Flat panel detector-CT with endovenous injection. Description of a novel technique for obtaining cerebral arteries imaging: Technical note


Romanian Neurosurgery  |  Volume XXXI  |  Number 4 |  2017  |  October-December 

 
Article 

 
Giant Frontoethmoidal osteoma with orbital 

involvement- a rare case report with review of 

literature  

 

Pankaj Gupta, Arvind Sharma, Jitendra Singh, Tarun Ojha 
INDIA 

 

 

 

DOI: 10.1515/romneu-2017-0084 
 



 
 
 
 
 
540 | Gupta et al - Giant Frontoethmoidal osteoma 

 

 
 
 
 
 
 

DOI: 10.1515/romneu-2017-0084   

Giant Frontoethmoidal osteoma with orbital involvement- 
a rare case report with review of literature 

Pankaj Gupta1, Arvind Sharma2, Jitendra Singh1, Tarun Ojha2 
1Department of Neurosurgery, Mahatma Gandhi Medical College, Jaipur, INDIA 
2Department of Neurosurgery, Sawai Man Singh Medical College, Jaipur, INDIA 

 
Abstract: Osteomas are benign tumours that involve paranasal sinuses more than other 
parts of body. Frontal sinus is most common while sphenoid is least one. They are usually 
asymptomatic and diagnosed incidentally on imaging for other reasons. Giant variety of 
frontoethmoid osteoma is very rare and only few cases are described in literature. Orbital 
involvement in giant frontoethmoid osteoma is even rarer. Due to threat to vision, this 
variety is an indication for surgical intervention followed by reconstruction of defect. As 
these tumours are very large, endoscopic approaches are less indicated and there is no 
clear consensus which open surgical approach is better. We are reporting such a rare case 
of giant frontoethmoid osteoma causing proptosis and restriction of eye movement that 
was treated with open surgical approach. 
Key words: giant, osteoma, frontoethmoid 

 
Introduction 

Osteomas are rare benign bony 
mesenchymal tumours. They commonly 
involve craniofacial bony skeleton and jaw 
bones (12). They constitute about 1% of all 
bone tumours & 11% of all benign bone 
tumours (2). They are slow- growing, often 
asymptomatic & incidentally detected in 1% of 
skull X-Ray and 3% of the cranial Computed 
tomography (CT) Scans. These tumours 
involves frontal, ethmoid, maxillary & 
sphenoid sinus in decreasing order of 
frequency. Giant frontoethmoidal osteomas 
are very rare and patient usually present early 

as there is limited anatomical space (14,15,16). 
orbital and skull base involvement is very 
unusual in ethmoidal osteoma and can 
produce neurologic and ophthalmic 
manifestation hence surgical intervention is 
required in these patients(14,16). CT scan 
remains the gold standard to diagnose this 
pathology and surgery remains the treatment 
of choice for symptomatic frontoethmoidal 
osteomas. We are reporting such a rare case of 
frontoethmoidal osteoma that was treated 
surgically with special focus on various 
surgical options. 

 



 
 
 
 
 

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Case report 
A 14 year male child referred from 

Otolaryngology department with chief 
complains of insidious onset, slowly 
progressive nasal blockage with difficulty in 
nasal breathing since last 4 years. Patients 
often had off and on mild headache for that he 
takes oral analgesic and his headache was 
relived after taking these medications. 
Gradually his mother notice broadening of his 
nasal bridge with deviation and bulging of his 
left eyes. CT scan of PNS showed a large 
frotoethmoidal osteoma. Patient further 
evaluated in neurosurgery department. He was 
conscious and oriented. His vitals were within 
normal range. On neurologic examination, his 
higher mental status was normal. There were 
no cranial nerve deficits nor any deficit in 
sensory or motor system. His cerebellar 
examination was normal. Position of his right 
eye was normal but his left eyes was slightly 
bulging and deviated to left & there was slight 
restriction of left eye movement on 
superiomedial direction. There was no 
relationship of proptosis with bending 
forward. Visual acuity & fundus examination 
of both eyes was normal. On palpation, 
swelling was bony hard in consistency. A CT 
scan of the brain with PNS (Figure 1) revealed 
a hyperdense giant mss of approximately 7.2 
cm of size occupying the left supraorbital 
region, frontoethmoid region.  

