Characteristics of paranasal sinus osteoma and treatment outcomes

Orbital osteomas associated with Gardner's syndrome: a case presentation and review of literature

Gardner syndrome (GS) is a rare genetic disorder characterized by numerous intestinal colon polyps with various extraintestinal manifestations. Osteomas are a known extracolonic manifestation of GS and can affect the orbit, as seen in our patient, as well as 13 other cases documented in literature. Excision of large orbital osteomas can be successful with a multi-disciplinary approach as presented in this article. Ophthalmologists can even be the first to diagnose GS, usually via the presence of congenital hypertrophy of the retinal pigment epithelium (CHRPE) lesions. Untreated, 100% of colon polyps will transform into cancer, thus it is important to be aware of this rare syndrome with ophthalmic manifestations and screen patients with osteomas for GS.

Surgical Approach to Frontal and Ethmoid Sinus Osteomas: The Experience of 2 Metropolitan Italian Hospitals

OBJECTIVES

The aim of this study was to report the surgical management experience of patients with osteomas of the frontal and ethmoid sinuses performed in 2 metropolitan Italian hospitals between 2012 and 2019.

METHODS

A retrospective chart review of cases of frontal and ethmoid osteomas from the Ca' Granda Niguarda Hospital of Milan and the Policlinico Umberto I University Hospital of Rome was performed. All patients underwent preoperative computed tomography and, when orbital or intracranial extension was suspected, magnetic resonance imaging. Surgical treatment was performed according to Chiu classification.

RESULTS

A total of 38 cases of frontal and ethmoid sinus osteomas were included in the study; 22 patients were men and 16 were women. The mean age at diagnosis was 49 years. Seven (18.4%) patients were treated using an open approach; 3 (7.9%) patients underwent open and endoscopic approach; the remaining 28 (73.7%) patients were treated with endoscopic approach. Seven (18.4%) patients had a cerebrospinal fluid leak intraoperatively and were treated with the placement of tissue graft through the defect. The mean follow-up time was 18 months; no recurrence was observed at 12-month follow-up.

CONCLUSION

Osteomas of the frontal and ethmoid sinuses can be treated using different techniques, mostly endoscopically. The choice of surgical approach (endoscopic vs open) depends on the location and size of the osteoma, anatomical size, characteristic of the sinus, surgeon's experience, and available existing technical facilities. Cerebrospinal fluid leak is a possible complication of surgery.

Management of Giant Frontoethmoid Osteoma by Combined Approach

Giant osteomas of the frontoethmoidal region often manifest early with ocular symptoms and intracranial complications. The management involves careful surgical planning of both the approach and reconstruction. In the present case report, a case of giant frontoethmoid osteoma presented with ocular symptoms and cosmetic deformity. The case was managed by a combined endoscopic and open surgical approach along with reconstruction of the sinus wall defect using a pericranial flap and titanium mesh. The outcome was found to be satisfactory with the resolution of ocular symptoms and good cosmesis.

Endoscopic Excision of Frontal Recess Osteoma in a Patient With Nasal Polyposis

Paranasal sinus (PNS) osteomas are benign growths that are usually asymptomatic and often discovered incidentally upon imaging. Nasal polyps, on the other hand, are relatively commoner than osteomas. With the adoption of endoscopic technology in the otorhinolaryngology (ORL) field, surgeons are shifting toward less invasive surgical methods in managing such cases. We present a case of a 23-year-old male who had chronic rhinosinusitis with nasal polyps. A computed tomography (CT) done as part of his preoperative planning revealed findings suggestive of nasal polyps with left frontal recess osteoma. Both pathologies were removed successfully via an endoscopic endonasal approach.

Nonmalignant Features Associated with Inherited Colorectal Cancer Syndromes-Clues for Diagnosis

Simple Summary

Familiarity with nonmalignant features and comorbidities of cancer predisposition syndromes may raise awareness and assist clinicians in the diagnosis and interpretation of molecular test results. Genetic predisposition to colorectal cancer (CRC) should be suspected mainly in young patients, in patients with significant family histories, multiple polyps, mismatch repair-deficient tumors, and in association with malignant or nonmalignant comorbidities. The aim of this review is to describe the main nonmalignant comorbidities associated with selected CRC predisposition syndromes that may serve as valuable diagnostic clues for clinicians and genetic professionals.

