CLINICAL STUDY
Giant Paranasal Sinus Osteomas: Surgical Treatment Options Togay Muderris, MD,* Ergun Sevil, MD,* Sami Bercin, MD,Þ Buket Canda, MD,* and Muzaffer Kiris, MDÞ Abstract: 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, 18Y54 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. Key Words: Giant paranasal sinus osteomas, diagnosis, management, endoscopic surgery (J Craniofac Surg 2014;25: 1287Y1291)
From the *Department of Otorhinolaryngology, Head and Neck Surgery, Ataturk Training and Research Hospital; and †Department of Otorhinolaryngology, Head and Neck Surgery, Yildirim Beyazit University Medical Faculty, Ankara, Turkey. Received October 20, 2013. Accepted for publication November 14, 2013. Address correspondence and reprint requests to Ergun Sevil, MD, Department of Otorhinolaryngology, Head and Neck Surgery, Ataturk Training and Research Hospital, 06800 Bilkent, Ankara, Turkey; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000588
The Journal of Craniofacial Surgery
O
steomas are the most commonly seen benign tumors of the paranasal sinuses. Histopathologically, they are well differentiated and have a slow-growing clinical behavior. Although their real incidence is not certain because of asymptomatic nature, incidence of paranasal sinus osteomas has been reported to be around 3%.1 Osteomas mostly arise from the paranasal sinus walls, and they could easily extend into the surrounding areas such as the cranium and orbit. Secondary orbital extension from the paranasal sinuses has historically been considered uncommon, comprising 0.9% to 5.1% of all orbital tumors.3 However, in 1 case series, orbital extension was found in 24% of cases of ethmoid sinus osteomas.4 Radiological investigations are important for their diagnosis. They most commonly develop in the frontal sinus.1 In addition, they might also be detected in the ethmoid, maxillary, and sphenoid sinuses.1 The etiology of paranasal sinus osteomas is not clear yet. However, 3 main pathogenic theories including osteogenic, traumatic, and infective have been suggested.5 Histopathologic types of paranasal sinus osteomas include ivory or compact, spongious, and mixed.6 Paranasal sinus osteomas are mostly asymptomatic, and they are detected accidentally on paranasal computed tomography (CT) scans, which were obtained for other reasons.7 Clinical signs and symptoms, including headache, chronic sinusitis, proptosis, diplopia, mucoceles, cerebral abscess, and so on, vary because of the extension of the tumor.8 Computed tomography scan is helpful for the diagnosis, and the most common radiologic image is a homogenous radiopaque mass with well-defined margins.9 The differential diagnosis includes other bone-originated lesions containing fibrous dysplasia and ossifying fibroma.10 Periodic follow-up is suggested in asymptomatic cases. However, surgical treatment is required for symptomatic, rapidgrowing cases and lesions that involve frontal recess or both walls of the frontal sinus.11 Surgical treatment includes open, endoscopic, and combined approaches depending on the size, anatomic localization, and dimension of the mass. The primary purpose of this study was to highlight the clinical manifestation of giant paranasal sinus osteomas and to explore the varied surgical strategies used to manage these lesions.
MATERIALS AND METHODS We reviewed the patient files of our 6 cases with giant paranasal sinus osteomas and presented their history, symptoms, diagnosis, management, follow-up, and further discussion with the review of the literature. Clinical parameters reviewed included history and examination findings, imaging characteristics, management decision making, operative goals (when applicable), postoperative course, and histopathology. Presenting symptoms of the patients were headache, proptosis, and diplopia.
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Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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TABLE 1. Demographics and Relevant Clinical Features of Giant Paranasal Sinus Osteoma Cases Examination Findings
Patient
Sex
Age, y
Sinus
Presenting Complaint
1
Male
54
Ethmoid
Swelling, pain, and decreased vision of the right eye with concomitant diplopia
Periorbital edema, 3.6 mm of proptosis
2
Male
41
Frontal
Progressive headache
A 4 3-cm immobile mass on both frontal sinuses
3
Male
55
Ethmoid, Headache and left eye pain frontal
4
Male
37
Ethmoid
5
Male
51
Ethmoid
6
Male
18
Frontal
Left periorbital edema and previous surgical scar on the left supraorbital area Left proptosis, left medial cantus palpable nodule
Tomographic Findings A 32 26 27-mm mass with bone density, originating from right posterior ethmoid cells and protruding to the medial orbital wall leading to severe deviation of the medial rectus muscle and the optic nerve A 48 33 18-mm bony mass filling both of the frontal sinuses A 38 33 18-mm bony mass filling the left frontal sinus and ethmoid sinus
Surgical Approach
Outcome and Complications
Endoscopic
Restoration of normal eye position, increased vision
Osteoplastic Resolution of flap symptoms Endoscopic CSF leak, resolution and open of symptoms
Endoscopic Resolution of A 34 32 23-mm bony mass symptoms protruding to the medial orbital wall Endoscopic Symptoms resolved A 35 30 25-mm dense, bony Right periorbital edema, Swelling, pain, and dramatically mass originating from right 2.5-mm proptosis, and decreased vision of the posterior ethmoid cells and restricted eye movements right eye with concomitant extending into both anterior to all directions diplopia, restricted eye ethmoid cells and the right movements to all orbit leading to medial deviation directions of the medial rectus muscle and the optic nerve Osteoplastic Postoperative A 30 25 18-mm mass with Left-sided frontal swelling A 3 2-cm, immobile mass flap follow-up a bone density originating and headache on the left side of the frontal was uneventful from left frontal sinus leading region of his head without any to puffiness of the anterior complications wall and extending to right side
Medial orbital palpable mass
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.
Technique of Endoscopic Sinus Surgery Initially, tampons filled with diluted cocaine (4%) were introduced into the nasal cavity and kept for 5 minutes. Before the endoscopic sinus surgery, intranasal submucosal 20 mg lidocaine/ 0.0125 mg epinephrine 2 mL was applied above the middle turbinate to avoid bleeding. By using 0- and 30-degree endoscopes, osteomas of the ethmoid sinus were excised by using a drill and punch forceps and angled curettes. After resection, nasal packing was left for 24 hours. Amoxicillin/clavulanic acid 3 g/d was administered to patients for 10 days with additional analgesics.
