Obtaining a thorough and comprehensive history is imperative in the initial triage and management of facial trauma patients.  Due to the nature of these injuries, patients may not have the capacity to provide this information themselves, making it essential for providers to gather data from family, friends, witnesses, and first responders.  Per the Advanced Trauma Life Support (ATLS) protocol, the evaluation of trauma patients begins with an assessment of the patient's airway, respiratory capacity, and circulatory status. While assessing the extent of the patient's disabilities, a thorough neurologic exam should be performed to calculate a Glasgow Coma Scale Score, assessing for cranial nerve function as well as other focal deficits and bony injury to the calvarium. The provider should inspect the entire head and neck for any lesions, abrasions, contusions, or active bleeding. It is important to assess for lacerations superficial to any sinus fractures, indicating the requirement of IV antibiotics. The anterior table of the frontal sinus should be palpated to determine if there is any bony step off, and any wounds or lacerations should be cleaned and explored. Examination of the ears can reveal battle sign, auricular hematomas, cerebrospinal fluid (CSF) otorrhea, or hemotympanum, suggesting the involvement of the skull base. A nasal examination should check for the mobility of the nasal bones, frank epistaxis, CSF rhinorrhea, septal hematomas, or active purulence. Examination of the orbit should include appropriate cranial nerve testing and inspection for raccoon eyes or retrobulbar hematoma.

After obtaining a comprehensive history and physical exam, the most important test to determine structural involvement and subsequent management is a non-contrast computed tomography scan (CT) of the head and facial bones. Various windows are available through CT imaging (osseous, soft tissue, heme windows), which make the evaluation of these and related injuries rapid and reliable. If CT is available and performed, there is no evidence showing any additional benefit from radiographs. Angiography can be considered if the provider is concerned about possible vascular involvement. Ultrasound has the ability to detect fractures with the use of the linear probe in a superficial mode; however, this should be viewed as an adjunct to the previously mentioned modalities.[7][9][10]

Currently, there is no general consensus on the classification of frontal sinus fractures.[2][3][6][11] One-third of all frontal sinus fractures include both the anterior and posterior tables of the frontal sinus, whereas two-thirds involve the anterior table only, and less than 1% involve only the posterior table. Below are some widely accepted classification systems of these fractures:

In 1997, Gonty et al. classified frontal sinus fractures into the following categories. A retrospective review of 158 patients by Gerbino et al. was performed using Gonty’s classification system and reported the percentage of patients with each type of fracture.[2][11][12]

• Anterior table involvement (61.4%)
• Anterior and posterior table involvement (33%)
• Posterior table involvement (0.6%)
• “Through and through,” which are defined as comminuted with the involvement of the orbit, ethmoids, and nasal base (2.5%)
• Fractures involving nasofrontal duct (2.5%)

In 2014, Torre et al. presented a classification and treatment schema that is based on maximal metric dislocation and involvement of surrounding structures (nasolacrimal system, orbit, CSF leak, or surrounding bone fracture). In their study of 164 patients, they classified fracture patterns into four types with Type A being most common (38.4%) followed by type B (22.6%), type C (14%), and type D (25%).[3]

• Type A: No displacement
•  Observation
• Type B: 0 to 2 mm displacement
• No concomitant injury - observation
• Concomitant injury - surgical repair
• Type C: 2 to 5 mm displacement
• No concomitant injury - observation
• Concomitant injury - surgical repair
• Type D: greater than 5 mm displacement
• Surgical repair

Treatment plans for these patients can vary immensely bared on their related injuries. Nondisplaced anterior table fractures can be monitored with observation and close practitioner followup. In the case of frontal sinus fracture with an overlying laceration (deemed open fracture), it is imperative to administer appropriate antibiotics and tetanus prophylaxis/immunoglobulin as indicated. If there is involvement of the anterior table without intracranial communication, IV amoxicillin-sulbactam BID is sufficient. The addition of a third-generation cephalosporin is appropriate if there is a displaced posterior table fracture. Surgical options, which will be described below, can include frontal sinus ablation/obliteration, closed fracture reductions, cranialization, open reduction internal fixation (ORIF), and conservative management with observation. As previously mentioned, classification and treatment guidelines are not universal, which could account for variations in patient management. Despite this lack of consensus, a posterior table fracture with greater than 5mm of displacement is generally accepted as an absolute surgical indication. Most procedures should take place within 12 to 48 hours, from initial presentation barring any more life-threatening injuries.[2][6][11][13][14][15][16][17]

Observation with Close Follow-Up

• Minimally displaced anterior table fractures (<1-2 mm), without nasofrontal recess injury

Closed Fracture Reductions/Minimally Invasive

• Various minimally invasive techniques exist for the closed repair of anterior table fractures. This type of repair often results in favorably aesthetic outcomes.
• Both percutaneous screws and inflating a foley catheter within the sinus have been reported as means of fracture reduction.

Open Reduction Internal Fixation (ORIF)

• It is generally indicated for fractures of the anterior table (>2 mm) without the involvement of the nasofrontal recess or in patients with an obvious cosmetic forehead deformity.
• Surgeons attempting this approach must be able to obtain adequate visualization and access to the sinus to perform the proper repair while considering aesthetic outcomes for the patient. These can be approached either endoscopically or in an open fashion depending on the extent of the fracture and surgeon preference.
• This approach uses small metal plates (microplates) and screws to secure the bony fragments. In some cases, reduction screws can be used to support the bone without fixation.

