinus after treatment for an erosive Pott's Puffy Tumor. A 61-year-old male presented with progressive swelling of his left forehead. Examination showed a doughy left forehead mass, and a sinus CT showed a lateral left frontal sinus mucocele with complete anterior table erosion. Frontal trephination with marsupialization of the mucocele was performed, and at 8 month follow-up, the patient had no visible defect and only minimally palpable bony defect. The anterior table had remodeled with no additional intervention resulting in a cosmetic outcome imperceptible from the patient's baseline.

Transcutaneous Reduction of Frontal Sinus Fracture Using Bony Tapper Device

Frontal sinus fractures are relatively common injuries presenting to trauma units. The optimal treatment of frontal sinus fractures remains controversial. Bicoronal approach is commonly used to obtain full exposure of both frontal bones and to repair any intracranial trauma; however, this approach requires long operative time and could lead to a long-lasting visible scar, alopecia, and paresthesias. In addition, patients have to stay in hospital for several days with this method. Endoscopic approach, less invasive than bicoronal method, has a steep learning curve. In this article, we suggest a simple reduction method in frontal sinus anterior wall fracture using the tapper instrument. Between 2005 and 2011, a transcutaneous reduction of closed anterior table frontal sinus fracture using a tapper instrument was performed in 13 patients. This group consists of 10 men and 3 women, and the mean age was 27.5 years. Under general anesthesia, the point that the tapper would be placed is marked considering the fracture site shown on computed tomographic scan and the clinically depressed area. A 3-mm slit incision was made just above the marked point. After drilling through this incision, the tapper device was applied to the depressed bone segment. Simply pulling out the tapper, the depressed frontal sinus anterior wall segment was reduced. Contour deformities were restored completely in all patients without any recurrent displacement, and all patients were satisfied with the results. There were no complications such as infection and uncontrollable sinus bleeding, but pneumocephalus had occurred in 1 patient owing to the posterior table injury that happened during the tapper-applying procedure. We treated him with preventive antibiotics, and he completely recovered after 1 week. This method has better aesthetic results, shorter operative time, and minimal hospital stay than other surgical approaches. Although it contains minimal risk of posterior wall injury, considering not only surgical results but also patients' satisfaction, the authors suggest that this simple percutaneous reduction method using the tapper instrument would be the treatment of choice in the frontal sinus anterior wall fractures.

Pott's puffy tumor in pediatric age group: A retrospective study

ObjectiveTo study the etiology, clinical features and treatment outcomes of pediatric Pott's puffy tumor (PPT). MethodsThis retrospective study was carried by reviewing medical case record of pediatrics PPT cases admitted to our hospital from January 2010 to august 2011. Data regarding the patient's demographic details, presenting symptoms and signs, etiology, laboratory findings, imaging findings, management, complications and outcomes of treatment were collected and analyzed. ResultsA total of five cases of PPT were found. Three were male and two were female with a mean age of 11.6 years. All patients presented with headache, fever and tender forehead swelling. Nasal polyps and discharging sinuses over forehead were present in one case and one case had preseptal orbital cellulites in addition to PPT. None of the patient had intracranial complications. Three cases (60%) were secondary to acute frontal sinusitis, one case was as complication of chronic sinusitis and one case was because of trauma. Contrast enhanced Computerized tomography (CECT) demonstrated features of acute sinusitis in 3 cases, sinonasal polyp in one, fracture of anterior table of frontal bone in one case, subperiosteal collection and erosion of anterior table frontal bone in all cases. All patients required surgical intervention; Endoscopic approach 2 cases (40%), combined approach in 2 cases (40%) and external approach in one case (20%) in addition to aggressive antibiotic treatment. There was purulent discharge in frontal sinuses in all cases.In 2 cases (40%), culture of pus drained during surgery was positive; one case methicillin resistant Staphylococcus aureus sensitive to vancomycin, other Pseudomonas aeruginosa sensitive to ceftazidime and amikacin. All cases improved with treatment. There were no postoperative complications or facial cosmetic deformity except facial scar in three cases. The average hospital stay was two weeks and ranged from 10 days to 21 days. All patients received antibiotics for 6–8 weeks to treat osteomyelitis of the frontal bone. The average length of follow up was 9 months (range 6–18 months). All patient are doing well and are under regular follow up. ConclusionsPPT is a complicated infection of frontal sinusitis and trauma that requires broad spectrum antibiotics and surgical treatment. Diagnosis is made by high clinical suspicion of this condition and confirmed by CECT. Early treatment results in favorable outcomes and decreases the risk of further complications.

