Benign Tumors of the Frontal Sinuses with and Fibro-Osseous Tumors of the Frontal Sinus: Their Propensity to Recur and Cause Local Open Approaches

Chapter 18 Benign Tumors 18 of the Frontal Sinuses Brent A. Senior, Marc G. Dubin Management of Benign Lesions of the Frontal Sinus . 157 Core Messages Preoperative Evaluation . 157 í Surgical Treatment of Bony Benign tumors of the frontal sinuses with and Fibro-osseous Tumors of the Frontal Sinus: their propensity to recur and cause local Open Approaches . 157 injury present unique challenges to the Surgical Treatment of Bony otolaryngologist and Fibro-osseous Tumors of the Frontal Sinus: Endoscopic Approaches . 158 í Fibro-osseous lesions may be managed ex- Cases: Fibro-osseus Lesions of the Frontal Sinus . 159 pectantly, or may be removed in the setting Case 1: Endoscopic Resection of Tumor of symptomatic pathology such as cosmet- in the Frontal Recess . 159 ic or functional deformity Case 2: Open Resection of Tumor of the Frontal Sinus . 160 í Inverted papillomas with their high rate of Surgical Management of Inverted Papilloma: associated malignancy should be complete- Open and Endoscopic . 161 ly removed Cases: Inverted Papilloma of the Frontal Sinus . 161 Case 1: Recurrent Inverted Papilloma of the Frontal Sinus . 161 í Tumors that in the past required open approaches may now be managed successful- Postoperative Considerations . 162 ly with endoscopic approaches alone or Conclusions . 163 with combined approaches, lowering over- References . 163 all morbidity while not sacrificing outcome í Cases must be individually assessed in or- der to determine the appropriate management approach Introduction Management of disease of the frontal recess and frontal sinus is one of the greatest challenges in rhi- nology. Despite advances in the understanding of the Contents anatomy and physiology of this area along with increased comfort with endoscopic techniques, man- Introduction . 153 agement of this area remains difficult due to its tight Fibro-osseous Tumors . 154 rigid bony anatomic constraints. As treatment of in- Osteoma . 154 flammatory disease of this area continues to pose a Fibrous Dysplasia and Ossifying Fibroma . 155 therapeutic challenge, it is of no surprise that frontal Inverted Papilloma . 155 sinus tumors are particularly difficult to manage. 154 Brent A. Senior, Marc G. Dubin Many of the benign tumors that occur in this area have the potential to recur and spread into adjacent structures and compartments. Anterior extension to the skin of the face can lead to significant cosmetic deformity, whereas posterior extension into the anterior cranial fossa can lead to dural erosion, brain compression, and increased intracranial pressure.In- ferior growth can lead to orbital symptoms including diplopia, proptosis, and decreased visual acuity. In all cases, tumor growth may lead to postobstructive frontal sinusitis with the possibility of spread to adjacent regions including the orbit, intracranially, or subcutaneously. For the purposes of this chapter, benign frontal sinus tumors will be primarily classified into: í Fibro-osseous tumors í Inverted papilloma í Mucoceles (discussed in Chapter 9) Fig. 18.1. Coronal CT through the frontal sinus illustrating typ- ical appearance of a frontal sinus osteoma in a patient presenting with complaints of head pain The fibro-osseous lesions will then be subdivided into the three most common lesions involving the frontal sinus: Vallisnieri was credited with detailing their bony origin [4]. The frequency of frontal sinus osteomas has í Osteoma been known for many years as Childrey, in 1939 cited í Ossifying fibroma an incidence of 0.43% in 3510 skull radiographs [24, í Fibrous dysplasia 27]. More recently, osteomas were found in 1% of frontal sinus radiographs in symptomatic individu- als [24, 27]. Each of these tumors varies with regard to risk of re- These bony tumors typically present in the third currence, degree of aggressiveness, and potential for to fourth decade of life with a male to female ratio of malignant degeneration. Therefore, the primary 1.5:1 to 2:1 [1]. In patients of Middle Eastern or West management of each lesion will take these factors Indian descent they may present earlier [1]. The most into consideration. common presenting