 
Figure 1 - Preoperative CT scan showing giant 

frontethmoid osteoma 
 

 
Figure 2 – Post-operative scan showing complete 

removal of osteoma 
 

Surgical intervention was advised and 
possible complications and outcomes were 
explained to them in detail. After taking 
written and informed consent patient taken to 
operation theatre. Patient put on supine 
position with a bolster placed below the 
shoulder so that neck remains in extension. 
Bicoronal skin incision given and skin flap 
raised with pericranium lifted separately.  
Supraorbital bifrontal craniotomy done. As 
soon as dura separated from anterior cranial 
base, ivory white osteoma visualized. 
Frontoethmoidal part of osteoma taken out 
with orbital part removed separately.  
Reconstruction of the anterior cranial base 
performed using pericranial patch. This was 
further reinforced by tissue glue. In post-



 
 
 
 
 
542 | Gupta et al - Giant Frontoethmoidal osteoma 

 

 
 
 
 
 
 

operative patient did well. There was no CSF 
leak from the nose and his proptosis was 
resolved with no diminution in vision. Post-
operative CT scan (Figure 2) showed complete 
removal of osteoma. Histopathological 
examination confirmed the diagnosis of 
benign osteoma. 

Discussion 
Osteomas are rare benign bony tumours. 

They invovles paranasal sinuses (13) most 
common, & found in the frontal sinus (71.8%) 
and less often in the ethmoid sinus (16.9%), 
maxillary sinus (6.3%) or sphenoid sinus 
(4.9%) (11). Osteomas of the other bony 
regions are also reported. 

Osteomas affect less than 1% of population 
with slight male preponderance (17). 95% of 
the patients having osteoma remain 
asymptomatic (11). The average reported size 
of osteoma involving paranasal sinuses is less 
than 2 cm (12) but when the size exceeds more 
than 3cm they are termed as giant (4). 

Most of osteomas are sporadic but few 
cases may have genetic predisposition like 
gardener syndrome (3). The pathogenesis of 
osteoma formation is not very clear and there 
are different theories (10,11,15). Traumatic 
theory of Gerber states that injuries suffered 
during puberty may cause the growth of 
osteoma from bone sequestra. Inflammatory 
theory which states that chronic sinusitis of 
paranasal sinuses can stimulate osteoblastic 
cell hence there is formation of osteoma. Most 
recent theory is embryologic theory which 
states that Osteoma arises from the remains of 
persistent embryologic cells located at the 
junction of the ethmoid and frontal sinuses. 

Traumatic and embryologic theories are most 
accepted one. 

Symptomatology of osteomas depends 
upon the location. Overall most common 
symptoms is headache (10). Sometimes 
osteoma may involve anterior cranial base and 
patients may have cerebrospinal fluid leak, 
meningitis, pneumatocele (5) and brain 
abscess (8). As the orbit is very close to 
ethmoid sinus, giant osteoma of 
frontoethmoidal region may involve the orbit 
and can produce proptosis, diplopia and other 
ocular symptoms (16). Very rare 
complications like amourosis (18) and orbital 
emphysema is also reported in 
frontoethmoidal osteoma. 

There are three different types of osteoma 
viz. Ivory, mature and mixed (12). This is very 
crude classification. Each osteoma has all these 
kind of cells but proportion of each cell varies. 
More mature cells migrate from the centre and 
align themselves to periphery and this is the 
reason that there is no recurrence after leaving 
some peripheral part of the osteoma (17). 

CT scan of the paranasal sinuses is the 
investigating modality of choice. It can exactly 
delineate which part of the craniofacial skeletal 
is involved but it lacks the sensitivity and 
specificity of MRI for soft tissue detail like 
optic nerve involvement. Radionuclide scan 
can be performed that shows more 
radionuclide uptake in active growing lesions. 

