The potential aggressiveness of sinus osteomas. A report of two cases

Frontal Sinus Osteoma: Complete Removal via Endoscopic Sinus Surgery and Frontal Sinus Trephination

Endoscopic sinus surgery has improved our understanding of normal sinus physiology and enabled us to provide better surgical treatment of sinus disease. A method for removal of frontal sinus osteomas was sought that would be less invasive and more physiologic than the conventional osteoplastic flap procedure. Endoscopic sinus surgery has been combined with conventional frontal sinus trephination to achieve total osteoma removal while maintaining normal sinus mucociliary flow. Two successive patients have been treated in this manner with gratifying results.

Paleopathological evidence of paranasal lesions: Two cases of frontal sinus osteomata from Imperial Rome

The archaeological excavations carried out in 1999 in the Collatina necropolis of the Roman Imperial Age (1st-3rd centuries AD) (Rome, Italy) discovered the skeletal remains of two adult males with evidence of paranasal lesions. Both individuals showed postmortem damage in the frontal bone, through which it was possible to macroscopically detect an oblong new bone formation. In both specimens, radiological examination of the defects' morphology showed new pediculated-based bone formations. Radiology also confirmed the presence of benign osseous masses arising from the right frontal sinus and interpreted as osteomata. Their dimensions did not exceed 10 mm, so that mechanical complications and compression of the adjacent structures could be ruled out. The osteomata of paranasal sinuses are rarely reported in paleopathology, since they can be discovered only incidental to bone breakage or radiography. Hence, the evaluation of their occurrence in past populations represents an important challenge. The two cases presented here show direct and rare evidence of frontal sinus osteomata dating back to the Roman Imperial Age.

Low-grade central osteosarcoma arising from bone infarct

Bone infarct-associated sarcoma is a rare sarcoma, accounting for less than 1% of all bone sarcomas. Its histology usually reflects a high-grade sarcoma, such as malignant fibrous histiocytoma of bone or conventional osteosarcoma. Low-grade sarcoma arising from bone infarct has not been described well in the literature. Here, we present a 17-year follow-up of a female patient with bone infarct in her right humerus, from which a low-grade central osteosarcoma developed during follow-up. A histologic diagnosis of low-grade central osteosarcoma was confirmed by immunohistochemical expression of MDM2 and CDK4. She underwent a wide resection surgery. As of 4 years after surgery, she has remained free of any evidence of recurrence or metastasis. Here, we present clinical and pathologic findings of our case in detail and discuss the differential diagnoses of this extremely rare condition.

Surgical management and outcome of large orbitocranial osteomas

Object

The goal of this study is to review the surgical management and outcome of patients who were treated for large orbitocranial osteomas at Gulhane Military Medical Academy over a period of 7 years.

Methods

Twenty-one patients with large orbitocranial osteomas were evaluated retrospectively. All patients were male and between 19 and 25 years old. Surgery was performed in all patients. The main surgical procedure was resection of the osteoma using orbitotomy and/or craniotomy followed by orbital reconstruction and cranioplasty. Cranioplasty was performed in 16 patients, using methyl methacrylate in 5 patients (31%) and porous polyethylene in 11 patients (69%). Thin, flexible, porous polyethylene was preferred for orbital reconstruction in 10 patients. The cranioplasty materials were attached to the intact bone using miniplates.

Results

There were no severe postoperative complications. Mild transient periorbital ecchymosis was noted in 19 patients. The mean follow-up period was 11.7 months (range 9–24 months) after surgery. No tumor regrowth was observed in any patient at the end of the follow-up period.

Conclusions

Large osteomas of the orbitocranial region must be resected for cosmetic and functional reasons. Selection and planning of the surgical technique should be based on the direction of the tumor growth and on the size of the tumor and the structures that are compressed by the tumor.

[Orbital osteoma: clinical evaluation of nine cases]

INTRODUCTION

Osteoma of the nasosinus cavities, particularly the frontoethmoidal cavities, is often a fortuitous radiographic discovery. Potential complications include ophthalmological, sinusal, and endocranial disorders.

MATERIAL AND METHODS

Nine patients (five men and four women), mean age 24.3 years (18-43) presenting orbital osteoma were managed from 1994 to 1999.

RESULTS

Clinical signs were dominated by ophthalmological disorders, basically non-reducible exophthalmia (n = 8). Two patients had permanent unilateral nasal obstruction and one had acute sinusitis. The bony orbital tumefaction was located in the superior medial angle in five patients. Radiography (Blondeau view) demonstrated an opacity in the sinus with an orbital extension. Computed tomography, performed in all patients, identified the lesion location: ethmoidofrontal (n = 4), anterior ethmoidal (n = 2), frontal (n = 2), ethmoidomaxillary (n = 1). There were no endocranial extensions. Surgery was undertaken for eight patients generally via the transfacial approach (n = 7); a bicoronal approach was used for one patient. En bloc resection (n = 4) or fragmentation (n = 4) was performed. There was one postoperative complication: regressive diplopy. These patients have been followed regularly with clinical and radiographic explorations and have been free of relapse for 2 to 6 years.