Abstract

Genetic diagnosis of affected individuals and predictive testing of their at-risk relatives, combined with intensive cancer surveillance, has an enormous cancer-preventive potential in these families. A lack of awareness may be part of the reason why the underlying germline cause remains unexplained in a large proportion of patients with CRC. Various extracolonic features, mainly dermatologic, ophthalmic, dental, endocrine, vascular, and reproductive manifestations occur in many of the cancer predisposition syndromes associated with CRC and polyposis. Some are mediated via the WNT, TGF-β, or mTOR pathways. However the pathogenesis of most features is still obscure. Here we review the extracolonic features of the main syndromes, the existing information regarding their prevalence, and the pathways involved in their pathogenesis. This knowledge could be useful for care managers from different professional disciplines, and used to raise awareness, enable diagnosis, and assist in the process of genetic testing and interpretation.

Recurrent CTNNB1 mutations in craniofacial osteomas

Osteoma is a benign bone forming tumor predominantly arising on the surface of craniofacial bones. While the vast majority of osteomas develops sporadically, a small subset of cases is associated with Gardner syndrome, a phenotypic variant of familial adenomatous polyposis caused by mutations in the APC gene resulting in aberrant activation of WNT/β-catenin signaling. In a sequencing analysis on a cohort of sporadic, non-syndromal osteomas, we identified hotspot mutations in the CTNNB1 gene (encoding β-catenin) in 22 of 36 cases (61.1%), harbouring allelic frequencies ranging from 0.04 to 0.53, with the known S45P variant representing the most frequent alteration. Based on NanoString multiplex expression profiling performed in a subset of cases, CTNNB1-mutated osteomas segregated in a defined "WNT-cluster", substantiating functionality of CTNNB1 mutations which are associated with β-catenin stabilization. Our findings for the first time convincingly show that osteomas represent genetically-driven neoplasms and provide evidence that aberrant WNT/β-catenin signaling plays a fundamental role in their pathogenesis, in line with the well-known function of WNT/β-catenin in osteogenesis. Our study contributes to a better understanding of the molecular pathogenesis underlying osteoma development and establishes a helpful diagnostic molecular marker for morphologically challenging cases.

Cartilaginous Fibrous Osteoma of the Ethmoid Sinus

Fibro-osseous lesions are common in the paranasal sinuses. The incidence of fibrous dysplasia (FD) in the ethmoid sinus is rare. Patients with such lesions are usually asymptomatic until the lesion is large enough to start compressing adjacent structures and organs. Common presentations include nasal obstruction, headache, eye swelling, and diplopia. Meanwhile, less common signs can include decreased visual acuity. We present a case of a 65-year-old male with comorbidities who presented to the clinic complaining of a chronic nasal obstruction, headache, and decreased visual acuity in the right eye. On endoscopic examination, a lesion was identified in the ethmoid sinus. Computed tomography was performed and confirmed the positioning of the lesion within the ethmoid sinus compressing the optic nerve. Total excision was performed through a direct nasal endoscopic approach. The lesion was excised completely with no recurrence. Histopathology report confirmed the lesion to be of cartilaginous nature, and a final diagnosis of cartilaginous fibrous osteoma was made. Such lesions are usually benign and symptomless. Excising the lesion completely is the best approach to decrease the chances of recurrence.

Benign Bone-Forming Tumors

Benign bone-forming tumors comprise osteomas, osteoid osteomas, and osteoblastomas. Osteomas affect a wide age range and are usually discovered incidentally. They occur predominantly in the craniofacial skeleton and are classically composed of compact bone. Osteoid osteomas and osteoblastomas are painful lesions occurring in young patients. They are morphologically similar and characterized by FOS gene rearrangement and c-FOS expression at a protein level. Osteoid osteomas are usually smaller than 2 cm in maximum dimension with limited growth potential; osteoblastomas are larger than 2 cm and may be locally aggressive. Histologically both are composed of anastomosing trabeculae of woven bone.

