www.bjorl.org
Brazilian
Journal
of
OTORHINOLARYNGOLOGY
REVIEW
ARTICLE
Giant
fronto-ethmoidal
osteoma
---
selection
of
an
optimal
surgical
procedure
夽
Maria
Humeniuk-Arasiewicz
a,∗,
Gra˙
zyna
Stryjewska-Makuch
a,
Małgorzata
A.
Janik
b,
Bogdan
Kolebacz
aaIndependentPublicResearchHospitalN◦7ofSilesianMedicalUniversity,UpperSilesianMedicalCentre,Departmentof LaryngologyandLaryngologicalOncology,Katowice,Poland
bUniversityofSilesiainKatowice,InstituteofComputerScience,DepartmentofBiomedicalComputerSystems,Sosnowiec, Poland
Received28March2017;accepted21June2017 Availableonline17July2017
KEYWORDS Osteoma; Surgery; Endoscopy; EthmoidSinus; FrontalSinus Abstract
Introduction:Osteomasoftheparanasalsinusesarebenignbonetumoursthatproduceclinical signsdependingontheirsizeandlocation.Inmostreportedcaseslargetumoursareexcisedby anexternalapproachorinconjunctionwithanendoscopictechnique.Endoscopictreatmentof suchtumoursisahugechallengefortheoperator.
Objective:Determinetheoptimalsurgicalapproachbyanalysinggiantosteomasofthefrontal andethmoidalsinusesintheliterature.
Methods:Group of 37 osteomas obtained from the literature review. A group of osteomas removedonlybyendoscopywascomparedwithagroupinwhichanexternalapproach(lateral rhynotomyorcraniotomy)orcombinedexternalandendoscopicapproachwasapplied. Results:Theauthors,basedonthestatisticalanalysisoftheliteraturedata,havefoundthat theaveragesizeofosteomasexcisedendoscopicallyandthoseremovedbyexternalapproaches doesnotdifferstatistically,whentheosteomasarelocatedintheethmoidalcells(p=0.2691) andthefrontalsinuses(p=0.5891).
Conclusion:Thechoiceofsurgicalmethodappearstobeindependentoftheosteomasizeand thedecisionislikelytobetakenbasedontheexperienceofthesurgeon,availableequipment andknowledgeofdifferentsurgicaltechniques.
© 2017 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Published by Elsevier Editora Ltda. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/).
夽 Pleasecitethisarticleas:Humeniuk-ArasiewiczM,Stryjewska-MakuchG,JanikMA,KolebaczB.Giantfronto-ethmoidalosteoma ---selectionofanoptimalsurgicalprocedure.BrazJOtorhinolaryngol.2018;84:232---9.
∗Correspondingauthor.
E-mail:humeniukmaria@gmail.com(M.Humeniuk-Arasiewicz).
PeerReviewundertheresponsibilityofAssociac¸ãoBrasileiradeOtorrinolaringologiaeCirurgiaCérvico-Facial. https://doi.org/10.1016/j.bjorl.2017.06.010
1808-8694/©2017Associac¸˜aoBrasileiradeOtorrinolaringologiaeCirurgiaC´ervico-Facial.PublishedbyElsevierEditoraLtda.Thisisanopen accessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).
PALAVRAS-CHAVE Osteoma; Cirurgia; Endoscopia; Seioetmoidal; Seiofrontal
Osteomafronto-etmoidalgigante---escolhadoprocedimentocirúrgicoideal Resumo
Introduc¸ão: Osteomasdosseiosparanasaissãotumoresósseosbenignoscujasmanifestac¸ões clínicas ocorrem em func¸ão de seutamanho e localizac¸ão.Na maioria doscasos relatados os tumores grandessão excisadospor uma abordagemexterna ouassociada auma técnica endoscópica. Otratamento endoscópico destes tumores ainda é um grande desafio para o cirurgião.
Objetivo: Determinar a abordagem cirúrgica ideal ao analisar osteomas gigantes dos seios frontaleetmoidalnaliteratura.
