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Year : 2021  |  Volume : 23  |  Issue : 2  |  Page : 55-59

Frontal sinus cranialization using pericranial flap: Experience in thirty cases

1 Department of Neurosurgery, Al Azhar University, Cairo, Egypt; Department of Neurosurgery, King Fahad Armed Forces Hospital - Southern Region, Khamis Mushait, Saudi Arabia
2 Department of ENT, King Fahad Armed Forces Hospital - Southern Region, Khamis Mushait; Department of ENT, King Fahad Armed Forces Hospital - Jeddah, Jeddah, Saudi Arabia

Date of Submission18-Dec-2020
Date of Decision15-Mar-2021
Date of Acceptance17-Mar-2021
Date of Web Publication10-Jun-2021

Correspondence Address:
Dr. Saeed Alsharif
Department of ENT, King Fahad Armed forces Hospital, P.O.Box 9862, Jeddah 21159
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sjoh.sjoh_57_20

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Introduction: Cranialization of the frontal sinuses has become a widely accepted treatment choice for the most challenging types of frontal sinus fractures, complicated mucoceles and mucopyoceles, severe frontal sinusitis with osteomyelitis, and others. We conducted a review of thirty cases who underwent cranialization using pericranial flaps. Materials and Methods: A total of thirty cases were reviewed done between January 2015 and June 2019. Results: The most frequent indication in our review was frontal sinus fracture in twenty cases (66.6%), six (20%) cases of frontal sinus mucoceles, and four (13.3%) cases of fontal sinus infection with intracranial extension. Conclusion: The use of a pedicled vascularized pericranial flap as an extra layer and autologous fence above the dura adds more protection to the brain. More prospective and randomized trials are recommended.

Keywords: Frontal mucocele, frontal sinus cranialization, frontal sinus fracture, pericranial flap

How to cite this article:
Hammad W, Mahmoud B, Alsharif S. Frontal sinus cranialization using pericranial flap: Experience in thirty cases. Saudi J Otorhinolaryngol Head Neck Surg 2021;23:55-9

How to cite this URL:
Hammad W, Mahmoud B, Alsharif S. Frontal sinus cranialization using pericranial flap: Experience in thirty cases. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2021 [cited 2021 Jul 23];23:55-9. Available from: https://www.sjohns.org/text.asp?2021/23/2/55/318133

  Introduction Top

The frontal sinuses have gained a lot of surgical and research interests due to the complexity of its drainage pathway and its close proximity to vital structures – the orbits and the brain. With a variety of surgical indications and approaches, cranialization of the frontal sinuses has become a widely accepted treatment choice for the most challenging types of frontal sinus fractures, complicated mucoceles and mucopyoceles, severe frontal sinusitis with osteomyelitis, and others.[1],[2],[3],[4]

Frontal sinus fractures account for 5%–15% of all maxillofacial injuries.[5] Due to its thick anterior wall (2–12 mm), a high impact force of 360–990 kg (800–2200 lb) is required to break this bone, and this is usually associated with other facial and cranial involvements.[6] Different management panaceas have been proposed depending on the type of fracture, involvement of the anterior or posterior table or both, cerebrospinal fluid (CSF) leak, and nasofrontal outflow tract (NFOT) obstruction.[7],[8],[9],[10] If left untreated, these fractures may lead to serious complications years after the incident.

Mucoceles, on the other hand, are primarily present in the frontal sinuses (about 60%–65%) and usually behave like real space-occupying lesions that cause bone erosion and displacement of surrounding structures. The proximity of mucoceles to the brain may cause morbidity and potential mortality, if left without intervention. The most common treatment modality is extirpation of the mucocele, cranialization or exclusion of the sinus, and nasofrontal duct obliteration.[11],[12]

Finally, the frontal sinus has been shown to have the highest rate of intracranial complications.[13] Bluestone showed a 10% incidence of intracranial complications among patients hospitalized for acute frontal sinusitis.[14] Infection from the frontal sinus enters the intracranial space typically by hematogenous spread through a communicating venous system. The small, valveless diploic veins (veins of Breschet) that extend through the posterior table of the sinus directly contribute to the venous plexus of the dura and periosteum.[15]

Recently, the use of pericranial flaps for cranialization of frontal sinuses has gained popularity with a good success rate.[16],[17] This approach mainly involves the complete removal of the posterior table on both sides along with all sinus mucosa and blockage of both NFOTs with bone chips or muscle grafts harvested from temporalis muscles.[18]

  Materials and Methods Top

A total of thirty cases were reviewed at the Armed Forces Hospital in the southern region of KSA between January 2015 and June 2019. They include 12 females and 18 males, with age ranging from 16 to 45 years [Table 1]. These patients were diagnosed with frontal sinus lesions and surgically managed by cranialization of the frontal sinus using pericranial flaps to separate the intracranial cavity from endonasal sinuses.
Table 1: Patients' characteristics

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On admission, a plain X-ray of the skull was done for each of the patients (anteroposterior and lateral views) and a plain brain computed tomography (CT) scan (axial, coronal, and sagittal), but contrast was used in cases of frontal mucoceles and frontal sinusitis.

