Osteoma fronto-etmoidal gigante - escolha do procedimento cirúrgico ideal

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www.bjorl.org

Brazilian

Journal

of

OTORHINOLARYNGOLOGY

REVIEW

ARTICLE

Giant

fronto-ethmoidal

osteoma

---

selection

of

an

optimal

surgical

procedure

Maria

Humeniuk-Arasiewicz

a,

,

Gra˙

zyna

Stryjewska-Makuch

a

,

Małgorzata

A.

Janik

b

,

Bogdan

Kolebacz

a

aIndependentPublicResearchHospitalN7ofSilesianMedicalUniversity,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/).

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/).

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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

(3)

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

(4)

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

(5)

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

(6)

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

(7)

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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References