RESULTS Mean patient age was 42.6 years (range, 18Y54 years). Main symptoms were headache, proptosis, and diplopia. Physical examination findings include proptosis and frontal puffiness. Paranasal sinus computed tomography revealed longer than 3-cm-diameter mass lesions in frontal and ethmoid sinuses. The surgical approach to each case was customized to the location, size, and presenting symptoms of the osteoma (Table 1). Total resection was planned and performed on all of the patients. Complication was observed in 1 patient who was operated on for a huge recurrent frontoethmoid osteoma. Cerebrospinal fluid (CSF) leak occurred while removing the osteoma from the skull base, and it was repaired using an artificial dura graft. Histopathology
Technique of Osteoplastic Flap Procedure An anteroposterior radiograph taken from 6 ft away (Caldwell view) was obtained preoperatively to demonstrate the configuration of the frontal sinus in nearly normal dimensions. The radiograph was cut, and a template of the frontal sinus obtained for use during surgery. Following bicoronal incision, the osteoplastic flap procedure was performed. The periosteum was divided approximately 1 cm outside the area of the template and reflected toward the osteoplastic flap for eventual use when the flap was returned to its anatomic position. At this time, care must be taken to avoid injury to the supraorbital nerves. A saw is used to cut from lateral to medial as the template is lifted. The osteomas were elevated from the posterior wall with the help of gouge forceps and were taken out successfully. Both patients were discharged on their postoperative fourth day.
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FIGURE 1. A 54-year-old man with right proptosis and anterior globe displacement from ethmoid sinus osteoma.
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
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Giant Paranasal Sinus Osteomas
FIGURE 2. Orbital and paranasal sinus computed tomography showing a 32 26 27-mm dense, bony mass originating from right posterior ethmoid cells and extending into anterior ethmoid cells and the right orbit leading to medial deviation of the medial rectus muscle and the optic nerve.
revealed paranasal sinus osteoma in all cases. All patients were evaluated with paranasal sinus CT scan postoperatively. At a mean follow-up of 15 months, no residual tumor or recurrence was detected following surgery.
Selected Cases Patient 1
FIGURE 4. Postoperative 13th-month paranasal CT showing no residual or recurrent tumor.
revealed osteoid osteoma. The postoperative 13th-month paranasal CT confirmed no residual tumor (Fig. 4).
Patient 2
A 54-year-old man was admitted to the department of ophthalmology with the complaints of swelling, pain, and decreased vision of the right eye with concomitant diplopia that progressed during the last 2 weeks. Periorbital edema, 3.6 mm of proptosis with diplopia, and restricted eye movements to all directions were the physical examination findings (Fig. 1). He had a history of rightsided periorbital pain and nasal obstruction for the last 9 months. He was then referred to our department, and we detected nasal polyposis arising from the middle meatus extending to the inferior turbinate in both sides on nasoendoscopic examination. Orbital and paranasal sinus CT showed a 32 26 27-mm mass with bone density, originating from the right posterior ethmoid cells and protruding to the medial orbital wall leading to severe deviation of the medial rectus muscle and the optic nerve (Fig. 2). Bilateral osteomeatal complexes were obliterated because of nasal polyposis. In addition, inflammatory fluid and mucosal thickenings were detected in all sinuses. Endoscopic surgery was carried out to treat both nasal polyposis and ethmoidal sinus osteoma. The osteoma was visualized as a bony mass strongly attached to the medial orbital wall. Because of the large size of the mass, it was drilled with a bur to reduce the size of the tumor and was successfully removed through the piriform aperture (Figs. 3A, B). Postoperative recovery was uneventful, and the patient was discharged on postoperative day 2. Histopathologic evaluation
FIGURE 3. A, Endoscopic surgical appearance of the ethmoidal osteoma as a hard, whitish mass strongly attached to the medial orbital wall. Surgical photograph showing the bur to thin the osteoma. B, Showing a part of extracted osteoma of 4 3 2.5 cm.
A 41-year-old male patient who had progressive headache for 3 months was admitted to our department. Neither trauma nor any additional disease was noted on his medical history. In his physical examination, we detected a 4 3-cm, immobile mass on the both frontal sinuses. Paranasal sinus CT showed a 48 33 18-mm bony mass filling both of the frontal sinuses (Fig. 5A). The osteoplastic flap approach was chosen as the surgical technique because of the large size of the mass. Following anterior wall elevation of both of the frontal sinuses, the mass lesion appeared and was extracted from the posterior wall with the help of a gouge forceps successfully (Fig. 5B, C, D). Histopathologic diagnosis of osteoid osteoma was obtained. The patient was discharged on postoperative fourth day. He is now on his postoperative ninth month without any recurrence and complications.
FIGURE 5. A, Paranasal sinus CT showing a 48 33 18-mm bony mass filling both of the frontal sinuses. B, Following bicoronal incision, the osteoplastic flap procedure was performed. C, Cutting from lateral to medial as the template is lifted. D, Osteoma was removed from the posterior wall with the aid of a gouge forceps successfully.
* 2014 Mutaz B. Habal, MD
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FIGURE 6. Paranasal sinus CT showing a 38 33 18-mm bony mass filling the left frontal and ethmoid sinus.
Patient 3 A 55-year-old man admitted to our clinic with complaints of headache and pain on the left eye that were present for the last 3 years. He had a history of left frontal osteoma surgery with external approach 2 years ago in another hospital. Paranasal sinus CT showed a 38 33 18-mm bony mass filling the left frontal sinus and ethmoid sinus (Fig. 6). Both endoscopic and open approaches were chosen as the surgical technique because of the frontal and ethmoid sinus osteoma. Endoscopic surgery was carried out to treat ethmoidal sinus osteoma. The osteoma was visualized as a bony mass strongly attached to the medial orbital wall. Because of the large size of the mass, it was drilled with a bur to reduce the size of the tumor. It was removed from the skull base completely. After removing the tumor, CSF leak was observed, and it was easily repaired with an artificial dura graft. Previous incision was used to reach the frontal osteoma. Frontal osteoma was removed with the aid of a drill. Histopathologic diagnosis was osteoid osteoma. He was discharged on postoperative fourth day. He is now on his postoperative 12th month without any complications.