Método: Umtotalde38osteomasforamavaliadosapartirdarevisãodaliteratura.Umgrupo deosteomasremovidosapenasporcirurgiaendoscópicafoicomparadocomumgrupoparao qualfoiutilizadoumaabordagemexterna(rinotomialateraloucraniotomia)ouumaabordagem combinada,externaeendoscópica.
Resultados: Osautores,combasenaanáliseestatísticadosdadosdaliteratura,observaram queotamanhomédiodososteomasexcisadosendoscopicamenteedaquelesqueforam removi-dosatravésdeumaabordagemexternanãodiferiramestatisticamente,tantoparaosteomas localizadosnoseioetmoidal(p=0.2691)quantoparaoslocalizadosnoseiofrontal(p=0.5891). Conclusão:A escolha do método cirúrgico parece ser independente do tamanho do osteoma e a decisão provavelmente será tomada com base na experiência prévia do cirurgião, nos equipamentos disponíveis e conhecimento de diferentes técnicas cirúrgicas.
© 2017 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Publicado por Elsevier Editora Ltda. Este ´e um artigo Open Access sob uma licenc¸a CC BY (http:// creativecommons.org/licenses/by/4.0/).
Introduction
Osteomasarefrequent,benignosteogenictumoursof
con-nective tissue arisingfromthe proliferation of cancellous
orcorticalbone.1,2Craniofacialosteomasoccurfrequently,
especially in the paranasal sinuses. Due to their slow
asymptomaticgrowth,inmostcasestheyaredetected
acci-dentally,in3%ofcomputedtomography(CT)scansand1%
ofradiographsofthesinuses.3
Osteomas within the paranasal sinuses are most often
localized in the fronto-ethmoidal region (95% of cases),
involving the frontal sinus 60%---70%, and ethmoidal cells
20%---30%. Osteomas of the maxillarysinus occur in 5% of
cases.2 Orbital involvement is theresult of the spreadof
anosteomafromtheneighbouringsinuses.Primaryorbital
involvementisexceedinglyrare.4
Theaetiologyofosteomasstillremainsunclear.Therole
of inflammatory factors is suggested here aswell as
pre-viousinjuries andtreatmentswithinthenose andsinuses,
orembryologicaltheory.1,5,6Geneticfactorsmayaffectthe
formationof osteomasinGardner’ssyndromewith
coexis-tence of intestinal polyps, epidermoid cysts and desmoid
tumours.7
Janovic’sobservationssuggestthatpatientswith
osteo-masdevelopanatomicalvariationsoftheparanasalsinuses
morefrequentlythanpatientswithoutosteomas.8Therehas
beenahigherincidenceofosteomasinmenthaninwomen
between the ages of 20---50 years in the ratio 2:1.9 The
higherprevalenceofosteomasinmalesmaybeduetomore
frequentexposuretoinjuries,andlargerparanasalsinuses
comparedtowomen.3
Osteomas ofthe paransalsinuses of large sizes are,in
mostreportedcases,excisedbyanexternalapproach.Giant
osteomasof the paranasalsinuses aretumours sized over
30mmor weighing110g10 andtheyareusuallyexcisedby
an external approach.3,4,11 Endoscopic treatment of such
tumoursisamajorchallengefortheoperator.Theauthorsof
thestudysuccessfullyremovedosteomassizedbelow30mm
located in the ethomoid sinuses by means of endoscopy,
osteomasofthesideportionofthefrontalsinusesby
cran-iotomy and tumours located in the area of the frontal
fasciaby endoscopycombined withtheapproach through
theanteriorwallofthe frontalsinus. Thispaperpresents
thecase ofa fronto-ethmoidalgiant osteomasuccessfully
removedviaendoscopywithoutintraoperativeand
postop-erativecomplications.