A complete and detailed systemic and neurological examination was done pre- and postoperation and at the time of discharge. The follow-up duration ranged from 6 to 24 months. At each visit, a CT brain scan with bone window was carried out for each patient including a complete systemic and neurological assessment.

Patient selection

Inclusion criteria

  1. Displaced posterior table fractures of the frontal sinus (>one table width)
  2. Frontal sinus mucocele with intracranial or orbital extension
  3. Frontal sinus infection with intracranial extension.

Exclusion criteria

  1. Isolated anterior table fractures
  2. Nondisplaced posterior table fractures
  3. Isolated posterior table fractures (<one table width)
  4. Frontal sinus mucocele without intracranial nor orbital extension
  5. Frontal sinus infection without intracranial extension.

Operative technique

Written informed consent was taken before the surgery was scheduled. Each patient is placed under general endotracheal anesthesia, prepped, and draped in a sterile fashion with exposure of the superior portion of the nose, the orbits, and the forehead. The classic bicoronal incision was used; a skin incision made just behind the hairline through the epidermis and subcutaneous tissue. Raney clips are applied immediately with the incision through the galea to control bleeding; the skin flap is dissected anteriorly in the subgaleal plane to the level of the supraorbital rims to adequately expose the frontal bone.

Once the anteriorly based pericranial flap is designed, its borders are incised sharply. Preservation of the supraorbital neurovascular bundles is crucial as they provide blood supply to the flap and sensation to the forehead. The pericranial flap is then gently elevated from the underlying calvarium using a periosteal elevator from the posterior to the anterior [Figure 1]a.
Figure 1: (a) Pericranial flap after elevation from the underlying calvarium. (b) Frontal sinus exposure after frontal craniotomy

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The frontal craniotomy is extended into the superior portion of the frontal sinus [Figure 1]b, which permits exposure of the posterior table of the frontal sinus as well as the inferior part of the sinus. The posterior wall of the sinus is drilled and removed as well as the bony septa within the sinus, the mucosa of the sinus is thoroughly removed with a drilling burr, and the nasofrontal duct is plugged with bone wax and bone fragments.

The frontal sinus is packed with temporalis fascia, muscle or bone fragment, or in some cases, with abdominal fat. The dura is examined carefully for any defect or tear and sutured. Dural graft is used sometimes if there is a big defect; the periosteal flap is draped over the frontal sinus anterior wall and floor as well as over the exposed anterior cranial fossa floor. Fibrin glue is applied over the periosteal flap for more protection. The bone flap is replaced with microplates [Figure 2]a. A subgaleal drain is inserted, and the galea is sutured with vicryl sutures. The skin is closed with nylon sutures or staples [Figure 2]b.
Figure 2: (a) Bone flap reposition and fixation with microplates, (b) Bicoronal incision after closure with staples

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Postoperative care and follow-up

Postoperative antibiotic coverage is administered for 5 days. The drain is removed after 48 h, and ambulation is advised 24 h postoperative. Follow-up is every 3 months in the 1st year for a full systemic and neurological examination and repeat CT brain scan for the assessment of instability, resorption, or infection of the reconstructed region and soft tissues.

  Results Top

A total of thirty patients, which include 18 males and 12 females with a mean age of 32.5 years (ranging between 16 and 45 years), participated in this review [Figure 3]. The mean follow-up time is 11 months (6–24 months).

