Life threatening intracranial complications of frontal sinus osteomas: report of two cases

Osteoblastoma of the frontal sinus: A rare case presenting with seizures and pneumocephalus

Key Clinical Message

Osteoblastoma of the frontal sinus, although rare, can manifest with seizures and pneumocephalus, underscoring the importance of thorough evaluation and complete surgical excision to prevent serious complications and ensure optimal patient outcomes.

Abstract

Osteoblastoma is an infrequent bone tumor, with origins typically in the vertebrae and long bones. While craniofacial involvement is rare, it may occur in regions such as the paranasal sinuses. We present a case of osteoblastoma located in the frontal sinus, an exceptionally uncommon site, resulting in seizures secondary to pneumocephalus. A 21-year-old male presented with a generalized tonic-clonic seizure and postictal confusion. Imaging studies revealed a well-defined lesion in the left frontal sinus causing cortical breach, destruction of the posterior wall, and pneumocephalus. A total surgical excision was performed through bifrontal craniotomy. Histopathological analysis confirmed the diagnosis of osteoblastoma. Postoperative recovery was uneventful, with a follow-up CT scan showing complete lesion excision. Osteoblastomas, especially in the cranial sinuses, are rare entities that may present asymptomatically but can lead to severe complications. The risk of recurrence underscores the importance of complete surgical resection for optimal patient outcomes.

Management of paranasal sinus osteomas: A comprehensive narrative review of the literature and an up-to-date grading system

BACKGROUND

Surgical excision represents the unequivocal treatment modality for symptomatic paranasal sinus osteomas. However, the optimal surgical approach and the extent of the surgery, as well as the management stance in the case of an asymptomatic tumor, remain controversial.

METHODS

The MeSH terms 'Osteoma', 'Nasal Cavity', and 'Paranasal Sinuses' were used to retrieve articles concerning the management of paranasal sinus osteomas that were published in the last 30 years, the vast majority of which comprised case reports of one or two cases. Original articles or large series of more than six cases were prioritized.

RESULTS

Our review summarizes previous findings and opinions relevant to the management of symptomatic and asymptomatic paranasal sinus osteomas. The recent shifts in trends of their management are thoroughly discussed. Currently, an extension of the lesion through the anterior frontal sinus wall; an erosion of the posterior wall of the frontal sinus; a far-anterior intraorbital extension; an attachment to the orbital roof beyond the midorbital point; and some patient-specific adverse anatomic variations that may restrict access, are considered strong contraindications to a purely endoscopic approach. On the grounds of this thorough review, a new grading system for frontal and frontoethmoidal osteomas is proposed to allow better conformity to recent advancements and current clinical, research, and educational needs.

CONCLUSION

Over the past 30 years, endoscopic techniques have emerged as the new standard of care for favorably located paranasal sinus osteomas. Nonetheless, open approaches remain indispensable for the management of the more perplexing cases of frontal sinus osteomas.

Reconstructing a Giant Frontal Osteoma With Porex

Osteomas are the most common benign tumors of the paranasal sinuses. They are usually localized in the frontal sinus. Giant osteomas of the frontal sinuses are very rare but readily extend into the intraorbital or intracranial cavity, causing serious complications. This is a report of a 14 year-old boy with a bulging in frontal area and asymptomatic giant osteoma of the frontal sinuses. He had a history of minor trauma that had a bulging after 3 months. However, he referred to a plastic surgeon after 15 months. Computed tomography of the sinuses revealed a 3.5 × 6 cm extremely dense bony mass in the frontal sinus that extended into the left orbit and ethmoid sinus. A bicoronal frontal flap was raised with a V-shaped skin incision starting from the tragus placed 5 cm posterior to the hairline. The osteoma was resected completely in the frontal sinus and the anterior wall of frontal sinus was reconstructed with Porex. The patient has not had any complications until the time of writing this report. Titanium mesh may still be a valuable option, but Medpore Porex has shown to be quite effective in this case.

The Analysis of Patients Operated for Frontal Sinus Osteomas

Objective

Paranasal sinus osteomas are benign tumors that are smooth-walled, slow-growing, and induced by bone tissue. Although their most common localization is the frontal sinus, some osteomas are seen in the ethmoid, maxillary, and sphenoid sinuses. Frontal sinus osteomas are often asymptomatic; however, when they become symptomatic, headache is the most common complaint. In this study, we aimed to analyze the postoperative results of patients who were diagnosed with frontal sinus osteoma and were operated with appropriate surgical techniques.