Osteoblastoma, osteoid osteoma (19), 
fibrous dysplasia, ossifying fibroma and 
chondroma (9) are major differential 
diagnosis of osteoma. There is no need for 
active management for osteoma except 
sphenoid osteoma (11) that threaten orbital 



 
 
 
 
 

Romanian Neurosurgery (2017) XXXI 4: 540 - 544 | 543 

 

 
 
 
 
 
 

apex or optic canal and a giant 
frontoethmoidal osteoma with involvement of 
orbit.  

There is no clear consensus among 
surgeons that which surgical treatment is 
better for frontoethmoidal osteoma. Open and 
endoscopic surgical approaches can be used to 
treat these pathologies. The choice of surgical 
approach is based upon tumor location, 
dimension, extension and experience of 
surgeon. There is rapid expansion in 
endoscopic technology and now a day’s 
endoscopic approaches are more commonly 
performed in small and medium size osteomas 
(13). Less morbidity, less blood loss, no 
operative scar, close and direct visualization of 
tumor and less hospital stay are usual benefits 
of endoscopic approach (13). Long learning 
curve, huge instrument cost, difficult intra-
operative control of bleeding, inability of bony 
reconstruction and non-familiarity with 
endoscopic anatomy of paranasal sinuses are 
usual drawbacks of endoscopic approach. 
Open surgical approaches remains treatment 
of choice for giant frontoethmoidal osteoma. 
The osteoplastic flap technique, anterior 
surgical exposure (craniofacial, transcoronal, 
and transcutaneous paranasal approaches), 
external fronto-ethmoidectomy, and lateral 
rhinotomy have all been described in the 
literature as possible techniques in the 
resection of giant osteomas that extends 
beyond the ethmoid sinus (6,7,14,21). 
Recurrent sinusitis, cranial nerve injury, 
ptosis, ophthalmic complication, meningitis, 
postoperative CSF leak and bleeding are the 
most common complications after open 
surgical procedures (1,20). In our case it was 

huge frontoethmoidal osteoma with 
involvement of orbit & requires post-operative 
reconstruction that renders endoscopic 
approach less favorable.   

The goal of surgery is complete excision of 
lesion. During surgery of frontoethmoidal 
osteoma with orbital involvement, nearby vital 
structures may got damaged like cribiform 
plate, optic nerve, eye globe, anterior and 
posterior ethmoidal arteries. Good aesthetic 
outcome is also important as far as possible 
(16). Tumours should be removed enbloc as 
far as possible and if surgeon is not able to do 
so than central hard part of osteoma should be 
drilled out and peripheral thinned rim of 
tissue should be taken out separately (4). Same 
technique should apply to orbital osteomas. In 
our case we first approach anterior skull base 
intracranially- extradurally & removed 
frontoethmoidal part of osteoma enbloc. 
Orbital part removed separately. Post-
operative defect after removal of giant 
frontoethmoidal osteoma should repair as far 
as possible. Small defect can be repair using 
pericranial patch or galeal-pericranial patch. 
Large defect should be repair using autologus 
calvarial bone graft, as this graft provides 
natural cranial contour. Synthetic implants 
can also be used for correction of post-
operative defect. We offered reconstruction of 
bony defect but due to financial constrains, 
patient and his parents refused for the same. 
Post-operative recurrence of osteoma is very 
unusual but few case reports are described of 
rapid recurrence (2). CSF leaks, meningitis, 
post-operative bleeding, and injury to vital 
structures like optic nerve and lacrimal 
apparatus injury are the common 
postoperative complications. 



 
 
 
 
 
544 | Gupta et al - Giant Frontoethmoidal osteoma 

 

 
 
 
 
 
 

Conclusion 
Giant frontoethmoidal osteomas with 

orbital invasion are very rare lesions. Most of 
the existing literature on this pathology is in 
the form of case reports or small case series 
hence no definitive approach is superior. In 
today’s era both surgical and endoscopic 
approaches can be used. In case of giant 
osteomas due to invasion of nearby structures 
like orbit, endoscopic approaches are less 
useful. Our case is very unique and adds a rich 
knowledge to the existing literature and 
reaffirms the open surgical procedure as 
preferred modality of treatment in case of 
giant frontoethmoidal osteoma. 

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