Treatment of Frontal Sinus Fractures: A Systematic Review and Meta-analysis

Purpose: There is still no consensus about the best treatment for frontal sinus fractures (FSFs). Thus, the aims of this study were to answer the following questions: 1) what treatment of FSFs has the lowest rate of postoperative complications? 2) does sinus preservation using observation produce a lower complication rate? 3) are FSFs with nasofrontal outflow tract (NFOT) injury associated with greater complication rates following different treatment options when compared to those patients without NFOT involvement? Methods: A systematic review and meta-analysis were performed based on PRISMA that included several databases with specific keywords, a reference search, and a manual search for suitable articles. Randomized clinical trials, controlled clinical studies, retrospective studies and case series that estimated complications rate after different treatments options for FSFs were included. The predictor variable was treatment groups, including observation, ORIF, cranialization and obliteration. The outcome variable was complication rate and correlation between complication rate and presence/absence of NFOT. A weighted complication rate/proportion using a random effect model, or risk ratio (RR) with a 95% confidence interval (CI), was performed to construct forest plots. Data analysis was done using a comprehensive meta-analysis. Results: A total of 2,911 patients with FSFs enrolled in 23 studies were included in this study. The weighted complication rate for different treatment was as follows: observation (7%), ORIF (9.4%), obliteration (10.6%), and cranialization (11%). Nonsurgical treatment decreased the complication rate by 2.1 times (low quality evidence, RR = 2.1, CI: 1.13 to 3.9, P =.000) when compared to surgical treatments for FSFs. CR for fractures with NFOT was 8 % (55/619) compared to a complication rate of 5% (18/353) for fractures without NFOT with insignificant difference (very low quality evidence, RR = 1.7, CI: 0.75 to 4.1, P =.158). Conclusions: FSFs vary in their severity and treatments. The more severe fractures, the higher the complication rate, no matter how they were treated.