Frontal Sinus Obliteration/Ablation

• This procedure can be indicated in patients who have comminuted anterior table fractures with a linear nondisplaced posterior table fracture or involvement with the frontonasal duct. Another indication is a significant mucosal disruption of the sinus or severely comminuted fracture of the anterior table.
• This entails the removal of all sinus mucosa, occlusion of the nasofrontal duct, and filling the sinus cavity with bone grafts or other materials.  
• Hydroxyapatite, pericranial flap obliteration, adipose tissue, calcium phosphate, and glass ionomer can also be used as grafting material.
• A potential complication of this procedure is a mucocele secondary to incomplete removal of the mucosa during obliteration. If left untreated, mucocele growth can cause further bony destruction.

Cranialization

• It is generally indicated for posterior table fractures with significant displacement or comminution, intracranial injury, or CSF leak. 
• It involves removing the entire frontal sinus contents, including the mucosa, external debris, bone fragmentation, and the posterior table of the frontal sinus. Any anterior table defects must be reconstructed to further protect the brain and dura that have herniated into the frontal sinus.

• Nasoorbitoethmoid (NOE) fracture
• Nasal bone fracture
• Temporal bone fracture
• Parietal bone fracture
• Pott puffy tumor

Clinical prognosis is related to the extent of the injuries sustained as well as the clinical condition of the patient. If there are many injuries, various specialists and subspecialists may be required to treat the underlying pathology. Ultimately, isolated frontal sinus fractures have a good prognosis, regardless of whether or not the nasofrontal outflow tract or posterior table is involved. Advancements in surgical technique and equipment have improved the preservation of the frontal sinuses as well as the patients’ quality of life.

Complications of frontal sinus fractures are typically divided into two categories based on chronicity: acute (less than 6 weeks) or chronic (greater than 6 weeks), but complications overlapping these timeframes can happen. These include but are not limited to:[2][3][9][11]

• Frontal sinusitis
• Meningitis
• Cerebrospinal fluid leak 
• Mucocele
• Mucopyocele
• Osteomyelitis
• Pneumocephalus
• Poor aesthetic outcome
• Brain abscess 
• Chronic frontal headaches
• Extrusion of graft material
• Intracranial hemorrhage
• Diplopia
• Ophthalmoplegia
• Blindness
• Paresthesia of the supraorbital, infraorbital, and/or supratrochlear nerves
• Hypoesthesia or paresthesia of the ophthalmic nerve (V1) or maxillary nerves (V2)
• Facial deformity

The list of possible consultations below varies per the injury to the frontal sinus itself as well as it's surrounding structures.

• Otolaryngology
• Trauma surgery
• Oral and maxillofacial surgery
• Ophthalmology
• Neurosurgery
• Facial plastic surgery
• Neurology - if associated traumatic brain injury (TBI) is present
• Intensivist - depending on injury severity and clinical condition
• Physical medicine and rehabilitation (PM&R) - depending on concurrent injuries and disease progression

Frontal sinus fractures are often caused by unanticipated trauma, so it is difficult to provide definitive guidelines on how to deter these situations. The authors recommend obeying safety precautions with vehicles and other machinery, which can help to reduce the severity of these injuries. Avoiding precarious situations can help to prevent assaults or falls.

• The most common etiologies of frontal bone fracture are motor vehicle collisions (MVCs), falls, assaults, falling objects, and penetrating trauma. These injuries most commonly occur in young males (92%) with a mean age of 20 to 31 years old.
• Trauma patients, especially those who have sustained cranial and facial injuries, must be critically evaluated based on ATLS protocols.  It is important to avoid distraction by obvious or deforming injuries and focus on establishing or maintaining a definitive airway, preserving respiratory status, and supporting circulatory volume.  After the initial stabilization, a thorough history and physical needs to be performed. The most important test to determine structural involvement and to plan management is a non-contrast computed tomography scan (CT) of the head and facial bones.  If a frontal sinus fracture is observed on CT, this indicates significant trauma, and it is imperative to search for corresponding injuries.
• Multiple classification systems have been proposed since 1999, but there is currently no universally agreed-upon system to follow. These protocols can guide treatment based on classification.
• Based on concurrent injuries, surgical intervention can vary immensely. Options can include frontal sinus ablation/obliteration, cranialization, open reduction internal fixation (ORIF), minimally invasive techniques, and conservative management with observation.
• Complications vary per the extent of the injury but can include frontal sinusitis, meningitis, CSF leak, mucocele, poor aesthetic outcome, brain abscess, frontal headaches, ophthalmoplegia, and/or local paresthesia.
• A multidisciplinary team will be necessary for the diagnosis and treatment of frontal sinus fractures depending on the local structures affected.

Frontal sinus fractures could require an interprofessional team depending on the extent of the injury. The emergency response team will be necessary to identify any life-threatening injuries and stabilize the patient upon presentation. Surgical reconstruction will need to be carried out by the proper surgical specialists, which could vary depending on any associated injuries and surgeon availability. One or multiple board-certified surgeons may be needed to treat these patients, which could include an otolaryngologist, facial trauma surgeon, oral and maxillofacial surgeon, facial plastic surgeon, neurosurgeon, and/or ophthalmologist. The operating room (OR) staff, including surgical technicians and circulating nurses, will be imperative to keep the OR moving smoothly and improve surgical outcomes. An intensive care unit or critical care team made up of physicians, advanced practice providers, nurses, and other staff may be needed to manage the patient medically either pre- or postoperatively.