Treatment of Frontal Sinus Fracture Using Bioabsorbable Mesh Plates

Accurate reduction and stable fixation are important in the treatment of frontal sinus fracture. Usually, metal plates and screws were used because of easy handling and delicate fixation. However, palpability and possibility for secondary operation for plate removal were shortcomings. For improving these problems, we used absorbable mesh plate for fixation of reduced frontal bones.In this study, 14 patients with frontal sinus fracture were treated by open reduction and rigid fixation using absorbable mesh plates. Mean follow-up period was 17.6 months. Considering anterior and posterior table involvement, nasofrontal duct injury, and concomitant neurosurgical problems, additional surgical procedures including degloving sinus mucosa, cranialization, and obliteration of nasofrontal duct were also conducted.There was no remarkable early and late postoperative complication. Aesthetic results were also satisfactory. Absorbable mesh plates were easy to mold and convenient for screw fixation. Moreover, there was no necessity of secondary operation for removal of plates.We believe that absorbable mesh plates might be a useful material for fixation instead of metal plates and screws especially in mild to moderate degree of frontal bone fractures.

Post-Traumatic Mucoceles: Does Encephalomalacia Predict Advanced Disease?

Introduction: Mucoceles are a rare delayed complication of frontal sinus fractures. Although usually heralded by typical sinonasal symptoms, advanced disease can present with meningitis or facial disfigurement (forehead swelling, globe dystopia) due to posterior or anterior table erosion, respectively. The forceful anterior impact required for frontal sinus fractures is also capable of contusing the frontal lobes, which may impair executive function. Such a cognitive deficit may permit the development of advanced disease despite asymptomatic facial disfigurement. Because encephalomalacia precedes mucocele formation, patients with frontal lobe injury may warrant closer radiographic surveillance.

Pectoralis Major Flap with Sternum

Sir:FigureThe vast majority of segmental bony defects of the mandible are treated with free vascularized bone flaps. There are certain patients, however, who are poor candidates for free tissue transfer but still require vascularized bone. These include patients who have no recipient vessels or donor sites, or are too ill for a lengthy procedure. The following case is one such patient. The patient was a 73-year-old man with a history of a T1N2bM0 squamous cell carcinoma of the tongue. Previous treatment included surgical excision and bilateral neck dissections in 2003, followed by irradiation (total, 160 Gy) to the oral cavity and neck. He subsequently developed osteoradionecrosis, treated with serial sequestrectomies, followed by recurrences in 2008 and 2009, requiring excision. He presented to our institution with another recurrence in 2011 and was scheduled for a composite resection of the body of the mandible and floor of the mouth. On examination, his neck was as solid as wood from the mandibular angle to the clavicle. On computed tomography, he had bilateral severe atherosclerosis of the carotids and no remaining branches of the external carotids. He had bilateral congenital club feet, for which he underwent nine operative procedures and was ambulatory only with orthoses. Finally, he had severe chronic obstructive pulmonary disease and hepatitis C and was an active smoker and alcoholic. Clearly, this patient was a poor candidate for free tissue transfer; however, his tumor was causing severe pain and ulceration and was growing rapidly. To achieve intraoral skin coverage, vascularized bony reconstruction, and neck coverage, we opted for a pedicled pectoralis major muscle flap with skin and a vascularized split sternum. The pectoralis major with a vascularized sternum was described by Green et al. in 19811 and further refined by Robertson2,3 but has been lost to history in the era of free tissue transfer. The technique involves a skin island oriented vertically over the lateral aspect of the lower third of the sternum (Fig. 1). The medial incision is made, and the anterior table of the ipsilateral lower third of the sternum is osteotomized with the oscillating saw. A curved osteotome separates the anterior and posterior tables. The skin incision is continued along the costal margin to create a rotation flap to close the donor site. The pectoralis muscle is elevated in the submuscular plane until the lateral border of the sternum is encountered. The sternocostochondral junction is separated with sharp Mayo scissors (Fig. 2). The remainder of the myo-osseocutaneous flap is elevated in standard fashion.4 The native mandible was burred down to create a step-cut in which the sternum was press-fit. Osteosynthesis was achieved with 8-mm nonlocking screws (Fig. 3). The patient had an uneventful hospital course and was discharged to home on postoperative day 6. After 2 weeks, the patient developed an orocutaneous fistula; however, on surgical débridement, the bone remained well vascularized by the muscle.Fig. 1: The skin island is centered over the ipsilateral border and the inferior half of the sternum. The bony sternal segment is marked over the ipsilateral half and the inferior third of the sternum, not including the xiphoid. The incision is designed to continue inferolaterally, creating a fasciocutaneous rotation flap to close the donor defect.Fig. 2: The medial incision is made first, and the anterior table of the ipsilateral lower third of the sternum is osteotomized with the oscillating saw. A curved osteotome separates the anterior and posterior tables. The skin incision is continued along the costal margin to create the rotation flap. The pectoralis muscle is elevated in the submuscular plane until the lateral border of the sternum is encountered. The sternocostochondral junction is separated with sharp Mayo scissors.Fig. 3: The native mandible was burred down to create a step-cut in which the sternum was press-fit. Osteosynthesis was achieved with 8-mm nonlocking screws. Different orientations of the bone and skin island are possible, depending on whether intraoral or extraoral skin is required.Free vascularized bone flaps are standard treatment for segmental mandibular defects. Occasionally, however, for reasons of donor-site, recipient-site, or patient disease, free tissue transfer is inadvisable. In these cases, pectoralis major flap with vascularized sternum represents one of the few remaining options for this subset of patients. Jesse Creed Selber, M.D., M.P.H. Shadi Ghali, M.D. University of Texas M. D. Anderson Cancer Center, Houston, Texas DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.

