Transorbital Approach to Surgical Resection for a Far-Lateral Frontal Sinus Osteoma

Purpose: The purpose of this article is to highlight a novel surgical approach to resection of a far-lateral frontal sinus osteoma.

Case Presentation: A 21-year-old male presented to otolaryngology clinic for chronic, intermittent left-sided nasal congestion. Computed tomography (CT) of the maxillofacial region without intravenous contrast demonstrated a uniform bone density mass in the left frontal sinus ([Fig. 1]). The mass measured 1.9 cm × 1.3 cm × 1.2 cm. The overall appearance was consistent with an osteoma. Given the size of the mass and its proximity to the posterior table of the frontal sinus, surgical management was recommended. The patient underwent a combined nasal septoplasty and endoscopic sinus surgery with otolaryngology, which resulted in a sub-total resection due to the far-lateral position ([Fig. 2]). Given the patient’s receding hairline, and the potential for aesthetically unacceptable scarring, a coronal-based approach was considered suboptimal. The patient was referred to oculofacial plastic surgery and a transorbital approach was planned. An eyelid-crease-based orbitofrontal approach was performed on the left side. Bone was drilled and removed in the superior orbit to access the posterior frontal sinus, anterior cranial fossa, and skull base. The mass was identified and widely exposed. An angled diamond burr was used to drill the base of the mass and it was excised in its entirety. Histopathological examination of the specimen confirmed osteoma. Postoperatively, the patient has demonstrated improving V1 hypoesthesia but otherwise excellent ocular and adnexal function. Visual acuity was 20/20 in both eyes with full extraocular movements, no diplopia, and normal levator function. A postoperative CT scan is scheduled.

Fig. 1 Preoperative coronal (A) and sagittal (B) CT maxillofacial imaging demonstrating a left frontal sinus mass.

Fig. 2 Coronal (A) and sagittal (B) CT maxillofacial images demonstrating the residual frontal sinus mass after initial subtotal endoscopic resection.

Discussion: About 70 to 80% of paranasal sinus osteomas are found in the frontal sinus.¹ These masses are classically benign, indolent, and asymptomatic. In most cases, the masses can be observed through periodic follow-up and surveillance imaging; however, if a paranasal sinus osteoma compresses surrounding structures or obstructs sinus drainage, surgical resection is recommended.² Historically, frontal sinus osteoma resections have followed one of three surgical approaches: (1) an external approach, (2) an endoscopic approach, or (3) a combination of both.^3,4 In scenarios such as the one presented in this report, when the endoscopic surgery results in a subtotal resection, a subsequent, traditional osteoplastic flap is recommended to provide a wide exposure and complete resection. The transorbital approach may provide an additional option with the potential for faster postoperative recovery, lower morbidity, decreased risk of damaging the surrounding nerves, more favorable cosmetic outcome, and less postoperative pain when compared with external skull-based procedures.

Conclusion: Our case represents the first description of a transorbital approach for the resection of a frontal sinus osteoma, therefore, demonstrating the potential of the transorbital approach as an adjunct to management of complex, far-lateral frontal sinus pathology.

 

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No conflict of interest has been declared by the author(s).

Publication History

Article published online:
07 February 2025