Ethmoid sinus osteoma: diagnosis and management

Endoscopically managed giant frontoethmoidal osteoma with orbital extension

A patient in his 20s presented with a change in the appearance of his left eye with evidence of relative afferent pupillary defect. Imaging revealed a giant frontoethmoidal osteoma, a benign sinonasal tumour, invading three-quarters of the orbit. Multidisciplinary discussion involving opthalmology, maxillofacial surgery, neurosurgery and otolaryngology resulted in the decision to attempt entirely endoscopic excision of this lesion, which was performed with successful outcomes. This case demonstrates how a sinonasal osteoma should be considered in the differential diagnosis for a patient presenting with proptosis or other eye signs suggestive of compression of the orbital compartment. This case report and literature review highlights the possibility of managing giant sinonasal osteomas with orbital extension through a completely endoscopic approach.

A Case of Giant Ethmoid Sinus Osteoma

Paranasal sinus osteomas are slow-growing benign tumors. They are generally asymptomatic in most patients and usually diagnosed incidentally with a sinus radiograph or more frequently with a CT scan of the paranasal sinuses. Osteomas can cause various signs and symptoms, depending on the location of the mass. Giant osteomas of the paranasal sinuses are very rare, with only a handful of case reports in the literature. Due to the rarity of giant osteomas, the clinical presentation and treatment are unclear. In this article, we present a case of giant ethmoid sinus osteoma, which was removed with an endoscopic endonasal approach, as well as a review of the literature.

Management of paranasal sinus osteomas: A comprehensive narrative review of the literature and an up-to-date grading system

BACKGROUND

Surgical excision represents the unequivocal treatment modality for symptomatic paranasal sinus osteomas. However, the optimal surgical approach and the extent of the surgery, as well as the management stance in the case of an asymptomatic tumor, remain controversial.

METHODS

The MeSH terms 'Osteoma', 'Nasal Cavity', and 'Paranasal Sinuses' were used to retrieve articles concerning the management of paranasal sinus osteomas that were published in the last 30 years, the vast majority of which comprised case reports of one or two cases. Original articles or large series of more than six cases were prioritized.

RESULTS

Our review summarizes previous findings and opinions relevant to the management of symptomatic and asymptomatic paranasal sinus osteomas. The recent shifts in trends of their management are thoroughly discussed. Currently, an extension of the lesion through the anterior frontal sinus wall; an erosion of the posterior wall of the frontal sinus; a far-anterior intraorbital extension; an attachment to the orbital roof beyond the midorbital point; and some patient-specific adverse anatomic variations that may restrict access, are considered strong contraindications to a purely endoscopic approach. On the grounds of this thorough review, a new grading system for frontal and frontoethmoidal osteomas is proposed to allow better conformity to recent advancements and current clinical, research, and educational needs.

CONCLUSION

Over the past 30 years, endoscopic techniques have emerged as the new standard of care for favorably located paranasal sinus osteomas. Nonetheless, open approaches remain indispensable for the management of the more perplexing cases of frontal sinus osteomas.

Gigantic paranasal sinuses osteomas: clinical features, management considerations, and long-term outcomes

PURPOSE

Paranasal sinus osteomas are slow-growing, benign bony tumours that when larger than 30 mm, they are termed 'gigantic'. Special considerations apply for tumours of this calibre, and their rarity renders their management fairly controversial. This study seeks to contribute to an increased understanding concerning their management by presenting a 12-year experience from a single institution.

METHODS

Retrospective review of files of patients treated for a gigantic paranasal sinus osteoma from January 2008 to December 2019. Additionally, all patients were prospectively reexamined in early 2020 for late complications or clinical recurrence.

RESULTS

Ten patients were included, with a mean age of 53.8 years (range: 23-77 years). The leading presenting findings were proptosis (80%) and diplopia (70%). Transient visual impairment was remarkably frequent (30%). Five patients were managed with an open approach, two with an endoscopic, and three with a combined technique. The most common adverse characteristics that dictated the use of an open approach, alone or in combination with an endoscopic approach, were the involvement of the anterior wall of the frontal sinus (40%), erosion of its posterior wall (30%), and a far-anterior intraorbital extension (30%). No major postoperative complications were observed, and also no recurrences.

CONCLUSION

Our study illustrates that these tumours may require a different management attitude. Despite substantial advances in the endoscopic management of benign sinonasal tumours, managing these massive tumours solely endoscopically could, in many cases, be inefficacious or impossible. Open approaches remain valuable, representing a safe and straightforward method for adequate exposure.

Orbital cellulitis secondary to giant sino-orbital osteoma: A case report

Background

Although osteoma is a common benign tumor of the paranasal sinuses, its orbital extension is not common. Secondary orbital cellulitis has rarely been reported in association with sino‐orbital osteoma.

