Treatment Guidelines

Treatment of asymptomatic osteomas is controversial: some authors suggest tumor removal regardless of size, whereas others recommend a "wait and see" policy with serial CT scan controls (Savic and Djeric 1990; Brodish et al. 1999).

Namdar et al. (1998) suggested the following guidelines for treatment: in case of associated nasal obstruction or rhinosinusitis, medical therapy with antibiotics, decongestants, and steroids may be appropriate. Whenever medical therapy fails because of tumor location, the lesion is adjacent to frontal sinus os-tium or more than 50% of the frontal sinus is occupied, or a noticeable increase in size has been documented by serial CT scans, surgery is recommended. Finally, chronic headache may be an indication for surgery when other causes are excluded.

Removal of the lesion may alternatively require a microendoscopic procedure or an external approach, in relation to tumor location, volume, and extension. Schick et al. (2001) precisely defined the limits and the indications for a microendoscopic removal: while most ethmoid osteomas can be resected endonasally, frontal osteomas are considered to be accessible whenever located medial to a virtual sagittal plane upward prolonging the lamina papyracea and originating from the inferior aspect of the posterior frontal sinus wall. Microendoscopic removal of frontal sinus osteomas can be achieved through Draf's type II or III frontal sinusotomy.

Tumor extension beyond the paranasal sinuses, or large osteomas which can not be entirely exposed through the nose must be removed via an external approach (SmiTh and CALcATErrA 1989; NAmdAR et al. 1998; Brodish et al. 1999; Schick et al. 2001). Osteoplastic frontal sinusotomy (with or without fat obliteration), with a coronal or uni-/bilateral brow incision, allows direct access to the frontal sinus and removal of osteomas with anterior and/or posterior wall involvement. Craniofacial resection has been described for the removal of giant fronto-ethmoid osteomas with intracranial complications (Blitzer et al. 1989).

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