A Case of Giant Ethmoid Sinus Osteoma

Paranasal sinus osteomas are slow-growing benign tumors. They are generally asymptomatic in most patients and usually diagnosed incidentally with a sinus radiograph or more frequently with a CT scan of the paranasal sinuses. Osteomas can cause various signs and symptoms, depending on the location of the mass. Giant osteomas of the paranasal sinuses are very rare, with only a handful of case reports in the literature. Due to the rarity of giant osteomas, the clinical presentation and treatment are unclear. In this article, we present a case of giant ethmoid sinus osteoma, which was removed with an endoscopic endonasal approach, as well as a review of the literature.

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.

Surgical treatment of frontal sinus osteoma

OBJECTIVE

The purpose of this study was to describe our experience in the surgical treatment of frontal sinus osteomas.

METHODS

This study involved 18 patients who underwent surgery for frontal sinus osteoma between January 2016 and December 2019. Demographic characteristics, site and size of osteoma, presenting symptoms, frontal sinus osteoma grading system, presence of frontal sinusitis, surgical methods, treatment outcome, operation time, and complications were reviewed.

RESULTS

The endoscopic approach was performed in all patients except one. Among patients who underwent an endoscopic approach, endoscopic sinus surgery was performed in ten patients and endoscopic-modified Lothrop procedure was performed in seven patients. The mean size of the frontal sinus osteoma was 1.5 ± 0.7 cm. According to the frontal sinus osteoma grading system, grade III (n = 9, 50.0%) was the most common, followed by grade II (n = 4), grade I (n = 3), and grade IV (n = 2). The size of the osteoma and frontal osteoma grading system exhibited statistical significance with the operation time (p < 0.05). There were no major surgical complications or recurrence.

CONCLUSION

The operation time was prolonged when the frontal sinus osteomas were more than 1.5 cm or in grade III and IV frontal osteomas.

Osteoma involving the olfactory groove: evaluation of the risk of a CSF leak during endoscopic surgery

Purpose

The olfactory groove (OG) is a common site of iatrogenic cerebrospinal fluid (CSF) leak during endoscopic sinus surgery. We aimed to evaluate the prevalence of CSF leak during endoscopic removal of osteomas involving the OG and identify CT findings indicating increased risk of this complication.

Methods

A retrospective review was conducted of patients operated on for frontoethmoidal osteoma from 11 years in a single institution. A retrospective review of the literature, 1999 to 2019, of perioperative complications in patients operated on for frontoethmoidal osteoma using endoscopic or combined approaches.

Results

Case series: 73 patients were identified including 17 with the OG involvement. The only case of CSF leak occurred in a patient with spongious part of osteoma at the OG. Among six osteomas with spongious component at the OG, one was detached and five had to be drilled down, leaving a small remnant in four. In contrast, all the 11 osteomas with ivory part at the OG were safely detached and completely removed from the OG after debulking. The prevalence of CSF leak was not statistically different between the patients without and with involvement of the OG. Systematic review of the literature: Among the 273 identified patients there were 8 cases of intraoperative CSF leaks (3%) including 2 from the OG (0.7%).

Conclusion

Involvement of the OG does not significantly increase the risk of intraoperative CSF leak. However, this risk may be increased in patients with the spongious part of the tumor attached to the OG.

