Giant paranasal sinus osteomas: surgical treatment options

Total removal of a giant frontal sinus osteoma with orbital extension - A case report

The Rationale:

Osteomas are benign tumours that are usually asymptomatic. However, giant osteomas can lead to severe complications. We report here the management of a giant frontal sinus osteoma with orbital extension.

Patient Concerns:

We present the case of a 17-year-old patient presenting with rapidly progressive isolated right exophthalmos.

Diagnosis:

A cerebral computed tomography scan was performed and showed a giant osteoma of the right frontal sinus extending to the orbit and massively eroding the anterior wall of the frontal sinus.

Treatment and Outcomes:

The patient underwent surgery and a complete removal of the osteoma was accomplished via an open approach, but without performing a bone flap. No recurrence was observed after 2 years of follow-up.

Take-away Lessons:

Although rare, giant frontal osteomas can cause severe functional impairment due to their proximity to noble structures. Therefore, open approach remains the mainstay of therapy.

Frontal Sinus Osteoma: From Direct Excision to Endoscopic Removal

Frontal sinus osteomas are benign bone-forming neoplasms. Ongoing advancements in endoscopic surgery have allowed less invasive surgical approaches to be adopted for removal. The authors systematically reviewed the literature to provide analysis and recommendations for management.One hundred ninety-three publications encompassing 1399 patients met inclusion, with mean age 42.1 ± 13.8 years and a male predominance (59.2%). Symptoms included pain (70.8%); orbital/ocular (20.7%); sinonasal (36.4%); neurologic (6.0%); other (14.5%); and asymptomatic (4.8%). Osteoma was isolated to the frontal sinus (82.9%) or extended into the ethmoid (16.6%), maxillary (0.3%), and sphenoid sinuses (0.2%). There was intracranial extension in 9.5% and intraorbital extension in 18.7%. Of those proceeding to surgery, majority (59.8%) underwent open approaches, followed by endoscopic (25.0%) and combined (11.5%). A significant (P < 0.01) increase in proportion of cases utilizing endoscopic approaches versus open/combined was observed over the period studied. Seventy-one postoperative complications were reported, in 7.5% of endoscopic cases, 27% of open, and 8.8% of combined. Complications were more likely in open/combined surgery, compared with endoscopic (22.3% versus 7.5%, P < 0.001). In 181 patients, completeness of resection was reported (complete resection; 87.8%) and found to be a significant predictor (P < 0.01) for disease recurrence/progression. Mean length of stay for the endoscopic group was 3.1 ± 1.3 days, compared with 7.9 ± 3.1 for open/combined (P < 0.0001).In the management of frontal sinus osteoma, indications for selecting endoscopic versus open approaches have expanded over the past 30 years, as techniques, equipment, and understanding of pathophysiology have evolved. Where endoscopic approaches are possible, they are associated with reduced morbidity and length of stay compared with open approaches.

Surgical Treatment of Paranasal Sinus Osteomas: A Single Center Experience of 58 Cases

OBJECTIVES

Osteomas are osseous tumors that primarily occur at the skull, in particular the paranasal sinus system. Surgical tumor resection is the "gold standard" treatment in symptomatic osteomas. The aim of this study was to investigate the use of surgical approaches (endoscopic, open, combined) and to provide a step-by-step approach for patients' management.

METHODS

Fifty-eight patients (31 m, 27 f, 42.1 ± 15.3 years) that were treated between 2001 and 2015 at our department were included in this retrospective, single center study.

RESULTS

In almost half of cases (n = 28, 48.3%) endoscopic, endonasal approaches were used for tumor resection while open (n = 11, 19%) or combined (n = 19, 32.8%) approaches were used in the rest of the cohort. Open or combined approaches were applied in patients suffering from osteomas localized in the maxillary or frontal sinuses only.

CONCLUSION

Beside interviews, clinical examination, nasal endoscopy, and computed tomography are crucial for diagnosis of paranasal sinus osteomas. Magnet resonance imaging can be useful in extensive pathologies. The preoperative selection of the optimal approach for osteoma resection might be most challenging in patients' management. Although useful recommendations regarding the use of surgical approaches have been published, technical requirements and surgical experience of surgeons have to be considered in the limitations of endoscopic approaches. If there are doubts about the resectability of an osteoma by an endoscopic approach, the surgical procedure may be started endoscopically, and, if necessary, it can be combined with an external approach.

LEVEL OF EVIDENCE

IV Laryngoscope, 130:2105-2113, 2020.