Thesuccessfulremovalofthegiantosteomainspiredthe
authorstoperform a retrospective literaturereview and,
basedon the data,try to determine the optimal surgical
approachtothegiantosteomaoftheethmoidalcells
invad-ingthefrontalrecessortheorbitandlocatedinthefrontal
sinuses.
Case
description
In 2016, a 75 year-old woman contacted the Department
ofOtolaryngology andOncological Surgery complainingof
epiphoraoftherighteye,persistentheadaches,post-nasal
drip,nasalobstruction,painandpressureintheareaofthe
rightmaxillarysinus.Severalyearsbefore,thepatienthad
Figure1 CTscanofthesinuses---fronto-ethmoidalosteoma sizedabout39.5×19.8×19.4mm,coronalplane.
Figure2 CTscanofthesinuses---fronto-ethmoidalosteoma, axialplane.
Onthedayofadmissiontohospital,aclinicaltrialshowed
asymmetryofthe eyeballswithmild exophthalmosofthe
righteyeball,withoutimpairmentofitsmobilityandahard
swellingwithintherightangleoftheorbit.Therewereno
visualdisturbancesandneurologicalsymptoms.TheCTscan
oftheparanasalsinusesshowedanodular,calcified,
poly-cyclic structure sized about 39.5×19.8×19.4mm within
theanterior ethmoidalcells onthe right side, protruding
intotherightorbit,andputtingpressureonthemedial
rec-tusmuscleandthelacrimalsac,aswellasinvadingthearea
ofthefrontalsinusandtheright ostiomeatalcomplex.An
osteomawithadiameterof about9mmwasfound inthe
ostiumoftheleftfrontalsinus.Accordingtoaradiologist,
theshading of the right maxillary,ethmoidal, frontaland
Figure 3 CT scan of the sinuses --- giant fronto-ethmoidal osteoma,sagittalplane.
sphenoidalsinuses suggested massivemucosal hyperplasia
andpurulentsecretionsormucus(Figs.1---3).
Undergeneral anaesthesiaandcontrolledhypotension,
asolidbonystructurewasvisualizedendoscopicallyonthe
rightside,fillingthemiddlenasalmeatus,ethmoidalcells
andfrontalrecess.Themiddleturbinategotthinner,pressed
by the tumour. Uncinectomy and antrostomy were
per-formedontherightside.Themedialportionofthetumour
fromtheside ofthemiddle turbinate,anteriorethmoidal
cellsandfrontalrecesswascarefullyremovedusingadrill.
Theremaininglesionwasgentlyremovedfromthe
superior-medialportionofthemaxillarysinusandthemedialportion
oftheorbit.Toenabletheremovalofthetumourthrough
the nasal passage, the anterior segment of the inferior
turbinate had to be removed. The material was sent for
histopathologicalexamination.Theroofofethmoidalcells,
theremnantsofposteriorethmoidalcellsandtheinteriorof
themaxillarysinuswerepurifiedfrompolypsandpurulent
secretions. Then, uncinectomy and antrostomy were
per-formedontheleftsideandthepolypswereexcisedfromthe
anteriorandposteriorethmoidalcellsusingamicrodebrider.
Nocerebrospinalfluidleakwasobservedduringthesurgery
orinthepostoperativeperiod.Thepatientwasdischarged
ingoodconditiononthethirddayafterthesurgery.
An osteomawithout evidenceof malignancywas
diag-nosedinthehistopathologicalexaminationofthetumour.
Thepatienthasbeenunderconstantlaryngological
con-trolfor14months.Aninterview,clinicaltrialandimaging
showed no recurrence of the tumour, and the symptoms
reportedbythepatientbeforethesurgeryhavecompletely
resolved. Figs. 4 and 5 present a CT scan of the sinuses
performedinanoperatedpatient12monthsaftersurgery.
