Considerations for the Head-Injured Air-Evacuated Patient: A Case Report of Frontal Sinus Fracture and Review of the Literature

Military Medicine, Jul 2005 by Helling, Eric, McKinlay, Alex J

Head and neck injuries are not uncommon in combat environments and may be increasing due to survivable injuries from the use of kevlar helmets and body armor. With the current capability of rapid evacuation from the battlefield, acutely injured patients with frontal sinus injuries may undergo further barometric challenges. Proper care during transport can prevent the occurrence of secondary injury (increased intracranial pressure, tension pneumocephalus) that would complicate the patient's management at the next level of care. Management principles (importance of low-level flight/pressurized cabin, preflight use of decongestants, avoidance of valsalva, and ability to manage complications either procedurally or by landing) are reviewed. In addition, we propose a simple mechanism for pressure equilibration of a compromised frontal sinus during air evacuation using an angiocatheter placed through the wound before closure.

Case Report

On July 7, 2000, a 32-year-old Kosovar male sustained multiple shrapnel wounds to his frontal sinus and right maxilla. The maxillary shrapnel penetrated transversely through the maxilla and septum, depositing in the left neck. His initial treatment at the Combat Support Hospital (CSH) at Camp Bondsteel included frontal sinus wound examination with shrapnel removal, primary closure, and nasal packing. Physical examination at the CSH showed a small anterior table frontal sinus defect and a minimally displaced posterior table fracture. He was then air evacuated to Landstuhl Regional Medical Center, Germany. On arrival he still had nasal packing in place and a raised, ballotable air pocket underlying the frontal sinus wound closure. His mental status examination was normal on arrival. A computed tomography (CT) was obtained and showed an anterior frontal sinus defect, a minimally displaced posterior table frontal sinus fracture, and no evidence of intracranial air. Air in the frontal sinus was "mushrooming" out of the anterior table defect and elevating the scalp tissue. The patient then underwent surgical evaluation and management of his wound. The frontal sinus closure was reopened for evaluation and a 6 x 8-mm anterior table frontal sinus defect was noted. His posterior table was visualized endoscopically, which revealed a 5 mm X 8-mm ovalshaped fragment without mucosal covering that was retrodisplaced approximately 2 to 3 mm. No gross cerebrospinal fluid (CSF) leak with valsalva was noted and the surrounding frontal sinus appeared unremarkable. The frontal sinus was then irrigated and closed. Repair of multiple intranasal injuries, septal perforation, and left neck exploration were performed. The patient had been preoperatively counseled for various surgeries (durai or posterior table repair if indicated). He declined further intervention of the frontal injuries preoperatively and asked for examination only, with further counseling after the examination. Findings were later reviewed and the patient opted for observance only. Large silastic splints were required for healing of the septal perforation and prevention of intranasal synechiae. The patient remained on antibiotics and splints were removed on postoperative day 10. Before transfer back to Kosovo, a standard 20-gauge. angiocatheter was placed into the anterior table defect and allowed to vent to air. A single suture was used to anchor this in place and a clear tape dressing was applied over the catheter without occluding the end (similar to taping a standard intravenous catheter). The patient then returned by lowlevel flight to Kosovo. Medical staff accompanied the patient on the return flight and was prepared to open the wound if signs of pneumocephalus or other findings to suggest barometric problems with the frontal sinus manifested. On arrival to Pristina, there was no clinical evidence of barotrauma and flexible nasopharyngoscopy showed no evidence of clinical CSF leak. The catheter was pulled at the airfield. Bacitracin and a Band-Aid were applied. The patient was again counseled regarding risks of meningitis or spontaneous CSF leak. He was instructed to follow-up with a local ear, nose, and throat physician and obtain an interval CT.

Discussion

Although the frontal sinus is the most resistant facial bone to fracture (taking 800-1,200 pounds offeree), it is estimated that they constitute 5 to 12% of all maxillofacial trauma.12 Anecdotal reports from current operations suggest that the extensive use of Kevlar helmets and body armor are resulting in a proportionally higher incidence of survlvable combat injuries with head and neck trauma as a major component (J. D. Casier, personal communication). Management objectives for frontal sinus injuries are to preserve the anatomic integrity of the brain and sinus cavity, prevent meningitis and numerous other complications (mucoceles and/or mucopyocele formation, recurrent sinusitis, osteomyelitis, osteoma formation, and cosmetic deformities), and provide an appropriate esthetic appearance to the forehead.2,3