Injuries to the sinuses: causes, symptoms, diagnosis, treatment

Traumatic injuries of the paranasal sinuses are much rarer than injuries and wounds of the nasal pyramid, but if they occur, they are clinically much more severe. The causes of trauma to the paranasal sinuses are the same as those of the nasal pyramid. With contusions of the maxillofacial and frontal region, fractures of the anterior paranasal sinuses may occur, and with contusions of the frontal region, fractures of the skull base in the area of the bottom of the anterior cranial fossa with ruptures (or without them) of the dura mater. With blunt injuries, damage to soft tissues, cracks in the walls of the paranasal sinuses, closed and open fractures of the maxilla, frontal, ethmoid and sphenoid bones may be observed, which are often accompanied by vibration, concussion and compression lesions of the brain. Symptoms and clinical course vary depending on the traumatic injury to a particular paranasal sinus.

Frontal bone lesion. The general condition most often manifests itself in various signs of traumatic shock and corresponding brain lesions. Locally: pain in the area of injury, swelling and hematoma, contusions and other wounds of soft tissues penetrating to the bone. In case of a fracture of the anterior wall of the frontal sinus, sharp pain and crepitation of bone fragments are felt upon palpation. Emphysema of soft tissues in the periorbital tissues, face, etc. often occurs. In case of contusions of the frontal bone and fractures of its walls, nosebleeds are often observed. In cases where there is a fracture of the brain wall with a rupture of the dura mater, nasal cerebrospinal fluid rhinorrhea is observed. X-ray of the frontal bone allows to establish the nature of the fracture, to identify the state of the skull base, the presence of a hemosinus and subarachnoid hemorrhage in the anterior cranial fossa.

Gunshot and shrapnel wounds to the frontal bone are characterized by significant severity of damage, since they are most often combined with wounds to the orbit and frontal lobes of the brain. Such wounds are the responsibility of neurosurgeons, and only those wounds to the frontal sinus that are mostly tangential (touching), violating only the integrity of the anterior wall of the frontal sinus and combined with wounds to the nasal cavity and lower parts of the ethmoid bone without penetration into the cranial cavity and rupture of the meninges, are treated in a specialized ENT department.

Injuries to the frontal sinus, especially those penetrating both into the sinus itself and into the nasal cavity and skull, are fraught with serious complications, which are reflected in the classification of N.S. Blagoveshchenskaya (1972).

Classification of complications after frontal sinus injuries

• Purulent complications after frontal sinus injuries.
  • Traumatic purulent-polypous frontal sinusitis.
    • Frontitis accompanied by extracerebral purulent complications:
      • frontal sinusitis and epidural abscesses:
      • Frontites and SDA.
    • Frontitis accompanied by intracerebral purulent complications:
      • frontal sinusitis and intracerebral abscesses:
      • frontal sinusitis and suppuration of the cerebral scar.
  • Limited purulent pachymeningitis in the frontal region.
• Non-purulent complications after frontal sinus injuries:
  • persistent nasal cerebrospinal fluid rhinorrhea;
  • valvular pneumocephalus;
  • nosebleeds.

Of the listed complications, the most common are purulent-polypous frontal sinusitis and frontoethmoiditis. The most severe are injuries to the frontal sinus, with intracerebral purulent complications. In addition to the above complications, it is necessary to note such as acute inflammatory processes in the skin of the frontal region (erysipelas, furuncles, subcutaneous empyema spreading to the convexital integuments) or in bone tissues (osteomyelitis), which can cause severe intracranial complications.

Combined injuries and wounds of the frontal and ethmoid bones are particularly severe, as they are accompanied by extra- or intradural lesions in 86%. Such lesions, especially those involving the brain matter, are accompanied by many neurological, mental and ocular complications.

In case of injuries to the bony fronto-ethmoidal massif with penetration of the wound channel into the anterior cranial fossa, into the orbital and infraorbital regions, various neurological symptoms arise, caused by damage to the formations on the base of the skull of the anterior cranial fossa, the most important of which are the substance of the frontal lobes with the nerve centers located in them, the olfactory and optic nerves, as well as the first branch of the trigeminal nerve, the upper branches of the facial nerve and the nerves innervating the extraocular muscles - the oculomotor, trochlear and abducent. Damage to these formations causes the corresponding symptoms (anosmia, amaurosis, gaze paralysis, etc.).

Lesions of the upper jaw can be open and closed (in relation to the maxillary sinus). Most often, there are household injuries caused by blunt blows to the zygomatic region and the region of the upper alveolar process. Usually, such injuries are accompanied by hemosinus, damage to the integrity of the teeth of the upper jaw, nosebleeds, and concussion. Frequently, fractures of the maxillary sinus are combined with bruises of the pyramid of the nose and fractures of its bones, as well as the zygomatic bone, therefore, such injuries are usually combined and, as a rule, the victims are admitted to the maxillofacial surgery department. Often, trauma to the maxillary sinus occurs during tooth extraction, mainly the upper 6th tooth, as well as during the removal of root cysts of the 5th, 6th and 7th upper teeth - a fistula is formed in the socket, a sign of which is the ingress of fluid into the nose through the socket. When blowing through the nose, air from its cavity through the outlet of the maxillary sinus enters the sinus and from it into the oral cavity through the perforated socket of the tooth.

Isolated fractures of the ethmoid bone and sphenoid sinus are very rare. They are usually combined with fractures of the base of the skull and severe TBI. Gunshot wounds to the sphenoid sinus and ethmoid bone usually result in the death of the victim at the site of the injury.

The clinical course of traumatic lesions of the paranasal sinuses is determined primarily by the severity of the injury, repercussion traumatic lesions of the brain and the type of destruction caused by the traumatic object. As a rule, if specialized surgical care and antibacterial treatment are not provided in a timely manner, such injuries are complicated by severe maxillofacial, orbital abscesses and phlegmons. In trauma to the nasal cavity with a fracture of the base of the skull and access of infection to the meninges, severe meningoencephalitis develops, the prognosis of which is on the verge of unfavorable.

Treatment of paranasal sinus trauma. In case of minor trauma to the paranasal sinuses without open fractures and damage to the mucous membrane, treatment is usually non-surgical (systemic antibiotic therapy, in case of hemosinus - puncture with elimination of blood and introduction of antibiotics into the sinus, vasoconstrictors - into the nasal cavity, antihistamines).

In case of moderate injuries accompanied by deforming fractures of the paranasal sinuses, with soft tissue injury, the same surgical interventions are used as in case of chronic purulent inflammatory diseases of these sinuses. Primary surgical treatment should be carried out in the mode of specialized care with reposition of fragments, elements of plastic surgery and optimal drainage of the sinuses. Systemic anti-inflammatory and analgesic treatment is carried out simultaneously.

In case of severe injuries with a fracture of the base of the skull and the risk of meningoencephalitis, the victims are sent to the neurosurgical department. In surgical intervention for such combined injuries, it is advisable to involve a rhinologist and a maxillofacial surgeon.

The prognosis is very cautious in severe injuries; the outcome depends on the timing of surgical intervention and the timeliness and intensity of antibacterial treatment. In mild and moderate injuries, the prognosis is generally favorable.