DISCUSSION Osteomas are the most common benign tumors of the paranasal sinuses that have a well-differentiated histology and a slow-growing clinical behavior. Given their slow growth rate (average, 1.6 mm/y), asymptomatic or incidentally discovered lesions are typically observed.12 Approximately 5% of osteomas become symptomatic or require surgery.5 Paranasal sinus osteomas are most commonly detected between the second and fifth decades of life with a male-to-female ratio of 3:1.2 Similar to the literature, all of our patients were men aged between second and fifth decades. Lesions larger than 3 cm in diameter are considered giant tumors.13 Paranasal sinus osteomas most commonly develop in the frontal sinus, followed by ethmoid, maxillary, and sphenoid sinuses.1 Ethmoid sinus osteomas often originate from the lateral portion of ethmoid sinus roof and extend toward the orbit and also toward the frontal sinus.4 Grossly, sino-orbital osteomas have a whitish coloration and a smooth or bosselated surface.3 Histologically, osteomas exhibit variable patterns, most commonly mature lamellar bone with trabeculae. The etiology of paranasal sinus osteomas is not very well understood. The 3 main pathogenic theories suggested include
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osteogenic, traumatic, and infective causes.5 In our cases, none of these factors has been detected. Histopathologic types of paranasal sinus osteomas include ivory or compact, spongious, and mixed.6 The ivory type is characterized by the presence of hard bone with a thick matrix, containing a small amount of fibrous tissue; the spongious type or cancellous is composed of mature bone; and the mixed one has both characteristics. The ‘‘osteoma with osteoblastoma-like features’’ histologic subtype is marked by interanastomosing trabeculae and fibrovascular stroma surrounded by osteoblasts and osteoclasts.14,15 Osteomas with osteoblastoma-like features are more likely to exhibit extracavitary extension, cause visual symptoms, and can be incompletely excised; however, they may be less likely to recur than other osteomas.14 They also have a distinct radiographic zonal appearance, with lower density, osteoblastoma-like material at the core, and denser mature bone in the periphery.15 Most paranasal sinus osteomas are asymptomatic and are diagnosed incidentally during radiological evaluation. Their symptoms might include headache, chronic sinusitis, mucocele formation and external deformity.8 Among the symptomatic patients, headache has been reported to be the most commonly detected symptom involving 52% to 100% of the individuals.10,16 Lesions extending to the orbital cavity might cause proptosis, periorbital pain, chemosis, diplopia, epiphora, and decreased visual acuity.8 Intracranial involvement might lead to meningitis with mucocele or abscess formation and pneumocephalus.8 Headache, proptosis, and diplopia were the clinical symptoms in our patients. Two of our patients had both proptosis and diplopia when they were admitted to our department. Proptosis and diplopia were suggested to develop because of the extension of the paranasal osteomas to the orbital cavity leading to compression of the oculomotor muscles17 as we demonstrated in our patients with paranasal sinus CT. Medical history, physical examination, and radiologic imaging modalities including simple sinus radiography, thin-slice CT, and magnetic resonance imaging are used for diagnosis.18 We evaluated all of our patients with thin-slice paranasal sinus CT, which helped us to determine the exact size, location, and extension of the mass lesions. These tumors have been reported to appear as wellcircumscribed structures with bone density.9 Magnetic resonance imaging could be used to demonstrate complications including mucoceles and orbital and intracranial extensions.8 The differential diagnosis of paranasal sinus osteomas includes other bone-originated lesions containing fibrous dysplasia and ossifying fibroma.10 These lesions may have similar radiological characteristics compared with paranasal sinus osteomas; however, their borders are usually less well defined.19 Indications for surgical intervention include vision loss or optic neuropathy, eye pain, proptosis or globe displacement, diplopia, palpable defect, postobstructive sinus disease, chronic headaches, or cosmetic deformity.3,20 Georgalas et al8 proposed treatment when the following criteria are met: (1) osteomas associated with symptoms after all other explanations for the symptoms have been excluded; (2) large (extending to 950% of the frontal sinus) or growing osteomas, as seen on serial CT scans; and (3) osteomas associated with current complications (mucocele, orbital symptoms, neurologic symptoms, external deformity) or imminent (complete obstruction of the frontal recess, intraorbital or intracranial extension) complications.8 Surgical treatment includes open, endoscopic, and combined approaches depending on the size, anatomic localization, and dimension of the mass. Chiu et al20 suggested a grading system regarding surgical decisions in the management of frontal sinus osteomas. They graded frontal sinus osteomas between grade I-IV due to location of the base of attachment, location of the lesion in relation to a virtual sagittal plane through the lamina papyracea, * 2014 Mutaz B. Habal, MD
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The Journal of Craniofacial Surgery
& Volume 25, Number 4, July 2014
and the anterior-posterior diameter of the osteoma in relation to the anterior-posterior dimension of the frontal recess. They suggested endoscopic, combined, or open approaches depending on the grade of the lesion. Because of the grading system of Chiu et al22 for the management of frontal sinus osteomas, our cases could be graded as IV, and open surgical treatment is recommended for these lesions.20 Likewise, Schick et al16 defined boundaries of the endoscopic approach to the frontal sinus osteomas, and their variables were similar to the grading system of Chiu et al.20 In addition, they suggested osteoplastic flap procedure with bicoronal incision as open approach, because of its advantage of excellent exposure to frontal sinus and preserving the supraorbital nerve, having better cosmetic results, and allowing surgeon to take grafts of the parietal region to close the frontal sinus wall defect without any additional incisions.16 The most frequent suggested surgical procedure in the management of ethmoidal sinus osteomas is endoscopic approach.10,20 For large ethmoid osteomas lateral rhinotomy, midfacial degloving, osteoplastic flap, external frontoethmoidectomy, and, in selected cases, endoscopic excision are suggested.16 Small ethmoidal osteomas are easily removed by a simple endoscopic technique.21,22 Not only small ethmoid osteomas but also large tumors extending to the orbit could be easily removed without any need for external approach causing an external scar.23 Endoscopic approach carries the advantages of better exposure that leads to preserve important anatomical structures such as skull base and the orbit, less morbidity, preservation of the physiologic mucociliary drainage, less bleeding, and better cosmetic results. It is possible to remove this huge tumors radically using endoscopic techniques because tumor boundaries can be controlled very easily.23 Duration of hospital stay is generally shorter in endoscopic sinus surgery compared with open approach. However, it might be more difficult and time consuming to deal with intraoperative complications including massive bleeding, intracranial complications, and CSF leak in endoscopic technique compared with open approach. In our series, only 1 CSF leak was observed, and it was easily repaired with an artificial dura graft. Surgeons should take care to avoid complications in performing the osteoma that is especially huge and adherent to the skull base removing. In describing the slow-growing and benign property of these tumors, partial resection is judicious when complete excision would constitute further morbidity or significantly complicate surgery or reconstruction. Nevertheless, total resection is easily managed, as is the surgeon’s experience and choosing the reasonable surgical technique. Recurrence is extremely rare, with only 1 study reporting recurrent frontal sinus osteoma 7 years after initial surgery.24 Proposed etiologies include developmental, traumatic, and infectious mechanisms, although no definitive cause has been established.22 Patients should be monitored for recurrence with periodic examination. If the clinical and radiologic stability over a period of several years is observed, the surgeon should choose to proceed to clinical examination with imaging performed on an as-needed basis for new symptoms or examination findings. In conclusion, osteomas are the most commonly seen benign tumors of the paranasal sinuses. Giant and symptomatic tumors might require open, endoscopic, or combined approaches depending on the anatomical location, size of the tumor, and the experience of the surgeon for successful outcomes. Both endoscopic and open osteoplastic procedures are safe and effective methods for removal of these tumors.