Successful,endoscopicremovalofthegiantosteomaof
theethmoidalsinusespromptedtheauthorstoanalyze
sur-gicalproceduresusedtoremoveosteomasexceeding30mm
in the greatestdimension andsmaller ones. The selected
publications describe osteomas located in the frontal or
ethmoidalsinuses withtheinvolvement ofadjacent areas
Figure4 CTscanofthesinuses---12months aftersurgery, coronalplane.
Figure5 CTscanofthesinuses---12months aftersurgery, axialplane.
Methods
The material, which was the basis of statistical analysis,
wasa group of 37 osteomas obtained from the literature
review.Fromtheavailableliterature,onlythoseworkswere
selectedforanalysisinwhichtheauthorspresented
oper-ated osteomas in the frontal plane in the sinus CT scan
and it was possible to read the tumour dimensions. The
rejectedworksincluded thosein whichthe dimensionsof
osteomas weregiven inother projectionsin a CTscanor
werecalculated aftertumour removalina
histopatholog-ical examination. A group of osteomas removed only by
transnasalendoscopywascomparedwithagroupinwhichan
externalapproach(throughtheanteriorwallofthefrontal
sinus, orbit, lateral rhynotomy or craniotomy), where an
endoscopewasnotusedinsurgery,orcombinedexternaland
endoscopicapproachwasapplied. The external and
com-binedmethod wasforreasons of simplicityreferred toas
‘‘other’’inTable1.Thelargestdiameterofthetumourin
thefrontal plane in the CT scanof theparanasal sinuses
wastakenintoconsideration inthe analysis.The size
dis-tribution of osteomas in each group was assessed by the
Shapiro---Wilk test and graphically using histograms. The
medianwaschosen asthemeasureofcentre,anda
quar-tilerangeasameasureofdiversity.Inordertocomparethe
averagesizeofosteomasremovedendoscopicallyandwith
anexternalapproachseparatelyforthefrontalsinusesand
ethmoidalcells,anunpairedt-testwasmadeor,injustified
cases,itsnonparametricequivalent,i.e.theMann---Whitney
U test. The statistical analysis wasmade using Statistica
12.Ap-valuelessthan0.05wasconsideredasstatistically significant.
Results
Among the collected literature data, including the case
describedbytheauthors,31.58%ofallosteomaswere
local-ized in the ethmoidal cells and excised endoscopically, a
similaramount(34.21%)constitutedosteomaslocatedinthe
ethmoidalcellsandremovedbyanexternalapproach.The
othercaseswerelocatedinthefrontalsinuses,ofwhichonly
1/3wereremovedendoscopically.Amongosteomasexcised
endoscopically,75% werelocalizedin theethmoidalcells,
the remaining 25% in the frontal sinuses. In the case of
methodsusingan external approach, 59.1%of caseswere
locatedin theethmoidalcells,theremaining40.9%inthe
frontalsinuses.Inthecaseofosteomaslocatedinthe
eth-moidalcells,48% wereexcisedendoscopicallyand 52%by
anexternalapproach.Innoneofthecasesthedifferences
innumberswerestatisticallysignificant,soitisnotpossible
toconcludethatthechoice ofmethodsis associatedwith
thelocationofosteomas.
Amongosteomaslocatedintheethmoidalcells,64%were
giant osteomas (≥30mm): 43.75% of them were removed
endoscopically,andtheremaining56.25%wereremovedby
anexternalapproach.Osteomasoftheethomoidcellssized
lessthan30mm accountedfor36%, ofwhich55.56%were
excisedendoscopically,theremaining44.44%byanexternal
approach.Of allosteomas located inthe ethmoidalcells,
28%were giant osteomas excisedendoscopically,and 36%
giantosteomasexcisedbyanexternal approach.Asinthe
caseof thelocation ofosteomas andthe chosenmethod,
therewasnorelationshipbetweenthesizeoftheosteoma
oftheethmoidalcellsandthemethodofitsremoval.The
samerelationshipsarein thecase of osteomas locatedin
thefrontalsinuses,butofallgiantosteomas(representing
73.92%ofallcaseslocatedinthefrontalsinuses);only20%
wereremovedendoscopically.