Methods

We retrospectively evaluated 14 patients who were diagnosed with frontal sinus osteoma and were operated in our department between March 2009 and July 2014. The following parameters were analyzed: patients' age and gender, complaints at the time of admission to our clinic, pathological findings from physically examination, tumor features observed in preoperative paranasal sinus computed tomography (size and localization), surgical methods applied, intra- and postoperative complications, and recurrence rates. All patients preoperatively provided informed consent.

Results

Of the 14 patients, 7 were males and 7 were females, with a mean age of 40.57 years. A total of 11 (79%) osteomas were located within the frontal sinus and 3 (21%) within the frontal recess. External surgical approach was performed to 11 patients, endoscopic approach was performed to 2 patients and external and endoscopic approach was performed to 1 patient together.

Conclusion

Although the preferred surgical method in frontal sinus osteoma depends depended on size and localization of tumors, experience of surgeon is also important. Although the external surgical approach is appropriate for large and laterally localized osteomas, the endoscopic approach is appropriate for small and inferomedially localized osteomas. In both surgical approaches the site of origin should be drilled.

Frontoethmoid osteoma with pneumocephalus: options for surgical management

Pneumocephalus is an exceedingly rare complication associated with neurological deficit in cases of frontoethmoid osteoma. The overarching management strategy for affected patients remains undefined. We describe the case of a 61-year-old female patient presenting with frontoethmoid osteoma manifesting as profound intraparenchymal pneumocephalus and associated neurological deficit, treated through a minimally invasive combined surgical strategy involving image-guided burr hole decompression of the pneumocephalus followed by transnasal endoscopic removal of the tumor. Using this approach, the patient rapidly recovered full neurologic function. We review the existing literature and, given the likely intraparenchymal location of pneumocephalus associated with these lesions with the potential of rapid clinical deterioration, recommend aggressive surgical management. Although these lesions can be removed from a purely endoscopic approach, we recommend burr-hole decompression of the pneumocephalus as an adjunct to ensure prompt resolution of the neurologic symptoms.

Giant paranasal sinus osteomas: surgical treatment options

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, 18-54 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.

Giant orbitoethmoidal osteoma: when an open surgical approach is required

Giant orbitoethmoidal osteoma in children is considered to be rare. This type of pathology can be associated with significant disfiguring proptosis and limitation of eye movement. Here, we report on a child who presented with a giant orbitoethmoidal osteoma that was removed through an orbitofrontal approach. The cosmetic result was excellent and evident immediately after surgery. A review of the literature complements this report.

Giant osteomas of the ethmoid and frontal sinuses: Clinical characteristics and review of the literature

Giant osteomas of the ethmoid and frontal sinuses ary very rare, with only a few dozen cases reported in the literature. Given their rarity, the clinical characteristics and treatment of this disease remain controversial. In this study, the clinical presentation and surgical methods used to treat three patients with giant osteomas of the ethmoid and frontal sinuses are described, combined with a review of the literature from 1975 to 2011. In total, 45 patients with giant osteomas arising from the ethmoid and frontal sinuses (including the present cases) have been reported in 41 articles. Headache and ocular signs are the most common symptoms. This disease often leads to intracranial or intraorbital complications. The main treatment for giant osteoma is surgery via an external approach. The outcome of surgery for giant osteoma is good, with rare recurrence, no malignant transformation and few persistent symptoms.

Transnasal endoscopic approach to symptomatic sinonasal osteomas

BACKGROUND

One of the most challenging benign tumors for the ear, nose, and throat (ENT) surgeon is represented by sinonasal osteomas. Surgical treatment should regard just symptomatic osteomas, because these tumors can provoke rhinosinusitis and mucoceles. Recently, new instruments have been applied in endoscopic sinus surgery (ESS). This study was designed to present our experience in the endoscopic management of osteomas of the paranasal sinuses. Clinical findings, preoperative imaging strategy, and surgical techniques are discussed.

METHODS

We retrospectively reviewed clinical records of patients who underwent ESS for sinonasal osteomas between 2003 and 2010 in our institutions.

RESULTS

We have treated with a transnasal endoscopic approach 29 patients affected by paranasal osteomas (13 men and 16 women; age range, 20-78 years; mean, 49.5 years). We found frontoethmoidal junction localization in 14 patients, frontal sinus in 6 patients, ethmoid in 6 patients, sphenoid in 1 patient, maxillary in 1 patient, and multiple osteomas in 1 patient. Initially, patients were treated by the cavitation technique with standard ESS instruments, whereas in more recent cases surgery was assisted by the use of ENT navigation system, curved drills, and ultrasound bone emulsifier. No major complications occurred. No radiological or endoscopic signs of recurrence (mean follow-up, 52 months; range, 6-89 months) have been observed.