REFERENCES 1. Earwaker J. Paranasal sinus osteomas: a review of 46 cases. Skeletal Radiol 1993;22:417Y423
Giant Paranasal Sinus Osteomas
2. Rappaport JM, Attia EL. Pneumocephalus in frontal sinus osteoma: a case report. J Otolaryngol 1994;23:430Y436 3. Mansour AM, Salti H, Uwaydat S, et al. Ethmoid sinus osteoma presenting as epiphora and orbital cellulitis: case report and literature review. Surv Ophthalmol 1999;43:413Y426 4. Pons Y, Blancal J-P, Ve´rillaud B, et al. Ethmoid sinus osteoma: diagnosis and management. Head Neck 2013;35:201Y204 5. Naraghi M, Kashfi A. Endonasal endoscopic resection of ethmoido-orbital osteoma compressing the optic nerve. Am J Otolaryngol 2003;24:408Y412 6. Fu YS, Perzin K. Non-epithelial tumors of the nasal cavity, paranasal sinuses, and nasopharynx: a clinicopathologic study. II. Osseous and fibroosseous lesion, including osteoma, fibrous dysplasia, ossifying fibroma, osteoblastoma, giant cell tumour and osteosarcoma. Cancer 1974;33:1289Y1305 7. Brunori A, de Santis S, Bruni P, et al. Life threatening intracranial complications of frontal sinus osteomas: report of two cases. Acta Neurochir (Wien) 1996;138:1426Y1430 8. Georgalas C, Goudakos J, Fokkens WJ. Osteoma of the skull base and sinuses. Otolaryngol Clin North Am 2011;44:875Y890 9. Sayan NB, Uc¸ok C, Karasu HA, et al. Peripheral osteoma of the oral and maxillofacial region: a study of 35 new cases. J Oral Maxillofac Surg 2002;60:1299Y1301 10. Castelnuovo P, Valentini V, Giovannetti F, et al. Osteomas of the maxillofacial district: endoscopic surgery versus open surgery. J Craniofac Surg 2008;19:1446Y1452 11. Savi( DL, Djeri( DR. Indications for the surgical treatment of osteomas of the frontal and ethmoid sinuses. Clin Otolaryngol Allied Sci 1990;15:397Y404 12. Koivunen P, Lo¨ppo¨nen H, Fors AP, et al. The growth rate of osteomas of the paranasal sinuses. Clin Otolaryngol Allied Sci 1997;22:111Y114 13. Summers L, Mascott C, Tompkins J, et al. Frontal sinus osteoma associated with cerebral abscess formation: a case report. Surg Neurol 2001;55:235Y239 14. McHugh JB, Mukherji SK, Lucas DR. Sino-orbital osteoma: a clinicopathologic study of 45 surgically treated cases with emphasis on tumors with osteoblastoma-like features. Arch Pathol Lab Med 2009;133:1587Y1593 15. Yazici Z, Yazici B, Yalcinkaya U, et al. Sino-orbital osteoma with osteoblastoma-like features: case reports. Neuroradiology 2012;54:765Y769 16. Schick B, Steigerwald C, el Rahman el Tahan A, et al. The role of endonasal surgery in the management of frontoethmoidal osteomas. Rhinology 2001;39:66Y70 17. Gerbrandy SJF, Saeed P, Fokkens WJ. Endoscopic and trans-fornix removal of a giant orbital-ethmoidal osteoma. Orbit 2007;26: 299Y301 18. Koyuncu M, Belet U, Sesen T, et al. Huge osteoma of the frontoethmoidal sinus with secondary brain abscess. Auris Nasus Larynx 2000;27:285Y287 19. Margo CE, Weiss A, Habal MB. Psammomatoid ossifying fibroma. Arch Ophthalmol 1986;104:1347Y1351 20. Chiu AG, Schipor I, Cohen NA, et al. Surgical decisions in the management of frontal sinus osteomas. Am J Rhinol 2005;19: 191Y197 21. Strek P, Zagolski O, Skladzien J, et al. Ethmoid sinus osteoma removed under endoscopic guidance-the literature review of the problem based on one case. Case Rep Clin Pract Rev 2005;6:207Y210 22. Eller R, Sillers M. Common fibro-osseous lesions of the paranasal sinuses. Otolaryngol Clin North Am 2006;39:585Y600 23. Muderris T, Bercin S, Sevil E, et al. Endoscopic removal of a giant ethmoid osteoma with orbital extension. Acta Inform Med 2012;20:266Y268 24. Selva D, White VA, O’Connell JX, et al. Primary bone tumors of the orbit. Surv Ophthalmol 2004;49:328Y342
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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Giant Paranasal Sinus Osteomas: Surgical Treatment Options Togay Muderris, MD,* Ergun Sevil, MD,* Sami Bercin, MD,Þ Buket Canda, MD,* and Muzaffer Kiris, MDÞ Abstract: 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, 18Y54 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. Key Words: Giant paranasal sinus osteomas, diagnosis, management, endoscopic surgery (J Craniofac Surg 2014;25: 1287Y1291)
From the *Department of Otorhinolaryngology, Head and Neck Surgery, Ataturk Training and Research Hospital; and †Department of Otorhinolaryngology, Head and Neck Surgery, Yildirim Beyazit University Medical Faculty, Ankara, Turkey. Received October 20, 2013. Accepted for publication November 14, 2013. Address correspondence and reprint requests to Ergun Sevil, MD, Department of Otorhinolaryngology, Head and Neck Surgery, Ataturk Training and Research Hospital, 06800 Bilkent, Ankara, Turkey; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000588
The Journal of Craniofacial Surgery
O