Frontal Sinus Osteoma: From Direct Excision to Endoscopic Removal

Frontal sinus osteomas are benign bone-forming neoplasms. Ongoing advancements in endoscopic surgery have allowed less invasive surgical approaches to be adopted for removal. The authors systematically reviewed the literature to provide analysis and recommendations for management.One hundred ninety-three publications encompassing 1399 patients met inclusion, with mean age 42.1 ± 13.8 years and a male predominance (59.2%). Symptoms included pain (70.8%); orbital/ocular (20.7%); sinonasal (36.4%); neurologic (6.0%); other (14.5%); and asymptomatic (4.8%). Osteoma was isolated to the frontal sinus (82.9%) or extended into the ethmoid (16.6%), maxillary (0.3%), and sphenoid sinuses (0.2%). There was intracranial extension in 9.5% and intraorbital extension in 18.7%. Of those proceeding to surgery, majority (59.8%) underwent open approaches, followed by endoscopic (25.0%) and combined (11.5%). A significant (P < 0.01) increase in proportion of cases utilizing endoscopic approaches versus open/combined was observed over the period studied. Seventy-one postoperative complications were reported, in 7.5% of endoscopic cases, 27% of open, and 8.8% of combined. Complications were more likely in open/combined surgery, compared with endoscopic (22.3% versus 7.5%, P < 0.001). In 181 patients, completeness of resection was reported (complete resection; 87.8%) and found to be a significant predictor (P < 0.01) for disease recurrence/progression. Mean length of stay for the endoscopic group was 3.1 ± 1.3 days, compared with 7.9 ± 3.1 for open/combined (P < 0.0001).In the management of frontal sinus osteoma, indications for selecting endoscopic versus open approaches have expanded over the past 30 years, as techniques, equipment, and understanding of pathophysiology have evolved. Where endoscopic approaches are possible, they are associated with reduced morbidity and length of stay compared with open approaches.

An Extremely Rare Cause of Headache; Osteoma of the Middle Concha Bullosa

Osteomas are benign, slow-growing tumors originating from bone tissue. Osteomas of the paranasal region, which are usually asymptomatic, are detected incidentally on tomographies taken for other medical needs. Paranasal sinus osteomas frequently localized in the frontal and ethmoid sinuses are among the infrequent reasons for headaches. In this case report, the authors submit the first case of an osteoma that was localized inside the middle concha bullosa and causing headache. It was successfully excised via an endoscopic endonasal approach without any complications.

Surgical Approach to Frontal Sinus Osteoma: A Systematic Review

Background

Osteoma of the paranasal sinuses are benign bony masses most commonly found in the frontal sinus. In the past, due to the anatomical complexity of the frontal sinus, these often required an open approach, but with the invention of angled tools and endoscopes, many rhinologists are now attempting endoscopic or combined resections. No large systematic reviews currently exist that describe the surgical management of frontal sinus osteoma.

Objective

To perform a systematic review detailing the surgical resection of frontal sinus osteoma. Review Methods: A systematic literature review was performed using PubMed, Embase, and Ovid databases. Data extracted included demographics, clinical presentation, radiologic, histologic findings, surgical approach, and recurrence.

Results

A total of 32 studies, with 477 surgically resected tumors, were included in the analysis. Sex data were available for 179 patients (M:F, 93:86), with a mean age of 43.2 years. All resected tumors presented symptomatically: facial pain/headache (80.2%), recurrent sinusitis (30.5%), mucocele (4.3%), cosmetic deformity other than proptosis (12.8%), and proptosis (5.5%). Transnasal endoscopic surgery alone was the most common surgical approach utilized (44.9%), followed by open osteoplastic flaps (36.9%) and endoscopic assisted (18.2%). Osteoma with anterior (79%) and posterior (73%) attachments were treated statistically more often with endoscopic approach compared with floor (42%) and extrasinus (50%) attachment ( P < .0005). There was no statistical difference in approach to masses that crossed the sagittal plane extending from the lamina papyracea (63% endoscopic, 29% endoscopic assisted, 8% open, P = .21). Mean follow-up was 29.7 months, with recurrence or persistent residual disease occurring in 12 patients.

Conclusion

Despite the increasing use of endoscopic alone procedures for expanding indications, patients may still require an open or endoscopic assisted approach for complete removal.

A Rare Cause of Headache: Pneumatized Nasal Septum Osteoma

Paranasal sinus osteomas are among the rare causes of headache and they are most commonly seen in the frontal and ethmoid sinuses. In this report, we presented the first case of pneumatized nasal septum osteoma causing headache, successfully treated with endoscopic transnasal approach.

The Management of the Paranasal Sinus Osteomas

OBJECTIVE

Osteoma is the most common benign tumor of the paranasal sinuses. The clinical characteristics and treatment of this disease remain controversial. The aim of this study is to determine the appropriate method of treatment approach according to the features of osteomas.