Discussion
Osteomasbelongtobenignparanasalsinusesthatmaybethe
causeof variousclinical symptomsdepending onthe
loca-tion,size and direction of tumourgrowth. Some tumours
areaccidentallydiagnosedduringradiologicalexaminations
Table1 Thegroupofosteomasobtainedfromtheliteraturereview.
Author Localization Method Size(mm)
Authorsofthispaper Ethmoidsinus endoscopically ≥30
Literaturereview
Mansouretal.3 Ethmoidsinus other ≥30
Zouloumisetal.4 Ethmoidsinus other <30
BlancoDominguezetal.9 Ethmoidsinus Other <30
Chengetal.10 Ethmoidsinus Other ≥30
Chengetal.10 Frontalsinus Other ≥30
Chengetal.10 Frontalsinus Other ≥30
Hazarikaetal.11 Frontalsinus Other ≥30
Zhuangetal.12 Ethmoidsinus Other ≥30
Ole´setal.13 Frontalsinus Endoscopically ≥30
Ole´setal.13 Frontalsinus Endoscopically ≥30
Str˛eketal.14 Ethmoidsinus Endoscopically <30
Str˛eketal.14 Ethmoidsinus Endoscopically <30
Str˛eketal.14 Ethmoidsinus Endoscopically <30
Str˛eketal.14 Frontalsinus Endoscopically <30
Panagiotopoulosetal.15 Frontalsinus Other ≥30
Nagashimaetal.16 Frontalsinus Other <30
Savastanoetal.17 Frontalsinus Other ≥30
Beitzkeetal.18 Frontalsinus Other ≥30
Kamideetal.19 Ethmoidsinus Other <30
Kim20 Ethmoidsinus Endoscopically <30
Torunetal.21 Ethmoidsinus Endoscopically ≥30
Simseketal.22 Ethmoidsinus Endoscopically ≥30
Lietal.23 Ethmoidsinus Endoscopically <30
Naraghietal.24 Ethmoidsinus Endoscopically ≥30
Akmansuetal.25 Ethmoidsinus Endoscopically ≥30
Saettietal.26 Ethmoidsinus Endoscopically ≥30
Kim27 Frontalsinus Endoscopically <30
Gerbrandyetal.28 Ethmoidsinus Other ≥30
Maharjanetal.29 Ethmoidsinus Other ≥30
Lodhaetal.30 Ethmoidsinus Other <30
Ansarietal.31 Ethmoidsinus Other ≥30
Müslümanetal.32 Frontalsinus Other ≥30
Müslümanetal.32 Ethmoidsinus Other ≥30
Manakaetal.33 Frontalsinus Other ≥30
Karbassietal.34 Ethmoidsinus Other ≥30
Saatietal.35 Ethmoidsinus Other ≥30
Alotaibietal.36 Ethmoidsinus Endoscopically ≥30
osteomastypicallyoccurasathick,sclerotic,homogeneous,
well-definedstructure, is sufficienttodiagnose and
accu-ratelyplanthesurgicalapproach.31Fourpathologicaltypes
of osteomas have been described: 1) ivory-hard, dense,
mature bone with total absence of Haversian canals, 2)
compact lamellar structure with small Haversian canals,
3)spongiose-periphery ofcompactbone withradial septa
andinterveningmarrowspaces,4)mixed-boneandfibrous
tissue.37Types3and4aremorerapidlygrowing.