steomas are the most commonly seen benign tumors of the paranasal sinuses. Histopathologically, they are well differentiated and have a slow-growing clinical behavior. Although their real incidence is not certain because of asymptomatic nature, incidence of paranasal sinus osteomas has been reported to be around 3%.1 Osteomas mostly arise from the paranasal sinus walls, and they could easily extend into the surrounding areas such as the cranium and orbit. Secondary orbital extension from the paranasal sinuses has historically been considered uncommon, comprising 0.9% to 5.1% of all orbital tumors.3 However, in 1 case series, orbital extension was found in 24% of cases of ethmoid sinus osteomas.4 Radiological investigations are important for their diagnosis. They most commonly develop in the frontal sinus.1 In addition, they might also be detected in the ethmoid, maxillary, and sphenoid sinuses.1 The etiology of paranasal sinus osteomas is not clear yet. However, 3 main pathogenic theories including osteogenic, traumatic, and infective have been suggested.5 Histopathologic types of paranasal sinus osteomas include ivory or compact, spongious, and mixed.6 Paranasal sinus osteomas are mostly asymptomatic, and they are detected accidentally on paranasal computed tomography (CT) scans, which were obtained for other reasons.7 Clinical signs and symptoms, including headache, chronic sinusitis, proptosis, diplopia, mucoceles, cerebral abscess, and so on, vary because of the extension of the tumor.8 Computed tomography scan is helpful for the diagnosis, and the most common radiologic image is a homogenous radiopaque mass with well-defined margins.9 The differential diagnosis includes other bone-originated lesions containing fibrous dysplasia and ossifying fibroma.10 Periodic follow-up is suggested in asymptomatic cases. However, surgical treatment is required for symptomatic, rapidgrowing cases and lesions that involve frontal recess or both walls of the frontal sinus.11 Surgical treatment includes open, endoscopic, and combined approaches depending on the size, anatomic localization, and dimension of the mass. The primary purpose of this study was to highlight the clinical manifestation of giant paranasal sinus osteomas and to explore the varied surgical strategies used to manage these lesions.
MATERIALS AND METHODS We reviewed the patient files of our 6 cases with giant paranasal sinus osteomas and presented their history, symptoms, diagnosis, management, follow-up, and further discussion with the review of the literature. Clinical parameters reviewed included history and examination findings, imaging characteristics, management decision making, operative goals (when applicable), postoperative course, and histopathology. Presenting symptoms of the patients were headache, proptosis, and diplopia.
& Volume 25, Number 4, July 2014
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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TABLE 1. Demographics and Relevant Clinical Features of Giant Paranasal Sinus Osteoma Cases Examination Findings
Patient
Sex
Age, y
Sinus
Presenting Complaint
1
Male
54
Ethmoid
Swelling, pain, and decreased vision of the right eye with concomitant diplopia
Periorbital edema, 3.6 mm of proptosis
2
Male
41
Frontal
Progressive headache
A 4 3-cm immobile mass on both frontal sinuses
3
Male
55
Ethmoid, Headache and left eye pain frontal
4
Male
37
Ethmoid
5
Male
51
Ethmoid
6
Male
18
Frontal
Left periorbital edema and previous surgical scar on the left supraorbital area Left proptosis, left medial cantus palpable nodule
Tomographic Findings A 32 26 27-mm mass with bone density, originating from right posterior ethmoid cells and protruding to the medial orbital wall leading to severe deviation of the medial rectus muscle and the optic nerve A 48 33 18-mm bony mass filling both of the frontal sinuses A 38 33 18-mm bony mass filling the left frontal sinus and ethmoid sinus
Surgical Approach
Outcome and Complications
Endoscopic
Restoration of normal eye position, increased vision
Osteoplastic Resolution of flap symptoms Endoscopic CSF leak, resolution and open of symptoms
Endoscopic Resolution of A 34 32 23-mm bony mass symptoms protruding to the medial orbital wall Endoscopic Symptoms resolved A 35 30 25-mm dense, bony Right periorbital edema, Swelling, pain, and dramatically mass originating from right 2.5-mm proptosis, and decreased vision of the posterior ethmoid cells and restricted eye movements right eye with concomitant extending into both anterior to all directions diplopia, restricted eye ethmoid cells and the right movements to all orbit leading to medial deviation directions of the medial rectus muscle and the optic nerve Osteoplastic Postoperative A 30 25 18-mm mass with Left-sided frontal swelling A 3 2-cm, immobile mass flap follow-up a bone density originating and headache on the left side of the frontal was uneventful from left frontal sinus leading region of his head without any to puffiness of the anterior complications wall and extending to right side
Medial orbital palpable mass
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.
Technique of Endoscopic Sinus Surgery Initially, tampons filled with diluted cocaine (4%) were introduced into the nasal cavity and kept for 5 minutes. Before the endoscopic sinus surgery, intranasal submucosal 20 mg lidocaine/ 0.0125 mg epinephrine 2 mL was applied above the middle turbinate to avoid bleeding. By using 0- and 30-degree endoscopes, osteomas of the ethmoid sinus were excised by using a drill and punch forceps and angled curettes. After resection, nasal packing was left for 24 hours. Amoxicillin/clavulanic acid 3 g/d was administered to patients for 10 days with additional analgesics.