Case

A 30‐year‐old woman presented with left side proptosis, orbital pain and inflammation. Orbital CT scan showed a well‐defined giant osteoma in the superonasal part of the left orbit originating from the left ethmoidal sinus associated with opacity of the ipsilateral ethmoidal sinus and infiltration of orbital soft tissue. After treatment by systemic antibiotics, osteoma was resected with combined external and endoscopic surgery and the patient recovered uneventfully.

Conclusion

Sino‐orbital osteoma may manifest primarily as orbital cellulitis and needs early surgical intervention.

Giant osteomas: Clinical results and surgical approach from ophthalmic point of view

PURPOSE

To present clinical ocular manifestations, radiological features and surgical results of giant paranasal osteomas involving the orbit.

DESIGN

Retrospective, interventional, case series.

METHODS

The study included patients treated for giant paranasal osteoma involving the orbit. Total or subtotal excision of the tumor was performed via external approach. Clinical characteristics including presenting symptoms, radiologic investigation, histopathology and details of the surgery were recorded.

RESULTS

Of the six patients included; four were male and two were female. Mean age was 46.8 years (range 12-70 years). Five patients had unilateral, one patient had bileteral disease. The presenting complaints included complete (n = 2/6) or partial (n = 4/6) limitation of eye movements depending on the location and size of the tumor, diplopia (n = 5/6), vision loss (n = 2/6) exophthalmos (n = 6/6) and reduced pupillary light reflex (n = 2/6). The presumed origin of the tumor was frontoethmoidal region (n = 2/6), frontal sinus (n = 3/6) and ethmoid sinus (n = 1/6). Total resection was achieved in three of the patients whereas partial resection was achieved in remaining three patients due to risk of incremental neurological damage. Mild ptosis was observed in all patients during the postoperative period (temporary, n = 4; permanent, n = 2).

CONCLUSION

Despite the benign nature of osteomas, severe functional impairment including vision loss due to compression of the optic nerve and diplopia might occur in case of orbital involvement. Osteomas with an orbital extension > %50 of the bony orbit volume are more prone to cause irreversible visual loss. Surgical resection is still the mainstay of therapy.

Fibro-osseous Lesions of Paranasal Sinus and Craniofacial Region: A Retrospective Study of 282 Cases

OBJECTIVES

To compare the clinical characteristics of osteoma, ossifying fibroma (OF) and fibrous dysplasia (FD) in the paranasal sinus and craniofacial regions.

METHODS

Totally 282 patients (112 males, 170 females) with osteoma (161), OF (44), and FD (77) involving the paranasal sinus, skull base and orbit treated surgically from January 2012 to August 2018 were analyzed retrospectively.

RESULTS

For osteoma, OF and FD, the onset ages were 40.3 (6-75), 24.5 (5-62), and 15 (1-63) years, and the most common locations were ethmoid sinus (49.7%), maxilla (36.4%) and maxilla (49.4%), respectively. There were significant differences of the preoperative serum alkaline phosphatase (ALP) levels between patients with osteoma (65 [25,184] U/L), OF (85.5 [41,474] U/L), and FD (104 [39,362] U/L) (Z = 44.9, P < .05). The ALP levels of OF and FD patients were comparable between monostotic and polyostotic lesions (P > .05). The recurrent rates of osteoma, OF, and FD were 0%, 13.6%, and 15.6%, respectively. The recurrent OF cases had significantly higher ALP level than the primary ones (283.5 [108,474] U/L vs. 76 [41,348] U/L, U = 14, P < .05).

CONCLUSION

There are differences in the onset age, location, and recurrence rate among osteoma, OF and FD involving the paranasal sinus and craniofacial region. Osteoma most commonly occurs in the ethmoid sinus, while OF and FD involve the maxilla most and are more likely to involve the orbit and the skull base, respectively. Endoscopic surgery is currently the main method for treatment, but individualized treatment regimen should be developed for patients.

LEVEL OF EVIDENCE

IV Laryngoscope, 131:E1-E7, 2021.

A Rare Cause of Headache: Pneumatized Nasal Septum Osteoma

Paranasal sinus osteomas are among the rare causes of headache and they are most commonly seen in the frontal and ethmoid sinuses. In this report, we presented the first case of pneumatized nasal septum osteoma causing headache, successfully treated with endoscopic transnasal approach.

The Management of the Paranasal Sinus Osteomas

OBJECTIVE

Osteoma is the most common benign tumor of the paranasal sinuses. The clinical characteristics and treatment of this disease remain controversial. The aim of this study is to determine the appropriate method of treatment approach according to the features of osteomas.

