This injury commonly results from a direct blow to the frontal bone with a blunt object—classically, a lead pipe or brick. This fracture is frequently associated with intracranial injury, secondary to disruption of the posterior table of the sinus. Dural tears are frequent, and patients may have associated injuries to the orbital roof (leading to blindness), as well as to the brain.14 Late complications include cranial empyema or mucopyoceles. Mucopyoceles are collections of pus and mucus that occur when fractures block the nasal frontal duct, preventing sinus drainage.
Physical examination may reveal disruption or crepitance of the supraorbital rims or subcutaneous emphysema. Fractures are often overlooked because of traditional prohibitions against skull films for head trauma. Patients with a suggestive mechanism or examination benefit from skull films or a Caldwell view of the face. If a depressed or posterior wall fracture is seen on plain film, obtain CT. Patients with hard signs of a frontal bone fracture (subcutaneous air, bony step-off, etc.) require only a CT.
Consult with an ENT specialist or a neurosurgeon regarding antibiotic use in patients with frontal sinus fractures. Many specialists recommend antibiotics that cover common sinus pathogens, although the literature lacks definitive evidence on this issue. Frequently prescribed antibiotics include first-generation cephalosporins, amoxicillin-clavulanate, erythromycin, and trimethoprim-sulfamethoxazole. Patients with depressed fractures, or those who have posterior wall involvement, require intravenous antibiotics, admission, and consultation. Those with isolated fracture of the anterior wall may be treated as outpatients.
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