Post-traumatic deformity of the anterior frontal table managed by the placement of a titanium mesh via an endoscopic approach

We describe delayed treatment of a post-traumatic fracture of the anterior table of the frontal sinus with a titanium mesh using an endoscopic approach. To our knowledge this is the first case of a delayed post-traumatic deformity of the anterior table being treated by this method.

Postoperative Complications of Frontal Sinus Fractures: A Retrospective Review of 47 Cases

Postoperative Complications of Frontal Sinus Fractures: A Retrospective Review of 47 Cases

Pediatric chronic maxillary atelectasis

Abstract Purpose : Chronic maxillary atelectasis (CMA) is an acquired condition characterized by decreased maxillary sinus volume with inward bowing of one or more antral walls, which may result in ipsilateral hypoglobus or enophthalmos. Its etiology is unclear. There are few reported cases in the pediatric literature. We present a case of CMA in a child with normal pre-disease CT scans, illustrating that this is an acquired condition occurring in the pediatric population. Theoretic mechanisms of pathogenesis are also discussed. Methods : A retrospective medical record review was conducted, as well a literature review to examine similar cases and proposed pathophysiologic mechanisms of the disease. Results : An 11-year-old female was referred to our Otolaryngology clinic for evaluation of frontal headaches. She had a history of right anterior table frontal sinus fracture and right ethmoid fracture after hitting her head on a school desk at age seven. She required frontal sinus obliteration after her initial trauma due to persistent fevers and headaches. Initial maxillofacial CT revealed normal appearing maxillary sinuses. Four years later a repeat CT showed an opacified, hypoplastic left maxillary sinus with inward bowing of medial and lateral walls, as well as a depressed left orbital floor. She was treated with endoscopic left maxillary antrostomy, and later underwent removal of hardware related to her frontal sinus obliteration. Her symptoms resolved after these interventions. Conclusion : Chronic maxillary atelectasis was first described nearly 50 years ago, and sparse literature exists on its impact in the pediatric population. Evidence exists which supports the theory of negative antral pressure leading to the observed anatomic defects. Primary management of the disease is surgical, and involves maxillary antrostomy with uncinectomy. Debate exists as to whether CMA and SSS are distinct entities or different descriptions of disease processes on a single spectrum.