METHODS

Forty-one patients with paranasal sinus osteomas were included in the study. According to the location and the size of tumors, patients were followed up or operated. Surgical treatment was performed via external, endoscopic, or combined approaches for symptomatic patients. Routine physical and radiological evaluations were performed for follow-up in asymptomatic patients.

RESULTS

Paranasal sinus osteomas were found most common in frontal sinus (n = 26, 63.4%) followed by ethmoid sinus (n = 10, 24.3%), maxillary sinus (n = 4, 9.7%), and sphenoid sinus (n = 1, 2.4%). Of the patients with frontal sinus osteomas, the endoscopic approach was performed in 11 patients, external approach (osteoplastic flap) in 9, and combined (external + endoscopic) approach in 5 patients. Endoscopic approach was preferred in all patients with ethmoid osteoma. The combination of Caldwell-Luc procedure and endoscopic approach was performed in 1 patient with maxillary sinus osteoma. In 3 patients, who underwent osteoplastic flap technique, mucocele developed in the postoperative period. Partial loss of vision developed postoperatively in 1 patient with a giant ethmoid osteoma. There were no other complications and recurrence in an average of 29 months follow-up.

CONCLUSION

Paranasal sinus osteomas are rare, slow-growing benign lesions, with potentially serious complications. Main treatment option for sphenoid and ethmoid sinus and other symptomatic osteomas are surgical resection. Radiographic follow-up is necessary for asymptomatic lesions. Selection of surgical resection method depends on tumor location and size. Patients should be observed for recurrence with periodic examination and imaging techniques. Follow-up should be performed at least in 1-year intervals after the surgery.

LEVEL OF EVIDENCE

1c.

Ossifying fibromas of the paranasal sinuses: diagnosis and management

Fibro-osseous benign lesions rarely affect the sinonasal tract and are divided into 3 different entities, namely osteoma, fibrous dysplasia and ossifying fibroma. They share several clinical, radiological and histological similarities, but have different behaviours. Ossifying fibroma, and in particular the "juvenile" histological subtype, may have a locally aggressive evolution and a high risk for recurrence if removal is incomplete. The purpose of the present study is to compare the clinical behaviour of ossifying fibroma with the other benign fibro-osseous lesions; highlight different behaviour between the histological subtypes; compare the advantages, limitations and outcomes of an endoscopic endonasal approach with reports in the literature. We retrospectively reviewed 11 patients treated for sinonasal ossifying fibroma at a tertiary care centre. All patients underwent CT scan, and MRI was performed in cases of cranial base involvement or recurrence. Pre-operative biopsy was performed in cases where it was possible to use an endoscopic approach. One patient underwent pre-operative embolisation with ipsilateral visual loss after the procedure. Depending on its location, removal of the tumour was performed using an endoscopic (n = 7), or an external (n = 3) or combined (n = 1) approach. Histopathologically, 5 patients presented the conventional type, 5 the juvenile psammomatoid variant, which was associated in 1 case with an aneurismal bone cyst, and 1 case presented the trabecular juvenile variant. Three patients affected by the juvenile psammomatoid histological variant presented invasion of the skull base and underwent a subtotal removal that subsequently required, due to the regrowth of the remnant, a transbasal approach. Clinical, radiological and histological findings should all be considered to establish differential diagnosis among fibrous osseous lesions. More studies are necessary to conclude if the localisation and extension of the disease at the time of diagnosis is more important than the histological variant. An endoscopic approach is the first choice in most of cases even if an external open approach may be necessary in selected patients.

A review of nasal, paranasal, and skull base tumors invading the orbit

Tumors that invade the orbit are uncommon. The majority are meningiomas arising from the sphenoid ridge (66%). Others are bone and cartilage tumors arising from the surrounding bones of the orbit, pituitary adenomas, and epithelial tumors arising from the paranasal sinuses and nasal cavity. Meningiomas occur more often in women, whereas epithelial tumors have a predilection for men. Meningiomas and epithelial tumors typically present in the sixth decade of life, whereas bone tumors tend to affect individuals in their third decade of life. Patients often present with a combination of ophthalmological and otorhinolaryngological symptoms, including proptosis, pain, decreased visual acuity, restrictions in motility of the eye, epistaxis, and nasal obstruction. Sarcomas and benign bone and cartilage tumors arise from surrounding structures, whereas carcinomas usually arise from the paranasal sinuses. Surgery is the mainstay of treatment. Depending on the aggressiveness and histology of the tumor, surgery may be combined with radiation and chemotherapy. The prognosis is generally poor, but varies depending on histology and cell origin, size of the tumor, and degree of invasion. Meningiomas and benign bone tumors have the best prognoses. Sinonasal undifferentiated carcinomas, small-cell neuroendocrine carcinomas, osteosarcomas, and rhabdomyosarcomas have poorer prognoses.

