Subcutaneous forehead nodules: attention to the button osteoma and frontalis-associated lipoma

Hemorrhage due to attempted excision of a frontal exophytic lesion: A cautionary tale

Background:

Despite mainly benign, exophytic subcutaneous cranial masses present with a myriad of differential diagnosis possibilities, ranging from simple, superficial lesions to complex lesions involving the central nervous system. Although the gold standard imaging modality for the diagnosis of these lesions is magnetic resonance imaging, Doppler Ultrasonography can be a useful, inexpensive, and available tool for evaluation of lesions that could potentially be safely treated in the primary care setting, and lesions that would demand advanced neurosurgical care.

Case Description:

This patient presented with a complex exophytic plasmocytoma that was first diagnosed and erroneously approached as a subcutaneous lipoma with surgical resection in an outpatient surgical setting. This interpretive approach resulted in the failure of the procedure due to significant hemorrhage. The patient was immediately referred to neurosurgical care and transferred to our center. Admission doppler ultrasound imaging revealed absence of the frontal bone, the enriched and profuse vascularization, allowing further and proper diagnostic approach and treatment.

Conclusion:

Ultrasound could be a reliable, fast, and simple imaging method aiding practitioners to perform a better workup for patients with exophytic subcutaneous cranial masses.

New 'ZISIS' (Zigzag Incision-Suction-Irrigation System) Technique for Endoscopic-Assisted Forehead Tumour Excision

Background

Endoscopic-assisted excision of forehead tumours like osteomas and lipomas is well established, but the conventional techniques suffer from many limitations like inadequate access, fogging of the endoscope and unclear vision due to collection of blood and debris.

Method

Three simple modifications of the conventional endoscopic forehead technique for benign tumour excisions are described by the acronym 'ZISIS'. ZI Zigzag scalp incision increases the surface area of the opening permitting easy insertion of multiple instruments along with the endoscope.S Suction tubing made from a disposable suction catheter tube is taped along the endoscope sheath for continuous suctioning and good vision.IS Irrigation system of warm saline made with an infant feeding tube is also taped along the endoscope just opening in the front of the suction tube.

Results

A total of 12 consecutive patients underwent endoscopic excision of forehead benign tumours in 2 years. This included 2 lipomas and 10 osteomas cases. All patients achieved excellent hidden scars in the scalp. All patients rated their results as excellent with respect to the hidden scar and aesthetic result. No early or late complications were reported with follow-up ranging from 6 months to 2 years.

Conclusion

A new simple modification called 'ZISIS' endoscopic forehead excision technique is described for benign forehead tumours excision making it easier, efficient and ergonomic.

Level of Evidence IV

Evidence obtained from multiple time series with or without the intervention, such as case studies.

Button Osteoma: A Review of Ten Cases

BACKGROUND

Button osteoma presents as small circumscribed ivory-like lumps on the skull vault. Although not rare, its diagnosis can be challenging for dermatologists.

OBJECTIVE

To clarify the clinical characteristics of button osteoma by reviewing 10 cases.

METHODS

Ten patients diagnosed with button osteoma at the Department of Dermatology, Kyungpook National University Hospital, between January 2011 and August 2014 were enrolled. We retrospectively reviewed medical records and analyzed demographic and clinical characteristics including sex, age, sites, number of lesions, symptoms, duration, histopathological finding, radiological findings, and treatment.

RESULTS

All patients presented with an asymptomatic small circumscribed hard lump fixed to a bony structure. There were 9 female and 1 male patient, and the mean age was 54 years (range, 28~61 years). The most common site was the forehead, and disease duration ranged from 2 weeks to more than 20 years. The differential diagnosis included cranial exostosis, ballooned osteoma, epidermal cyst, and lipoma. Simple radiography, ultrasonography, and computed tomography (CT) were used to make a confirmative diagnosis. Histopathological findings showed lamellated bony structures with poor vascularization. Ostectomy was performed for 5 patients, and no recurrence was detected within an average of 13.4 months after treatment.

CONCLUSION

This review characterized button osteoma. Surgical excision is a useful therapeutic modality after CT-based diagnosis. Further studies with more patients are required to confirm the findings.

Multiple peripheral osteomas of forehead: report of a rare case

Osteoma is a benign slow growing osteogenic lesion, composed of well-differentiated mature bone tissue, characterized by the proliferation of compact or cancellous bone, almost exclusively found in the head and neck region. Central, peripheral and extra skeletal are the three variants of osteoma. Trauma, inflammation, developmental disorders and genetic defects are considered as the etiologic factors. Paranasal sinuses are the favourite locations of peripheral osteoma of the craniofacial region; frontal and ethmoidal sinuses being the common ones. Although, peripheral osteomas are usually benign, innocuous lesions, their size and prominent location on the visible parts of the face makes the surgical intervention necessary. We report case of multiple peripheral osteomas of forehead, without involvement of the frontal sinus, which is a rare variety.