Frontal Sinus Repair Through a Frontalis Rhytid Approach

Frontal sinus fractures have traditionally been repaired through a bicoronal approach. This incision provides a wide exposure, but is not without complications, particularly in the patient with or at risk for hairline recession. We present a series of 15 patients who underwent open reduction and internal fixation of anterior table frontal sinus fractures through a frontalis rhytid forehead incision and their results based on the scar appearance, forehead contour, frontalis function, sensation and fracture reduction. Paresthesias cranial to the incision in the supraorbital or supratrochlear distribution were noted in 12 of the 15 patients with resolution in all except 1 patient who did not regain sensation at 4 months follow-up. In all patients, satisfactory forehead contour and fracture reduction were achieved, as were scar appearance and frontalis function at 4 months follow-up. We thus recommend this approach in the treatment of anterior table frontal sinus fractures, with special consideration for the patient with or at risk for anterior hairline recession.

Single-stage strategy for management of anterior table frontal sinus fractures involving the frontal sinus outflow tract

Treatment of frontal sinus fractures has been controversial for years. The aim of treatment, besides cosmetic restoration, is to create a “safe” sinus especially in those with evidence of injury to the frontal sinus outflow tract. Early and late complications include acute and chronic sinusitis, mucocoele and mucopyocoele formation, brain abscess and osteomyelitis. Osteoplastic flap with frontal sinus obliteration or cranialisation is most commonly performed. With the advent of modern endoscopic and advanced imaging techniques, endoscopic sinus surgery for treatment of diseases of the frontal sinus is ever increasing. In this paper, we describe our successful experience using a single-stage, combined open and transnasal endoscopic technique in management of patients with anterior table frontal sinus fractures involving the frontal sinus outflow tract.

The Bipedicled Anterior Septal (BAS) Flap for Anterior Frontal Table and Skull Base Reconstruction: A Radioanatomic and Cadaveric Study

The Bipedicled Anterior Septal (BAS) Flap for Anterior Frontal Table and Skull Base Reconstruction: A Radioanatomic and Cadaveric Study

Role of the Sagittal View of Computed Tomography in Evaluation of the Nasofrontal Ducts in Frontal Sinus Fractures

Frontal sinus fractures are relatively uncommon due to the high-impact force required to produce these. However, their management is quite complex, with the treatment algorithm incorporating many factors in which the status of the nasofrontal ducts is critically important. Traditionally, this has been evaluated by both axial and coronal computed tomographic (CT) scan views. Anatomically, we propose that this is better evaluated by coronal and sagittal CT views. We evaluated the role of sagittal CT scan views in determining the status of the nasofrontal ducts in patients with frontal sinus fractures. A retrospective analysis examining 8 patients with frontal sinus fractures, from August 2004 to January 2008, was performed. Axial, coronal, and sagittal CT scan views were obtained routinely as part of the facial trauma workup. These views were assessed to determine the status of the nasofrontal ducts. The operative findings were also reviewed. Five of the 8 patients had displaced anterior and posterior table frontal sinus fractures. Of these, 4 required surgical intervention that included addressing the nasofrontal ducts. Two of the 8 patients had displaced anterior table fractures that required no intervention of the nasofrontal ducts. One patient had nondisplaced anterior and posterior table fractures and did not require surgery. The sagittal CT view clearly demonstrated the anatomy of the nasofrontal ducts in all 8 patients, including patients in whom the axial and/or coronal views were questionable. Intraoperatively, where the patency of the nasofrontal ducts was directly evaluated, there was a direct correlation with the sagittal image findings. The sagittal CT view provides invaluable information for evaluating the patency of the nasofrontal ducts in frontal sinus fractures. The ability to evaluate the frontal sinus in an anteroposterior dimension (the usual vector of the injury) and in a superoinferior dimension (the anatomic pathway of the ducts) is the reason for this imaging advantage.

