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The Utilization Of Endoscopic Techniques In The Management Of Frontal Sinus Fractures: A Systematic Review
Robert P. Lesko, BA1, Eric J. Macdonald, BS1, Brandon J. De Ruiter, BS1, Edward H. Davidson, MD2.
1Division of Plastic Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA, 2Department of Plastic Surgery, Case Western Reserve University, Cleveland, OH, USA.

Purpose:
Endoscopic approaches to frontal sinus fracture management are an emerging challenge to the traditional algorithmic paradigm, especially in the management of anterior table fractures. Endonasal cannulation and/or stenting of the nasofrontal outflow tract can obviate the need for obliteration. Endoscopic assistance can also be an adjunct to anterior table reconstruction and obliteration. There have been no systematic reviews analyzing utilization and outcomes of endoscopic management of isolated anterior table fractures of the frontal sinus.
Methods:
A comprehensive search of PubMed/MEDLINE, Embase, Web of Science, and Cochrane was performed in September 2019 through consultation with a research librarian using the key terms "frontal sinus fracture" or "frontal sinus injury". Articles met criteria for inclusion if they were human studies written in English, primary literature, and discussed the management of isolated anterior table frontal sinus fractures. All unrelated articles, non-human studies, case reports, those not in English, and those without outcomes data were excluded. Variables extracted included mean patient age, age range, diagnosis, treatment method, complications, and any other reported outcomes data.
Results:
Of 606 articles identified in our initial search, 89 were reviewed in their entirety and 22 were ultimately included in our analysis (Figure 1). 8 papers were retrospective reviews and 14 were case series. 786 patients (mean age 28.8) with isolated anterior table frontal sinus fractures were included in our analysis. 35 patients (4.5%) underwent endoscopically-assisted procedures. 7 patients (0.9%) underwent endoscopically-assisted reduction and 28 patients (3.6%) underwent endoscopically-assisted reduction and fixation with no complications reported for patients undergoing either surgery. Nasofrontal outflow tract involvement was discussed in 5(83%) of the papers utilizing endoscopic techniques and obstruction was noted in 2 patients. In the studies describing traditional methods of treating isolated anterior table fractures such as observation, ORIF, and obliteration, reported complication rates ranged from 2.13% to 50%.
Conclusions:
Endoscopically-assisted repair of isolated anterior table frontal sinus fractures is emerging as a safe evolution from traditional methods. Utilization of endonasal cannulation and stenting of the nasofrontal outflow tract has potential to obviate the need for obliteration and challenge the traditional management algorithm but requires further study.


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