Osteomas are characterized by slow asymptomatic
growththatcantake yearsuntilthefirstsymptomsofthe
disease appear. Most commonly they include headaches,
facial deformities, vertigo, sinusitis, disorders of nasal
obstruction.9 The symptoms of the disease appear when
normalsinusdrainagebecomesimpairedduetothe
obstruc-tion of its ostium by the tumour growth. Ocular and
central nervous system symptoms result from the spread
of osteomas located in the fronto-ethmoid region and
can cause exophthalmos, dacryorrhea, retrobulbar pain,
doublevision.2,4,9,36Insomecasestheymaycause
intracra-nial complications such as cerebral abscess, meningitis,
mucocele,andevenleadtocerebraloedemaasinthecase
oftheethomoidosteomadescribedbyKamid,manifesting
itself asheadaches andmild hemiparesis.15,16,18,19,38 Giant
ethomoidosteomasarerare,accountingforapproximately
0.9%---5.1%ofallorbitaltumours.31 Ethomoidosteomascan
produce symptomsmuch faster than thoselocated in the
frontalsinusesduetolimitedspaceintheethomoidregion
and, consequently,due tofaster invasionof neighbouring
structures.34
Indications for surgical treatment of osteomas are
asymptomatic tumours or those discovered accidently by
performingCTscansregularlyevery12months.14 Magnetic
resonanceimagingisusefulindifferentialdiagnosisandin
casesoforbitalinvolvementandintracranialspread.7
Surgery is recommendedin cases of significant tumour
growth10 accompaniedbytheappearanceofclinical
symp-toms, involvement of the orbit or anterior cranial fossa
andthe resultingcomplications.9,16,17,36In thecase of the
asymptomatic osteoma of the frontal sinus described by
Hazarika,thepatienthadbeenunderconstantobservation
for10years,thetumoursized38.1mmwasoperated,and
then the patientdeveloped symptoms such as headaches
andexcessiveepiphora.11Panagiotopoulosproposessurgical
removalofsmallosteomasbeforetumourprogression, the
appearanceof symptomsandintracranialcomplications.15
Itissuggestedthatosteomasinvolvingtheareaofthe
naso-lacrimalductormorethanhalfofthefrontalsinusshould
beexcised.3Eachsphenoidsinusosteomarequiresrapid
sur-gical treatment regardless ofsymptomatology, due tothe
possibility of optic neuropathy resulting from oppression
of a slow-growing tumourand blindness.7,9 Lee describes
the case of sphenoid sinus osteoma,which wasobserved
in accordance with the ‘‘wait-and-see policy’’. Surgical
treatment wasnot initiated because of the small size of
the lesion.39 In recent years, with the development of
endoscopic sinus surgery, the removal of paranasal sinus
osteomas via endoscopy has become a method of choice
becauseofthelowmorbidityrate,aestheticaspects,lower
costoftreatmentandgreaterexperienceofsurgeons.
Literatureanalysisconductedbytheauthorsshowedthat
among osteomas excised endoscopically, 75% were
local-izedintheethmoidcells,theremaining25%inthefrontal
sinuses. The results suggest that in the case of osteomas
below 30mm located in the ethomoid sinuses, endoscopy
may be the surgical method of choice. Giant osteomas
in the ethomoid sinuses were removed via endoscopy
and theexternal approachequally often. Lee claims that
the endoscopic approach allows for the removal of all
ethmoid osteomas with skull base or lamina papyracea
involvement.39Alotaibidescribesthecaseofanosteomaof
theanteriorethmoidalcellssized30×25×15mmgrowing
inthedirectionoftheorbit,whichwasexcised
endoscop-icallyusingneuronavigation, asin thecase of thetumour
sized30×20×15mmdescribedbyZhuang.12,36Endoscopic
excision of osteomas from the ethomoid cells is
recom-mended,butinsufficientwhenthelesionsspreadoutsidethe
sinuses.40 Karbassidrawsattentiontothecases,described
intheliterature,ofgiantosteomasintheethomoidregion
removed endoscopically, which were not accompanied by
orbitalcomplications.He suggeststhatexternalsurgeryis
thepropermethodforremovingosteomaswithdeep
inva-sionoftheorbit.34
The resultsof statistical analysisoftheavailable
liter-ature showedthattherewasnorelationship between the
sizeoftheosteomaoftheethmoidalcellsandthemethod
ofitsremoval.Thecaseofgiantosteomadescribedinthis
paperconfirms the validityof endoscopic treatment. The
analysiswasdifferentinthecaseofthefrontalsinuses.All
giantosteomas(representing73.92%ofallcaseslocatedin
thefrontalsinuses),only20%wereremovedendoscopically.