DISCUSSION

Frontoethmoidal osteoma is a relatively rare benign tumor. Severity depends on the orbital and endocranial extension. Imaging provides the positive diagnosis and guides the surgical approach. Therapeutic indications depend on the tumor size, its course, and the development of complications. We observed total relapse free outcome after complete resection.

Skeletal benign bone-forming lesions

The imaging features of benign osseous lesions of the bone are often characteristic and suggestive of a specific diagnosis. This is particularly true for skeletal benign bone-forming lesions such as enostosis, osteoma, osteoid osteoma and osteoblastoma. Enostosis or bone island is an incidental finding in the axial skeleton (pelvis, spine, ribs) of asymptomatic patients; it appears as a small (0.2-2 cm) round to oval sclerotic area with irregular, radiating ('thorny') spicules peripherally. Osteoma is a benign slow-growth tumor and usually an incidental finding in cranial sinuses, vault and mandible, and presenting as a homogeneous, sharply defined bone mass arising from bone surface; its signs and symptoms are rare and depend on the tumor size and location--e.g. sinusitis, headache, exophthalmos, diplopia. Osteoid osteoma is a painful highly vascularized benign tumor usually affecting the long bone diaphysis cortex of young patients; it generally appears as a small radiolucent nidus with or without central calcification and surrounding bone sclerosis on radiographs, and as a 'hot' spot on scintigraphy. CT is the method of choice for the definite location of the nidus especially in sites of complex anatomy, such as the spine, pelvis and hindfoot. Osteoblastoma is a rare tumor, histologically similar to osteoid osteoma but with a significantly different clinical potential because of the possibilities of postoperative recurrence, of its locally aggressive behavior or, rarer still, malignant transformation; the spine and long bones are affected in more than half the cases. Its radiologic appearance is not always distinctive and usually characterized by a lytic lesion with varying bone production and expansile behavior; CT and MRI are required for the diagnosis of spinal osteoblastomas. When a bone-producing tumor or tumor-like lesion is suspected but no specific diagnosis can be made, the knowledge of the range of the imaging findings of these lesions will allow a suitably ordered differential diagnosis. Radiography is the single most effective imaging method in this respect. CT is required for the tumors in complex anatomical sites, such as the spine, pelvis and hindfoot, as well as for the optimal assessment of the tumor matrix. MRI is specifically required to study the lesion effect on the spinal canal.

Cranial osteomas: their classification and management. Report on a giant osteoma and review of the literature

BACKGROUND

Cranial osteomas are regarded by some as very common; yet their classification, symptomatology, and management have been neglected.

METHODS

We report on a giant enostotic convexity osteoma and have reviewed the medical literature.

RESULTS

A new comprehensive classification for cranial osteomas is proposed: (1) intraparenchymal, (2) dural, (3) skull base, and (4) skull vault. The latter is in turn, subdivided into exostotic and enostotic variants. Three symptom producing enostotic convexity osteomas have been reported in the world literature. We also describe a giant enostotic skull vault osteoma and propose an original surgical technique used to successfully resect this unusual tumor.

CONCLUSIONS

Most cranial osteomas are asymptomatic and need not be resected. Those that are symptomatic should be managed properly. Their excision, if nor properly performed, may lead to unforeseen cerebral complications.

Fronto-ethmoid osteoma: the place of surgery

Osteomas of the paranasal sinuses are common. Most are, however, asymptomatic and a chance radiographic finding. We describe four cases histories which help to illustrate the benefits and hazards of surgery, and highlight the importance of patient selection. A review of the literature is presented.

Benign bone-forming lesions: osteoma, osteoid osteoma, and osteoblastoma. Clinical, imaging, pathologic, and differential considerations

The benign bone lesions--osteoma, osteoid osteoma, and osteoblastoma--are characterized as bone-forming because tumor cells produce osteoid or mature bone. Osteoma is a slow-growing lesion most commonly seen in the paranasal sinuses and in the calvaria. When it occurs in the long bones, it is invariably juxtacortical and may need to be differentiated from, among others, parosteal osteosarcoma, sessile osteochondroma, and a matured juxtacortical focus of myositis ossificans. Osteoid osteoma and osteoblastoma appear histologically very similar. Their clinical presentations and distribution in the skeleton, however, are distinct: osteoid osteoma is usually accompanied by nocturnal pain promptly relieved by salicylates; osteoblastoma arises predominantly in the axial skeleton, spinal lesions constituting one-third of reported cases. This review focuses on the application of the various imaging modalities in the diagnosis, differential diagnosis, and evaluation of these lesions. Their histopathology also is discussed, and their treatment briefly outlined.

Paranasal sinus osteomas: a review of 46 cases

In a survey of 1500 coronal sinonasal CT scans, 46 patients were found to have paranasal sinus osteomas. The overall incidence was 3%, with a predilection for decades 5 and 6 and a male-to-female ratio of 1.3:1. The frontal sinus was most commonly involved, and of these lesions 37% were in the immediate vicinity of the nasofrontal duct and 21% above and lateral to the ostium. Tumour size varied from a mean diameter of 1.5 mm to 30 mm; however, 17 lesions were 5 mm in size or less. Five matrix patterns were observed. Only two patients were symptomatic and only three osteomas excised. Isotope bone scanning may be a useful screening test with specific follow-up utilising computed tomography.