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|Year : 2014 | Volume
| Issue : 2 | Page : 207-208
Fronto-ethmoid osteoma: Addressing surgical challenges
JV Lodha, JP Dabholkar, H Dhar
Department of ENT and Head and Neck Surgery, Seth G S Medical College and KEM Hospital, Parel, Mumbai, Maharashtra, India
|Date of Web Publication||13-May-2014|
Dr. J V Lodha
Department of ENT and Head and Neck Surgery, Seth G S Medical College and KEM Hospital, Parel, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Lodha J V, Dabholkar J P, Dhar H. Fronto-ethmoid osteoma: Addressing surgical challenges. J Postgrad Med 2014;60:207-8
Osteomas are a part of fibro-osseous lesions which encompasses fibrous dysplasia, ossifying fibroma and osteomas.  Osteomas are slow growing with a prevalence of 0.01-0.43%. Due to their unique location in the fronto-ethmoid region, they pose a challenge cosmetically as well as functionally, raising issues of when and how to operate upon them.
A 65-year-old female patient presented to us with a gradually increasing swelling in the medial aspect of the right eye for 5 years, associated with epiphora. The patient also complained of mucopurulent discharge from the nasal cavity and associated frontal headache. On examination, there was a 2 cm × 2 cm bony hard globular swelling palpable in the medial aspect of the right eye, causing hypertelorism. Vision and extraocular movements were preserved. Nasal endoscopy revealed features of right sided mild rhinosinusitis. Non-contrast computed tomography of paranasal sinuses and orbit revealed extremely dense sclerotic globular mass, which was well-defined in the right fronto-ethmoid region, with erosion of the ipsilateral lamina papyracea and no intracranial extension [Figure 1].
|Figure 1: Non contrast computed tomography of paranasal sinus axial cut showing sclerotic globular mass in right Fronto-ethmoid region with erosion of lamina papyracea|
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Patient underwent excision of the tumor through external approach using the Lynch Howarth incision. Intra operatively, the patency of the frontal recess was confirmed by doing the lavage of the frontal sinus and establishing the free flow of saline into the middle meatus. Besides this, the frontal sinus glow (light transmitted by endoscope through the anterior frontal table) was also well seen externally. The medial canthal ligament was meticulously sutured back at the end of the surgery. Lacrimal sac syringing showed free flow of fluid in the nasal cavity without any regurgitation through the canaliculi, thus establishing the patency of the nasolacrimal duct system.
Regarding the etiology of osteomas, a combination of (a) embryological (b) traumatic theories seems most likely in majority of patients. , They cause symptoms due to the space occupying nature, which blocks the pathway of the sinuses and nasolacrimal duct. It can also cause orbital proptosis, diplopia and subperiosteal abscess. 
External surgical procedures have traditionally been the method of choice in the treatment of symptomatic paranasal sinus osteomas.  With recent advances in endoscopic sinus surgery, small osteomas can be removed endoscopically, provided easy access can be achieved. Our patient was appropriately treated using an external approach given the dimensions and the extent of the tumor. Because of the anterior location of the tumour and its broad based attachment to the ethmoidal borders, patient was deemed appropriate for an external approach. Furthermore, in our experience endoscopic drilling in the region of the frontal recess causes osteitis with resultant stenosis of the frontal recess, leading to secondary frontal sinusitis. Considering the above mentioned reasons, the patient was chosen for an external approach. The patient had resolution of the complaints of cosmetic deformity, epiphora, sinusitis and proptosis.
Thus, we emphasize that not only complete tumor excision is essential but focus should also be given on other symptoms such as epiphora, hypertelorism and secondary sinusitis, which if not addressed and thought of pre-operatively can lead to unacceptable morbidity.
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