Surgical Approach to Frontal Sinus Osteoma: A Systematic Review

Background

Osteoma of the paranasal sinuses are benign bony masses most commonly found in the frontal sinus. In the past, due to the anatomical complexity of the frontal sinus, these often required an open approach, but with the invention of angled tools and endoscopes, many rhinologists are now attempting endoscopic or combined resections. No large systematic reviews currently exist that describe the surgical management of frontal sinus osteoma.

Objective

To perform a systematic review detailing the surgical resection of frontal sinus osteoma. Review Methods: A systematic literature review was performed using PubMed, Embase, and Ovid databases. Data extracted included demographics, clinical presentation, radiologic, histologic findings, surgical approach, and recurrence.

Results

A total of 32 studies, with 477 surgically resected tumors, were included in the analysis. Sex data were available for 179 patients (M:F, 93:86), with a mean age of 43.2 years. All resected tumors presented symptomatically: facial pain/headache (80.2%), recurrent sinusitis (30.5%), mucocele (4.3%), cosmetic deformity other than proptosis (12.8%), and proptosis (5.5%). Transnasal endoscopic surgery alone was the most common surgical approach utilized (44.9%), followed by open osteoplastic flaps (36.9%) and endoscopic assisted (18.2%). Osteoma with anterior (79%) and posterior (73%) attachments were treated statistically more often with endoscopic approach compared with floor (42%) and extrasinus (50%) attachment ( P < .0005). There was no statistical difference in approach to masses that crossed the sagittal plane extending from the lamina papyracea (63% endoscopic, 29% endoscopic assisted, 8% open, P = .21). Mean follow-up was 29.7 months, with recurrence or persistent residual disease occurring in 12 patients.

Conclusion

Despite the increasing use of endoscopic alone procedures for expanding indications, patients may still require an open or endoscopic assisted approach for complete removal.

Giant Frontal Sinus Osteomas: Demographic, Clinical Presentation, and Management of 10 Cases

BACKGROUND

Osteomas are rare benign and slow-growing osteogenic tumors mainly involving frontal and ethmoid sinuses.

OBJECTIVES

The primary objective of our study is to present the management of cases of giant frontal sinus osteomas. Secondarily, we describe our modified unilateral osteoplastic flap approach without obliteration to remove these osteomas.

METHODS

Retrospective chart review at a tertiary academic center ("Hôpital de l'Enfant-Jésus") from July 2006 to October 2016. Demographics characteristics, tumor characteristics, presenting symptoms, frontal sinus surgery technique (osteoplastic flap, endoscopic surgery, or a combination of both), and outcomes of giant frontal sinus osteomas (≥30 mm) were recorded. For laterally placed osteomas, tumors with posterior wall involvement, orbital roof involvement, or intracranial extension, the modified unilateral osteoplastic flap approach was used. A decision-making algorithm is proposed for the choice of surgical approach.

RESULTS

Ten giant frontal osteomas were analyzed (7 men and 3 women). The mean age at diagnosis was 38 years old (range, 24-55 years; median, 39 years; standard deviation, 11 years). The most common presenting symptom was headache (43% of symptomatic patients). Five patients had complications preoperatively due to tumoral extension (sinusitis, cellulitis, mucocele, optic nerve compression, and convulsions). One patient was treated endoscopically, 3 patients had an open approach and 6 patients had a combined technique. One patient experienced a postoperative complication (local infection treated with oral antibiotics). Six patients had minimal residual tumor with one patient needing reoperation.

CONCLUSION

Osteomas are rare paranasal sinus tumors. Due to the proximity to noble structures, a giant frontal osteoma should be managed surgically. The modified unilateral osteoplastic flap without obliteration offers good long-term surgical and aesthetic results. Osteomas are not known for malignant transformation and recurrences are rare; thus, subtotal resection is warranted and safe when a cleavage plan is not found.

Reconstructing a Giant Frontal Osteoma With Porex

Osteomas are the most common benign tumors of the paranasal sinuses. They are usually localized in the frontal sinus. Giant osteomas of the frontal sinuses are very rare but readily extend into the intraorbital or intracranial cavity, causing serious complications. This is a report of a 14 year-old boy with a bulging in frontal area and asymptomatic giant osteoma of the frontal sinuses. He had a history of minor trauma that had a bulging after 3 months. However, he referred to a plastic surgeon after 15 months. Computed tomography of the sinuses revealed a 3.5 × 6 cm extremely dense bony mass in the frontal sinus that extended into the left orbit and ethmoid sinus. A bicoronal frontal flap was raised with a V-shaped skin incision starting from the tragus placed 5 cm posterior to the hairline. The osteoma was resected completely in the frontal sinus and the anterior wall of frontal sinus was reconstructed with Porex. The patient has not had any complications until the time of writing this report. Titanium mesh may still be a valuable option, but Medpore Porex has shown to be quite effective in this case.