RESULTS Mean patient age was 42.6 years (range, 18Y54 years). Main symptoms were headache, proptosis, and diplopia. Physical examination findings include proptosis and frontal puffiness. Paranasal sinus computed tomography revealed longer than 3-cm-diameter mass lesions in frontal and ethmoid sinuses. The surgical approach to each case was customized to the location, size, and presenting symptoms of the osteoma (Table 1). Total resection was planned and performed on all of the patients. Complication was observed in 1 patient who was operated on for a huge recurrent frontoethmoid osteoma. Cerebrospinal fluid (CSF) leak occurred while removing the osteoma from the skull base, and it was repaired using an artificial dura graft. Histopathology
Technique of Osteoplastic Flap Procedure An anteroposterior radiograph taken from 6 ft away (Caldwell view) was obtained preoperatively to demonstrate the configuration of the frontal sinus in nearly normal dimensions. The radiograph was cut, and a template of the frontal sinus obtained for use during surgery. Following bicoronal incision, the osteoplastic flap procedure was performed. The periosteum was divided approximately 1 cm outside the area of the template and reflected toward the osteoplastic flap for eventual use when the flap was returned to its anatomic position. At this time, care must be taken to avoid injury to the supraorbital nerves. A saw is used to cut from lateral to medial as the template is lifted. The osteomas were elevated from the posterior wall with the help of gouge forceps and were taken out successfully. Both patients were discharged on their postoperative fourth day.
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FIGURE 1. A 54-year-old man with right proptosis and anterior globe displacement from ethmoid sinus osteoma.
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
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Giant Paranasal Sinus Osteomas
FIGURE 2. Orbital and paranasal sinus computed tomography showing a 32 26 27-mm dense, bony mass originating from right posterior ethmoid cells and extending into anterior ethmoid cells and the right orbit leading to medial deviation of the medial rectus muscle and the optic nerve.
revealed paranasal sinus osteoma in all cases. All patients were evaluated with paranasal sinus CT scan postoperatively. At a mean follow-up of 15 months, no residual tumor or recurrence was detected following surgery.
Selected Cases Patient 1
FIGURE 4. Postoperative 13th-month paranasal CT showing no residual or recurrent tumor.
revealed osteoid osteoma. The postoperative 13th-month paranasal CT confirmed no residual tumor (Fig. 4).
Patient 2
A 54-year-old man was admitted to the department of ophthalmology with the complaints of swelling, pain, and decreased vision of the right eye with concomitant diplopia that progressed during the last 2 weeks. Periorbital edema, 3.6 mm of proptosis with diplopia, and restricted eye movements to all directions were the physical examination findings (Fig. 1). He had a history of rightsided periorbital pain and nasal obstruction for the last 9 months. He was then referred to our department, and we detected nasal polyposis arising from the middle meatus extending to the inferior turbinate in both sides on nasoendoscopic examination. Orbital and paranasal sinus CT showed a 32 26 27-mm mass with bone density, originating from the right posterior ethmoid cells and protruding to the medial orbital wall leading to severe deviation of the medial rectus muscle and the optic nerve (Fig. 2). Bilateral osteomeatal complexes were obliterated because of nasal polyposis. In addition, inflammatory fluid and mucosal thickenings were detected in all sinuses. Endoscopic surgery was carried out to treat both nasal polyposis and ethmoidal sinus osteoma. The osteoma was visualized as a bony mass strongly attached to the medial orbital wall. Because of the large size of the mass, it was drilled with a bur to reduce the size of the tumor and was successfully removed through the piriform aperture (Figs. 3A, B). Postoperative recovery was uneventful, and the patient was discharged on postoperative day 2. Histopathologic evaluation
FIGURE 3. A, Endoscopic surgical appearance of the ethmoidal osteoma as a hard, whitish mass strongly attached to the medial orbital wall. Surgical photograph showing the bur to thin the osteoma. B, Showing a part of extracted osteoma of 4 3 2.5 cm.
A 41-year-old male patient who had progressive headache for 3 months was admitted to our department. Neither trauma nor any additional disease was noted on his medical history. In his physical examination, we detected a 4 3-cm, immobile mass on the both frontal sinuses. Paranasal sinus CT showed a 48 33 18-mm bony mass filling both of the frontal sinuses (Fig. 5A). The osteoplastic flap approach was chosen as the surgical technique because of the large size of the mass. Following anterior wall elevation of both of the frontal sinuses, the mass lesion appeared and was extracted from the posterior wall with the help of a gouge forceps successfully (Fig. 5B, C, D). Histopathologic diagnosis of osteoid osteoma was obtained. The patient was discharged on postoperative fourth day. He is now on his postoperative ninth month without any recurrence and complications.
FIGURE 5. A, Paranasal sinus CT showing a 48 33 18-mm bony mass filling both of the frontal sinuses. B, Following bicoronal incision, the osteoplastic flap procedure was performed. C, Cutting from lateral to medial as the template is lifted. D, Osteoma was removed from the posterior wall with the aid of a gouge forceps successfully.
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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Muderris et al
FIGURE 6. Paranasal sinus CT showing a 38 33 18-mm bony mass filling the left frontal and ethmoid sinus.
Patient 3 A 55-year-old man admitted to our clinic with complaints of headache and pain on the left eye that were present for the last 3 years. He had a history of left frontal osteoma surgery with external approach 2 years ago in another hospital. Paranasal sinus CT showed a 38 33 18-mm bony mass filling the left frontal sinus and ethmoid sinus (Fig. 6). Both endoscopic and open approaches were chosen as the surgical technique because of the frontal and ethmoid sinus osteoma. Endoscopic surgery was carried out to treat ethmoidal sinus osteoma. The osteoma was visualized as a bony mass strongly attached to the medial orbital wall. Because of the large size of the mass, it was drilled with a bur to reduce the size of the tumor. It was removed from the skull base completely. After removing the tumor, CSF leak was observed, and it was easily repaired with an artificial dura graft. Previous incision was used to reach the frontal osteoma. Frontal osteoma was removed with the aid of a drill. Histopathologic diagnosis was osteoid osteoma. He was discharged on postoperative fourth day. He is now on his postoperative 12th month without any complications.