Complications of Frontal Sinus Fractures With Emphasis on Chronic Craniofacial Pain and Its Treatment: A Review of 43 Cases

Frontal sinus fractures constitute 5% to 12% of all facial fractures. The optimal management of frontal sinus fractures is controversial but involves preserving the function of the nasofrontal ducts when feasible. We reviewed the postoperative complications of a series of 43 patients treated surgically for frontal sinus fractures. The data from 43 patients treated from 2000 to 2006 were reviewed. The information reviewed included patient age and gender, mechanism of injury, type of frontal sinus injury, associated facial injuries, treatment method, and complications. The institutional review board approved the present study. The average patient age was 32.5 years; 36 were men and 7 were women. Of the 43 patients, 23 (53.5%) had had anterior table fractures and 20 (46.5%) had had both anterior and posterior table fractures. Postoperative complications occurred in 7 patients (16.3%). Of these 7 patients, 2 experienced continued headache and pain and required surgical removal of infected hardware, 3 also experienced frequent headaches and pain in the frontal-temporal region, 1 had a post-traumatic deformity, and 1 developed periorbital cellulitis and abscess formation within the frontal sinus. Frequent headaches and complaints of continued pain were the most common complications experienced by our series of patients. We also reviewed treatment strategies for postoperative follow-up and treatment of chronic pain.

Use of Titanium Mesh for Reconstruction of Extensive Defects in Fronto-orbito-ethmoidal Fracture

Traumatic injuries treatment of the fronto-naso-orbito-ethmoidal region has been one of the most challenging treatments within maxillofacial surgery, particularly of extensive orbital defects, very common in this type of pathologic condition. A 48-year-old man involved in a car collision presented an extensive bilateral fracture of the orbit medial wall, nasal bones, the nasal septum, and the frontal anterior table. The clinical and tomographic findings concluded the diagnosis of a maxilla and fronto-naso-orbito-ethmoidal fracture. Among the variety of biomaterials, the titanium mesh was elected because of the extension and magnitude of the bone defect, obtaining this way esthetic and functional results with better prognosis.

CT measurement of the frontal sinus – Gender differences and implications for frontal cranioplasty

To describe frontal sinus anatomy and explore gender variations that may have significance for cranioplasty and sinus surgery. 150 subjects who underwent maxillofacial computed tomography (CT) between 1/1/2008 and 6/11/2008 were enrolled. Frontal sinus dimensions and forehead measurements were taken at midline and at 10, 20, and 30 mm to the left and right of midline using sagittal, coronal, and axial images. The data was analyzed for significant differences between measurements made at the selected points in the frontal sinus, for left to right variations, and for gender variations. Mean anterior table thickness ranged from 2.6 to 4.1 mm and was thinnest at 10 mm left and right of midline (2.9 and 2.6 mm). Mean anteroposterior depth of the frontal sinus ranged from 8.0 to 9.3 mm and did not vary significantly at any distance from midline. Frontal sinus height was greatest at midline (mean=24.5 mm) and progressively lessened at lateral distances. Mean total width at the level of the supraorbital ridge was 52.2 mm. For all measurements, no significant left to right variation was noted. Comparing the sexes, males were found to have greater dimensions in most frontal sinus measurements, though these differences were only found to be significant at or close to midline. The male forehead was marked by more acute nasofrontal angle (119.9° versus 133.5°) and a steeper posterior forehead inclination (-7.2° versus -3.5°). The glabella was wider in males (44.4 versus 33.9 mm) and more frequently protruded beyond the ideal forehead slope line (51% versus 30%). Using CT imaging, forehead and frontal sinus dimensions have been described. Generally, males had larger overall frontal sinus dimensions, and this was most pronounced in the medial area of the supraorbital ridge known as the glabella.

Frontal Sinus Fractures: Current Concepts

Frontal sinus injuries may range from isolated anterior table fractures resulting in a simple aesthetic deformity to complex fractures involving the frontal recess, orbits, skull base, and intracranial contents. The risk of long-term morbidity can be significant. Optimal treatment strategies for the management of frontal sinus fractures remain controversial. However, it is critical to have a thorough understanding of frontal sinus anatomy as well as the current treatment strategies used to manage these injuries. A thorough physical exam and thin-cut, multiplanar (axial, coronal, and sagittal) computed tomography scan should be performed in all patients suspected of having a frontal sinus fracture. The most appropriate treatment strategy can be determined by assessing five anatomic parameters including the: frontal recess, anterior table integrity, posterior table integrity, dural integrity, and presence of a cerebrospinal fluid leak. A well thought out management strategy and meticulous surgical techniques are critical to success. The primary surgical goal is to provide a safe sinus while minimizing patient morbidity. This article offers an anatomically based treatment algorithm for the management of frontal sinus fractures and highlights the key steps to surgical repair.