Surgical decisions in the management of frontal sinus osteomas.

Background: The development of chronic rhinosinusitis, a mucocele, or persistent headaches is a common indication for the removal of a frontal sinus osteoma. The best surgical approach to ensure complete and safe removal of the lesion is less clearcut. The advent of specialized frontal sinus instruments, angled endoscopes, and surgical navigational systems has made removal of frontal sinus osteomas possible through an endoscopic approach. The aim of this study is to review our recent experience with the surgical management of frontal sinus osteomas, and the anatomic features that make specific lesions more or less amenable to endoscopic resection.

Methods: A retrospective review of all frontal sinus osteomas surgically resected from the years 1999 to 2003 was used. This period was selected to reflect the invention and popularization of surgical navigation systems and specialty instruments designed specifically for the frontal sinus. CT scans, operative reports and postoperative course were reviewed.

Results: Nine patients were identified. A grading system was devised to reflect the three variables involved in the limitations for endoscopic removal. These are the location of the base of attachment, relative size to the frontal recess, and location in relation to a virtual sagittal plane through the lamina papyracea. Three osteomas were removed through an endoscopic approach. Four were removed by a combined osteoplastic flap and endoscopic dissection of the frontal recess. Two were removed through an osteoplastic flap with obliteration of the sinus.

Conclusion: The ability to remove a frontal sinus osteoma endoscopically can be determined preoperatively, taking into account the location and size of the lesion. There is still a role for external procedures in the surgical management of these lesions, and such procedures may be combined with endoscopic techniques for optimal results.