DISCUSSION Osteomas are the most common benign tumors of the paranasal sinuses that have a well-differentiated histology and a slow-growing clinical behavior. Given their slow growth rate (average, 1.6 mm/y), asymptomatic or incidentally discovered lesions are typically observed.12 Approximately 5% of osteomas become symptomatic or require surgery.5 Paranasal sinus osteomas are most commonly detected between the second and fifth decades of life with a male-to-female ratio of 3:1.2 Similar to the literature, all of our patients were men aged between second and fifth decades. Lesions larger than 3 cm in diameter are considered giant tumors.13 Paranasal sinus osteomas most commonly develop in the frontal sinus, followed by ethmoid, maxillary, and sphenoid sinuses.1 Ethmoid sinus osteomas often originate from the lateral portion of ethmoid sinus roof and extend toward the orbit and also toward the frontal sinus.4 Grossly, sino-orbital osteomas have a whitish coloration and a smooth or bosselated surface.3 Histologically, osteomas exhibit variable patterns, most commonly mature lamellar bone with trabeculae. The etiology of paranasal sinus osteomas is not very well understood. The 3 main pathogenic theories suggested include
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osteogenic, traumatic, and infective causes.5 In our cases, none of these factors has been detected. Histopathologic types of paranasal sinus osteomas include ivory or compact, spongious, and mixed.6 The ivory type is characterized by the presence of hard bone with a thick matrix, containing a small amount of fibrous tissue; the spongious type or cancellous is composed of mature bone; and the mixed one has both characteristics. The ‘‘osteoma with osteoblastoma-like features’’ histologic subtype is marked by interanastomosing trabeculae and fibrovascular stroma surrounded by osteoblasts and osteoclasts.14,15 Osteomas with osteoblastoma-like features are more likely to exhibit extracavitary extension, cause visual symptoms, and can be incompletely excised; however, they may be less likely to recur than other osteomas.14 They also have a distinct radiographic zonal appearance, with lower density, osteoblastoma-like material at the core, and denser mature bone in the periphery.15 Most paranasal sinus osteomas are asymptomatic and are diagnosed incidentally during radiological evaluation. Their symptoms might include headache, chronic sinusitis, mucocele formation and external deformity.8 Among the symptomatic patients, headache has been reported to be the most commonly detected symptom involving 52% to 100% of the individuals.10,16 Lesions extending to the orbital cavity might cause proptosis, periorbital pain, chemosis, diplopia, epiphora, and decreased visual acuity.8 Intracranial involvement might lead to meningitis with mucocele or abscess formation and pneumocephalus.8 Headache, proptosis, and diplopia were the clinical symptoms in our patients. Two of our patients had both proptosis and diplopia when they were admitted to our department. Proptosis and diplopia were suggested to develop because of the extension of the paranasal osteomas to the orbital cavity leading to compression of the oculomotor muscles17 as we demonstrated in our patients with paranasal sinus CT. Medical history, physical examination, and radiologic imaging modalities including simple sinus radiography, thin-slice CT, and magnetic resonance imaging are used for diagnosis.18 We evaluated all of our patients with thin-slice paranasal sinus CT, which helped us to determine the exact size, location, and extension of the mass lesions. These tumors have been reported to appear as wellcircumscribed structures with bone density.9 Magnetic resonance imaging could be used to demonstrate complications including mucoceles and orbital and intracranial extensions.8 The differential diagnosis of paranasal sinus osteomas includes other bone-originated lesions containing fibrous dysplasia and ossifying fibroma.10 These lesions may have similar radiological characteristics compared with paranasal sinus osteomas; however, their borders are usually less well defined.19 Indications for surgical intervention include vision loss or optic neuropathy, eye pain, proptosis or globe displacement, diplopia, palpable defect, postobstructive sinus disease, chronic headaches, or cosmetic deformity.3,20 Georgalas et al8 proposed treatment when the following criteria are met: (1) osteomas associated with symptoms after all other explanations for the symptoms have been excluded; (2) large (extending to 950% of the frontal sinus) or growing osteomas, as seen on serial CT scans; and (3) osteomas associated with current complications (mucocele, orbital symptoms, neurologic symptoms, external deformity) or imminent (complete obstruction of the frontal recess, intraorbital or intracranial extension) complications.8 Surgical treatment includes open, endoscopic, and combined approaches depending on the size, anatomic localization, and dimension of the mass. Chiu et al20 suggested a grading system regarding surgical decisions in the management of frontal sinus osteomas. They graded frontal sinus osteomas between grade I-IV due to location of the base of attachment, location of the lesion in relation to a virtual sagittal plane through the lamina papyracea, * 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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& Volume 25, Number 4, July 2014
and the anterior-posterior diameter of the osteoma in relation to the anterior-posterior dimension of the frontal recess. They suggested endoscopic, combined, or open approaches depending on the grade of the lesion. Because of the grading system of Chiu et al22 for the management of frontal sinus osteomas, our cases could be graded as IV, and open surgical treatment is recommended for these lesions.20 Likewise, Schick et al16 defined boundaries of the endoscopic approach to the frontal sinus osteomas, and their variables were similar to the grading system of Chiu et al.20 In addition, they suggested osteoplastic flap procedure with bicoronal incision as open approach, because of its advantage of excellent exposure to frontal sinus and preserving the supraorbital nerve, having better cosmetic results, and allowing surgeon to take grafts of the parietal region to close the frontal sinus wall defect without any additional incisions.16 The most frequent suggested surgical procedure in the management of ethmoidal sinus osteomas is endoscopic approach.10,20 For large ethmoid osteomas lateral rhinotomy, midfacial degloving, osteoplastic flap, external frontoethmoidectomy, and, in selected cases, endoscopic excision are suggested.16 Small ethmoidal osteomas are easily removed by a simple endoscopic technique.21,22 Not only small ethmoid osteomas but also large tumors extending to the orbit could be easily removed without any need for external approach causing an external scar.23 Endoscopic approach carries the advantages of better exposure that leads to preserve important anatomical structures such as skull base and the orbit, less morbidity, preservation of the physiologic mucociliary drainage, less bleeding, and better cosmetic results. It is possible to remove this huge tumors radically using endoscopic techniques because tumor boundaries can be controlled very easily.23 Duration of hospital stay is generally shorter in endoscopic sinus surgery compared with open approach. However, it might be more difficult and time consuming to deal with intraoperative complications including massive bleeding, intracranial complications, and CSF leak in endoscopic technique compared with open approach. In our series, only 1 CSF leak was observed, and it was easily repaired with an artificial dura graft. Surgeons should take care to avoid complications in performing the osteoma that is especially huge and adherent to the skull base removing. In describing the slow-growing and benign property of these tumors, partial resection is judicious when complete excision would constitute further morbidity or significantly complicate surgery or reconstruction. Nevertheless, total resection is easily managed, as is the surgeon’s experience and choosing the reasonable surgical technique. Recurrence is extremely rare, with only 1 study reporting recurrent frontal sinus osteoma 7 years after initial surgery.24 Proposed etiologies include developmental, traumatic, and infectious mechanisms, although no definitive cause has been established.22 Patients should be monitored for recurrence with periodic examination. If the clinical and radiologic stability over a period of several years is observed, the surgeon should choose to proceed to clinical examination with imaging performed on an as-needed basis for new symptoms or examination findings. In conclusion, osteomas are the most commonly seen benign tumors of the paranasal sinuses. Giant and symptomatic tumors might require open, endoscopic, or combined approaches depending on the anatomical location, size of the tumor, and the experience of the surgeon for successful outcomes. Both endoscopic and open osteoplastic procedures are safe and effective methods for removal of these tumors.