The most frequent indication [Figure 4] in our review was frontal sinus fracture [Figure 5] in twenty cases (66.6%), six (20%) cases of frontal sinus mucoceles [Figure 6], and four (13.3%) cases of fontal sinus infection with intracranial extension [Figure 7].{Figure 2}
Figure 3: Sex distribution of all patients

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Figure 4: Distribution of cases according to the indication

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Figure 7: (a) Computed tomography brain scan showing frontal sinus pyogenic infection with intracranial extension, (b) Intraoperative image before extradural collection, (c) Intraoperative image after cranialization and removal of the collection

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Figure 7: (a) Computed tomography brain scan showing frontal sinus pyogenic infection with intracranial extension, (b) Intraoperative image before extradural collection, (c) Intraoperative image after cranialization and removal of the collection

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In the cases of frontal sinus fractures [Figure 5], we found that the most common mechanism of injury was motor vehicle accidents (60%), falling from heights (22%), and blunt trauma (18%). Fifty-six percent of these fractures were open fracture. On the other hand, frontal sinus infection of pyogenic origin was 60% of cases and fungal infection was 40%.

Postoperative length of hospital stay varied from 5 to 20 days, on average 12 days.

There was no intraoperative complication; however, two (6.6%) cases had postoperative complication, both of which were posterior wall frontal sinus fractures. The first case complained of screw elevation under the skin causing discomfort at 9 months postoperative. It was removed under local anesthesia. In the second case, the patient developed meningitis 1 week after surgery, and the CSF examination revealed Streptococcus pneumoniae. Systemic antibiotics were administered; the patient improved and was discharged 2 weeks later.

  Discussion Top

Surgical management of chronic frontal sinus diseases and fractures continues to undergo changes with the advances in medical knowledge and facilities. The procedures can be grouped into two main categories. The first involves obliteration or ablation of the sinus with blockage of the frontal sinus drainage pathways. Procedures in this category include the Riedel operation, osteoplastic flap, and cranialization of the sinus. Riedel operation was first described in 1889; it eliminates the sinus by removing the anterior wall, plugging the NFOT with muscle, meticulously burring away all the mucosa from the posterior wall, and allowing the skin to collapse against the posterior wall. This method causes a significant esthetic deformity.[19],[20],[21] In the frontal sinus cranialization (as in this study), the posterior table is removed, allowing the brain to expand forward into the frontal sinus. Similar to previous procedures, all the mucosa must be meticulously removed from the sinus, and the NFOTs must be obliterated.[19],[20] In osteoplastic flap procedure, the interior of the frontal sinus of the anterior table is hinged inferiorly on the pericranium by creating a flap. Through this exposure, the mucosa of the frontal sinus can be carefully removed, the NFOTs plugged, and the sinus obliterated using fat tissue, which is the most commonly used.[22],[23]

The second category involves re-establishment of the outflow tract and reaeration of the sinuses. These frontal sinus preservation procedures include the external fronto-ethmoidectomy (Lynch approach) and the endoscopic intranasal frontal sinusotomy or the modified Lothrop (Draf III) approach.[24]

In our review, we found that cranialization of the frontal sinus is most appropriate in the management of frontal sinus fractures, mucocele with intracranial or orbital extension, and frontal sinus infection with intracranial extension. There were no intraoperative complications; only two (6.6%) cases had postoperative complications. This is consistent with other published series.[2],[8],[25]

Donath and Sindwani reported a complication rate of 5.2% from 19 frontal sinus cranialization and one postoperative CSF leak originating from the lateral sphenoid sinus.[16] Furthermore, Lotfinia et al. reported two cases (6.9%) of complications with the same technique – a CSF discharge from the operation site in one case and rhinorrhea in the other case.[8]

Therefore, the pericranial flap technique is considered a safe and effective method for cranialization of the frontal sinus. The pericranial flap is a pedicled myofascial flap that consists of a scalp periosteum and an overlying loose connective (areolar) tissue. The flap is well vascularized, it is enriched by the supraorbital, supratrochlear, and superficial temporal vessels.[16],[26] This rich vascularity allows for versatility in design, the flap may be unilateral or bilateral, and it can be based either anteriorly or laterally. The flap can be harvested easily and quickly, and its use in the frontal sinus surgery obviates the morbidity of another donor site as it is already within the surgical field.[16]

One of the crucial goals of this approach is to prevent future mucocele formation and subsequent infectious sequelae. This procedure requires meticulous attention to the techniques in regard to removing all of the sinus mucosa and permanently occluding the frontal sinus outflow tract.[18],[25]

  Conclusion Top

Cranialization is becoming more widely used today as it is a reliable and safe maneuver in the management of frontal sinus fractures, mucoceles, and prevention of complications (infections). The use of a pedicle vascularized pericranial flap as an extra layer and autologous fence above the dura adds more protection to the brain. This flap may reduce the risk of CSF leak and perioperative infections and improve the overall results. Yet, more prospective and randomized trials are recommended.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]

  [Table 1]


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