Choice of Material for Nasofrontal Duct Obliteration in Frontal Sinus Fracture

Abstract

Introduction: Within the surgical management algorithm for frontal sinus fracture (FSF), the choice of material for nasofrontal duct (NFD) obliteration is controversial, and a multitude of materials have been described in the literature. The present study aims to perform a systematic review to determine postoperative outcomes associated with various NFD obliteration materials. Methods: Two independent reviewers identified studies to be included based on inclusion and exclusion criteria. Odds ratios and Fisher’s Exact Tests were then used to compare outcomes between cohorts based on the material used for NFD obliteration. Complications under review included donor site complications, reoperations, frontal sinus infections, cerebrospinal fluid leaks, cosmetic defects, persistent pain and/or headaches, and mucocele formation. Results: Twenty-nine studies met inclusion criteria. The use of a vascularized flap was associated with a reduced risk of reoperation and postoperative frontal sinus infection compared with non-flap materials (OR = 0.23 (CI: 0.05, 1.04), P = .05. The use of avascular bone graft was associated with an increased risk of reoperation (OR = 8.89 (CI: 2.24, 29.94), P < .001. Use of bone graft was associated with increased postoperative frontal sinus infection compared with non-bone materials (OR = 3.92 (CI: 1.28, 11.96)), P = .017 and postoperative mucocele formation, P = .0035. The use of bone graft was associated with increased risk of total postoperative complications (OR = 2.68 (CI: 1.41, 5.11), P < .01. Use of autologous materials was associated with decreased number of total complications when compared with non-autologous materials (OR = 0.13 (CI: 0.02, 0.99), P = .02. Conclusions: Avascular grafts, such as bone grafts, for NFD obliteration may be associated with an increased risk of reoperation. In particular, bone grafts are associated with higher rates of reoperation, postoperative infection and mucocele formation. Vascularized flaps appear to offer excellent postoperative outcomes with minimal operative morbidity. This systematic review may be useful in further refining the roles of certain materials in NFD obliteration for FSF surgery.