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2. Rappaport JM, Attia EL. Pneumocephalus in frontal sinus osteoma: a case report. J Otolaryngol 1994;23:430Y436 3. Mansour AM, Salti H, Uwaydat S, et al. Ethmoid sinus osteoma presenting as epiphora and orbital cellulitis: case report and literature review. Surv Ophthalmol 1999;43:413Y426 4. Pons Y, Blancal J-P, Ve´rillaud B, et al. Ethmoid sinus osteoma: diagnosis and management. Head Neck 2013;35:201Y204 5. Naraghi M, Kashfi A. Endonasal endoscopic resection of ethmoido-orbital osteoma compressing the optic nerve. Am J Otolaryngol 2003;24:408Y412 6. Fu YS, Perzin K. Non-epithelial tumors of the nasal cavity, paranasal sinuses, and nasopharynx: a clinicopathologic study. II. Osseous and fibroosseous lesion, including osteoma, fibrous dysplasia, ossifying fibroma, osteoblastoma, giant cell tumour and osteosarcoma. Cancer 1974;33:1289Y1305 7. Brunori A, de Santis S, Bruni P, et al. Life threatening intracranial complications of frontal sinus osteomas: report of two cases. Acta Neurochir (Wien) 1996;138:1426Y1430 8. Georgalas C, Goudakos J, Fokkens WJ. Osteoma of the skull base and sinuses. Otolaryngol Clin North Am 2011;44:875Y890 9. Sayan NB, Uc¸ok C, Karasu HA, et al. Peripheral osteoma of the oral and maxillofacial region: a study of 35 new cases. J Oral Maxillofac Surg 2002;60:1299Y1301 10. Castelnuovo P, Valentini V, Giovannetti F, et al. Osteomas of the maxillofacial district: endoscopic surgery versus open surgery. J Craniofac Surg 2008;19:1446Y1452 11. Savi( DL, Djeri( DR. Indications for the surgical treatment of osteomas of the frontal and ethmoid sinuses. Clin Otolaryngol Allied Sci 1990;15:397Y404 12. Koivunen P, Lo¨ppo¨nen H, Fors AP, et al. The growth rate of osteomas of the paranasal sinuses. Clin Otolaryngol Allied Sci 1997;22:111Y114 13. Summers L, Mascott C, Tompkins J, et al. Frontal sinus osteoma associated with cerebral abscess formation: a case report. Surg Neurol 2001;55:235Y239 14. McHugh JB, Mukherji SK, Lucas DR. Sino-orbital osteoma: a clinicopathologic study of 45 surgically treated cases with emphasis on tumors with osteoblastoma-like features. Arch Pathol Lab Med 2009;133:1587Y1593 15. Yazici Z, Yazici B, Yalcinkaya U, et al. Sino-orbital osteoma with osteoblastoma-like features: case reports. Neuroradiology 2012;54:765Y769 16. Schick B, Steigerwald C, el Rahman el Tahan A, et al. The role of endonasal surgery in the management of frontoethmoidal osteomas. Rhinology 2001;39:66Y70 17. Gerbrandy SJF, Saeed P, Fokkens WJ. Endoscopic and trans-fornix removal of a giant orbital-ethmoidal osteoma. Orbit 2007;26: 299Y301 18. Koyuncu M, Belet U, Sesen T, et al. Huge osteoma of the frontoethmoidal sinus with secondary brain abscess. Auris Nasus Larynx 2000;27:285Y287 19. Margo CE, Weiss A, Habal MB. Psammomatoid ossifying fibroma. Arch Ophthalmol 1986;104:1347Y1351 20. Chiu AG, Schipor I, Cohen NA, et al. Surgical decisions in the management of frontal sinus osteomas. Am J Rhinol 2005;19: 191Y197 21. Strek P, Zagolski O, Skladzien J, et al. Ethmoid sinus osteoma removed under endoscopic guidance-the literature review of the problem based on one case. Case Rep Clin Pract Rev 2005;6:207Y210 22. Eller R, Sillers M. Common fibro-osseous lesions of the paranasal sinuses. Otolaryngol Clin North Am 2006;39:585Y600 23. Muderris T, Bercin S, Sevil E, et al. Endoscopic removal of a giant ethmoid osteoma with orbital extension. Acta Inform Med 2012;20:266Y268 24. Selva D, White VA, O’Connell JX, et al. Primary bone tumors of the orbit. Surv Ophthalmol 2004;49:328Y342
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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