Giant paranasal sinus osteomas: surgical treatment options

Giant paranasal sinus osteomas are rare tumors that may be very closely adherent to surrounding anatomical structures, and complete removal of these tumors may be very challenging. We report 6 cases of giant paranasal sinus osteomas that were removed completely and discussed their symptoms, diagnostic workup, and our surgical approach. We reviewed the patient files of our 6 cases with giant paranasal osteomas and summarized their history, symptoms, diagnosis, management, and follow-up. Three of our patients underwent endoscopic sinus surgery; the other 2 patients underwent open surgical approach (osteoplastic flap procedure with bicoronal incision), and 1 patient underwent both endoscopic and open approaches, all under general anesthesia. Mean patient age was 42.6 years (range, 18-54 years). Main symptoms were headache, proptosis, and diplopia. Physical examination findings include proptosis and frontal puffiness. Paranasal sinus computed tomography revealed larger than 3-cm-diameter tumors in the frontal and ethmoid sinuses. The surgical approach to each case was customized to the location, size, and presenting symptoms of the osteoma. Histopathology revealed osteoma in all cases. All patients were evaluated with paranasal sinus computed tomography scan postoperatively. At a mean follow-up of 15 months, complication was observed in 1 patient; no residual tumor or recurrence was detected following surgery. In symptomatic cases with huge tumors, open, endoscopic, or combined approaches could be applied because of the location and size of the tumor with successful outcomes. Both endoscopic and open approaches are safe and effective methods for removal of these tumors.

Characteristics of paranasal sinus osteoma and treatment outcomes

CONCLUSION

The incidence of paranasal sinus (PNS) osteoma was 6.4%. The most common site of PNS osteoma was the ethmoid sinus. All surgically treated patients underwent endoscopic surgery, and there was no recurrence in any patient. Technical improvements, including an image guidance system, extended the indications for endoscopic surgery for PNS osteomas, especially in the frontal sinus region.

OBJECTIVE

The purpose of this study was to investigate the incidence and location of PNS osteomas detected by computed tomography (CT) scan at our hospital, and to describe our experience in the surgical treatment of PNS osteomas.

METHODS

This study was performed on 1724 patients undergoing CT scans because of suspected sinus disease between 2004 and 2013. Endoscopic surgery was performed in 34 symptomatic patients. Medical records of the patients were reviewed, and clinical findings and treatment outcomes were investigated.

RESULTS

PNS osteomas were detected in 110 patients (6.4%). Triple osteomas were detected in two patients. Double osteomas were detected in seven patients. In total, 121 lesions were identified as PNS osteomas. The ethmoid sinus was the most commonly affected site (57.0%), followed by the frontal sinus (25.6%), frontal recess (9.1%), maxillary sinus (5.0%), olfactory fissure (1.7%), and sphenoid sinus (1.7%) in descending order of frequency. Thirty-three patients were surgically treated for PNS osteomas through a purely endoscopic approach, and one patient with a frontal sinus osteoma underwent combined endoscopic surgery and frontal trephination. Image-guided surgery was performed in nine patients with involvement of the orbit and skull base, including the frontal sinus/recess. There were no major surgical complications and there was no tumor recurrence.

Ethmoid osteoma as a culprit of orbital emphysema: a case report

Orbital emphysema is generally recognized as a complication of orbital fractures involving any paranasal sinuses. The recognition about its etiology has extended beyond sole trauma, but few articles mentioned tumors to be a possible cause.In this case report, we present a patient with orbital emphysema associated with ethmoid osteoma without orbital cellulitis or trauma history. The patient developed sudden proptosis, eyelid swelling, and movement limitation of the left eye, peripheral diplopia, and left periorbital crepitus after a vigorous nose blowing.Complete surgical resection of ethmoid osteoma followed by repair of the orbital medial wall was performed with assistance of combined endoscopy and navigational techniques. Twelve-month follow-up showed no residual lesion or recurrence; the orbital medial wall was accurately repaired with good visual function and facial symmetry.Tumors should be considered for differential diagnosis of orbital emphysema, and combined endoscopy and navigational techniques may improve safety, accuracy, and effectiveness of orbital surgeries.

Giant orbitoethmoidal osteoma: when an open surgical approach is required

Giant orbitoethmoidal osteoma in children is considered to be rare. This type of pathology can be associated with significant disfiguring proptosis and limitation of eye movement. Here, we report on a child who presented with a giant orbitoethmoidal osteoma that was removed through an orbitofrontal approach. The cosmetic result was excellent and evident immediately after surgery. A review of the literature complements this report.