METHODS

Forty-one patients with paranasal sinus osteomas were included in the study. According to the location and the size of tumors, patients were followed up or operated. Surgical treatment was performed via external, endoscopic, or combined approaches for symptomatic patients. Routine physical and radiological evaluations were performed for follow-up in asymptomatic patients.

RESULTS

Paranasal sinus osteomas were found most common in frontal sinus (n = 26, 63.4%) followed by ethmoid sinus (n = 10, 24.3%), maxillary sinus (n = 4, 9.7%), and sphenoid sinus (n = 1, 2.4%). Of the patients with frontal sinus osteomas, the endoscopic approach was performed in 11 patients, external approach (osteoplastic flap) in 9, and combined (external + endoscopic) approach in 5 patients. Endoscopic approach was preferred in all patients with ethmoid osteoma. The combination of Caldwell-Luc procedure and endoscopic approach was performed in 1 patient with maxillary sinus osteoma. In 3 patients, who underwent osteoplastic flap technique, mucocele developed in the postoperative period. Partial loss of vision developed postoperatively in 1 patient with a giant ethmoid osteoma. There were no other complications and recurrence in an average of 29 months follow-up.

CONCLUSION

Paranasal sinus osteomas are rare, slow-growing benign lesions, with potentially serious complications. Main treatment option for sphenoid and ethmoid sinus and other symptomatic osteomas are surgical resection. Radiographic follow-up is necessary for asymptomatic lesions. Selection of surgical resection method depends on tumor location and size. Patients should be observed for recurrence with periodic examination and imaging techniques. Follow-up should be performed at least in 1-year intervals after the surgery.

LEVEL OF EVIDENCE

1c.

Giant fronto-ethmoidal osteoma - selection of an optimal surgical procedure

Introduction

Osteomas of the paranasal sinuses are benign bone tumours that produce clinical signs depending on their size and location. In most reported cases large tumours are excised by an external approach or in conjunction with an endoscopic technique. Endoscopic treatment of such tumours is a huge challenge for the operator.

Objective

Determine the optimal surgical approach by analysing giant osteomas of the frontal and ethmoidal sinuses in the literature.

Methods

Group of 37 osteomas obtained from the literature review. A group of osteomas removed only by endoscopy was compared with a group in which an external approach (lateral rhynotomy or craniotomy) or combined external and endoscopic approach was applied.

Results

The authors, based on the statistical analysis of the literature data, have found that the average size of osteomas excised endoscopically and those removed by external approaches does not differ statistically, when the osteomas are located in the ethmoidal cells (p = 0.2691) and the frontal sinuses (p = 0.5891).

Conclusion

The choice of surgical method appears to be independent of the osteoma size and the decision is likely to be taken based on the experience of the surgeon, available equipment and knowledge of different surgical techniques.

[Endoscopic endonasal surgery of paranasal sinus osteomas]

This article was designed to summarize the experience gained withendoscopic endonasal removal of paranasal sinus osteomas during the period from January 2013 till February 2016. In addition a review of the relevant literature is presented encompassing the publicationsthat provide information about etiology, pathogenesis, clinical picture, diagnostics, and treatment of bone tumours. The objective of the study was to enhance the effectiveness and safety of the surgical treatment of the patients presenting with paranasal sinus osteomas. A total of 81 cases of paranasal sinus osteoma were documented in the patients admitted to I.P. Pavlov Saint-Peterburg First State Medical Universityduring the period from January 2013 till February 2016. Forty nine of them were given the surgical endoscopic endonasal treatment with the removal of the neoplasm. The remaining 32 patients were included in the group for the further dynamic follow up. The authors report the data of morphological studies and the results of computed tomography performed in the pre- and postoperative periods with special reference to the potential for the use of the electromagnetic navigation station (an image-guidance system) that makes it possible to significantly reduce the risk of development of possible complications. In addition, the findings suggestive of the progressive tumour growth in the group of the patients under dynamic observation are discussed.