Chiu recommended endoscopic resection of small frontal
osteomas medial to the sagittal line passing through the
laminapapyracea(GradeIandII),whileusingtheexternal
approachifthelocationwaslateraltothesagittalline
pass-ingthroughthelaminapapyraceaorfillingthefrontalsinus
(GradeIII and IV).41 Savastanosuggests removalof
osteo-masofthefrontalsinuseswithanexternalapproachifthey
arelocatedonthefrontorsidewallofthesinus.According
toHazarika, osteomas of the frontal sinuses arising from
the back wall of the sinus with a wide base should not
beoperated endoscopically due tocomplications,
includ-ingcerebrospinalfluidleak.11,17Intheliterature,thereare
cases of endoscopic treatment of frontal sinus osteomas
of a diameter greater than 3cm using Draf III access.13
Endoscopictreatmentoflesionsinthefrontalsinusesis
pos-sibleincasesoftumourslocatednearthefrontalrecess.17
Endoscopicsurgeryofosteomasinthefrontalrecessregion
mayaffectthepostoperativecourse.Basedonoperational
experience, Lodha describes the possibility of secondary
sinusitisafterendoscopicdrilling,whichcancauseosteitis
withfrontalrecessstenosis.42Nagashimadescribestheuse
ofcraniotomyinthecaseofosteomaswithinvolvementof
theorbit,anteriorcranialfossa,oraportionofthefrontal
sinus.16
According to Müslüman, multicompartmental osteomas
should be excised via the external approach due to the
possibilityof recurrence, as in the case of the described
giant fronto-ethomoid osteoma with orbital involvement,
usingthe transcranialapproachfor radicalexcision ofthe
lesion.Inthecaseofgiantosteomas,thetranscranial
surgi-calapproachissaferandmoreeffectivecomparedtoother
externalandendoscopicoperationsusedastheonly
surgi-calmethod.32AccordingtoKarapantzos,thetranscutaneous
paranasalapproach(rhynotomy)allows,toagreaterextent,
forproperdiagnosisandprotectionofthelacrimaldrainage
apparatus.43
Vermadescribesanattempttoremoveendoscopicallya
maxilliarysinustumoursized4×5×3cm,whichendedwith
theWeber-Fergussonapproachduetothedifficultaccessto
thebackandlateral partof thetumour.2Maxillary
osteo-maslocatedintheupperpartofthemaxillarysinuscanbe
treatedviatheendoscopicapproach.39
Recurrence of osteomas after surgery is very rare,
about 10%, usually after earlier incomplete removal of
the tumour.15,44 There is a possibility of partial osteoma
removalaslongasitsaveragegrowthrateisnotmorethan
1.61mm/year.19,45Thentheconstantobservationofpatients
andregularimagingtestsarenecessaryinordertoexclude
recurrence. It is often sufficient to perform a radiogram
every6monthsforseveralyearsaftersurgery.14
Conclusion
Basedonthestatisticalanalysisofliteraturedataand
hav-ingregard tothe described case, the authors have found
that theaverage size of osteomas excised endoscopically
andthoseremovedbytheexternalapproachdoesnotdiffer
statistically,inthecaseofosteomaslocatedbothinthe
eth-moidalcells(p=0.2691)andthefrontalsinuses(p=0.5891).
The choice of surgical method appears tobe
indepen-dent of the osteoma size andthe decision is likely tobe
takenbasedonthepastexperienceofthesurgeon,available
withinthefrontal sinuses. It appearsthat the endoscopic
approach,beinglesstraumatic,leavingnoscarsand
allow-ingshorter stay in hospital,willbethe methodof choice
especiallyinfronto-ethmoidalcases.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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