CONCLUSION

Endoscopic removal of osteomas of the sinonasal region is feasible, taking into account the location and size of the lesion. Particular importance should be given to new instruments that have been applied in the last years in ESS.

A giant, complex fronto-ethmoidal ivory osteoma: Surgical technique in a resource-limited practice

Background:

Unlike small and medium size fronto-ethmoidal osteomas which are amenable to surgical excision through limited craniofacial openings, giant lesions require extensive and complex craniofacial dissection, and post lesionectomy reconstruction using an array of modern-day surgical adjuncts. This is a report of our surgical technique for the successful and esthetically fair operative resection of a giant fronto-ethmoidal osteoma in a difficult practice setting.

Case Description:

A 32-year-old Nigerian lady harbored a giant complex fronto-ethmoidal ivory osteoma. Deploying our understanding of modern-day advanced microsurgical anatomy and technique of skull base surgery, but under severe resource limitations, a radical total surgical resection was performed and an esthetically fair post lesionectomy reconstruction was achieved. The patient remains tumor-free in 20 months, so far, of postoperative follow-up.

Conclusions:

Even under severe resource limitations, inventive adaptations of modern-day skull base surgery techniques can facilitate hitherto unusual functional and esthetically successful resection of giant osteomas of the fronto-ethmoidal sinus complex.

Osteomas of the maxillofacial district: endoscopic surgery versus open surgery

Maxillofacial district osteomas are benign lesions with very slow growth. The most frequent localization is the frontal sinus, about 57% of all paranasal cavity osteomas; less frequently, they can be located in the ethmoidal sinus or sphenoidal and maxillary. Etiology has not completely clarified yet; nevertheless, there are 3 main pathogenetic theories: osteogenic, traumatic, and infective. Open procedures represent the gold standard, but there is still an unsolved debate for the best treatment option. Endoscopic techniques offer an alternative approach, enabling closer and more direct visualization of the anatomy as well as avoiding damage to surrounding structures. In our study, we analyzed all patients treated with endoscopic approach for paranasal sinus osteomas in the ENT unit of the University of Varese and compared them with patients treated for the same pathology with open surgery in the Maxillo-facial Department of the University of Rome "La Sapienza." The purpose of the work was to compare the advantages and disadvantages of the 2 procedures. In conclusion, this study underlines the importance of flexibility in surgical approach decision, which must fit the different issues of the pathology and of the patient.

Pneumoencephaly following lumbar puncture in association with an ethmoidal osteoma and porencephalic cyst

A 50-year-old woman developed pneumoencephaly following a CSF examination for evaluation of dysequilibrium. Previous investigations had demonstrated a number of high signal T2 lesions on MRI of the brain. In addition, there was what was thought to be an asymptomatic cystic lesion in the left frontal lobe communicating with the lateral ventricle. After the lumbar puncture she developed extensive pneumoencephaly with pressure dilatation of the ventricular system. There was CSF rhinorrhoea. Further CT scans showed an osteoma in the ethmoidal air sinus with protrusion into the cystic area. This was the site of both the CSF leak and air entry. Caution must be taken when considering a CSF examination in the presence of either a presumed asymptomatic porencephalic cyst or ethmoid osteoma.

Endonasal endoscopic resection of ethmoido-orbital osteoma compressing the optic nerve

Osteomas are the most common benign tumors of the paranasal sinuses. Open procedures for removal of ethmoid osteomas have been the method of choice, but debate over optimal treatment continues. We report resection of a large ethmoido-orbital osteoma via endonasal endoscopic approach with minimal morbidity. A 42-year-old man presented with a 1-year history of slowly progressive proptosis and lateral gaze diplopia. Imaging studies of orbits and sinuses revealed a large bony mass in left ethmoid sinus extending into the left orbit. The mass had compressed and slightly diverted the optic nerve. The patient had also bilateral extensive polyposis for which bilateral ethmoidectomy and sphenoidotomy were performed. Using a curved blunt elevator, the osteoma was gently and meticulously detached from adjacent structures. Finally, frontal recesses were cleaned form the polyps. The postoperative period was uneventful. After 18 months, he is still free of symptoms. The previously used management modality of symptomatic osteomas has mostly consisted of open approaches. Endonasal endoscopic approach provides a safe and effective alternative to open approaches, offering cosmetic advantages and lowering the morbidity. This approach could be judiciously used in large ethmoido-orbital osteomas in selected cases.