symptoms are headache and pain in the frontal area; however, many tumors are asymptomatic and are detected on imaging obtained Fibro-osseous Tumors for other reasons [34]. Symptoms consistent with frontal sinusitis due to outflow obstruction are also Osteoma common. With larger tumors, facial cosmetic deformity may result from anterior growth, while proptosis,diplopia,and visual changes may result from infe- 18 Fibro-osseous tumors are the most frequent tumors rior extension. Posterior extension may lead to intra- arising in the frontal sinus and frontal recess cranial complications [34]. with descriptions of men- (Fig. 18.1). Of these, the most common is the osteoma. ingitis, seizures, and hemiparesis all found in the lit- In 1941, Wallace Teed credited Veiga with the first de- erature, as well as a report by Cushing of pneumo- scription of a frontal sinus osteoma in 1506, whereas cephalus in 1938 [7,34] (Fig. 18.2). Benign Tumors of the Frontal Sinuses Chapter 18 155 cancellous bone. Both histologic types are well localized, rarely recur, and arise from the subperiosteal or endosteal surfaces of bone [6].Neither has the potential to degenerate into osteosarcoma [6]. Fibrous Dysplasia and Ossifying Fibroma Polyostotic fibrous dysplasia was first described by Albright in 1937, and ossifying fibroma was distin- guished from it in 1963 by Reed [22,29]. In contrast to osteomas, these lesions tend to occur in a younger population. Both fibrous dysplasia and ossifying fibroma are less frequently found in the region of the frontal recess, and they tend to be less well localized. It is for this reason that resection of a focus of fibrous dysplasia tends to require multiple attempts. Ossify- ing fibroma has a tendency to recur more so than osteomas but less so than fibrous dysplasia [11]. Fur- thermore, pain tends to be less common whereas fa- Fig.18.2. Coronal CT illustrating pneumocephalus as a compli- cation of a fibro-osseous tumor of the left ethmoid. Patient cial asymmetry and cosmetic deformity are more originally presented with change in mental status following a common (Fig. 18.3). Of note, radiation is avoided in sneeze the treatment of fibrous dysplasia due to the risk of malignant transformation. Histologically, fibrous dysplasia is composed of Osteomas are also a common feature of Gardner’s highly cellular fibrous tissue with uniform spindle- syndrome, an autosomal dominant disorder. This shaped fibroblasts. Irregular trabeculae of woven disorder is characterized by multiple osteomas, soft bone without lamellar bone or osteoblastic rimming tissue tumors (subcutaneous fibrous tumors or epi- may also be found. Multifocal or polyostic disease is dermal/sebaceous cysts), and colonic polyposis [34]. well recognized with associated involvement of long As the true morbidity of this disease stems from the bones, cranial bones, mandible, or maxilla. In con- 40% malignant degeneration of the colon polyps, the trast, ossifying fibroma is nearly uniformly mono- diagnosis must at least be entertained in a patient stotic and lacks the osteoid and osteoblastic rimming presenting with an osteoma [34]. of fibrous dysplasia. Psammomatoid ossifying fibro- Osteomas are assumed to grow in a slow but con- ma is a variant that tends to occur in the ethmoid re- tinuous fashion, as was first noted in 1951 by Gibson gion of younger children and exerts more destructive and Walker [12]. Exact rates of growth will vary from growth [21]. case to case, though their growth is theoretically greatest during puberty with maximal skeletal growth [1]. The etiology of osteomas is now believed Inverted Papilloma by most investigators to be developmental [34]. (Pre- vious theories included trauma and infection; how- Inverted papilloma was first described in 1854 and is ever, few patients with osteomas present with a histo- one of the most common lesions of the nose and si- ry of trauma, and only a minority (approximately nuses [38]. Classified by the World Health Organiza- 30%) have an antecedent history of infection [34]. tion as a type of Schneiderian (respiratory) papillo- These lesions occur in two histologic variants: ivory ma (including cylindrical cell papilloma and exo- and mature. The ivory lesions are formed by mature phytic papilloma), it has been alternatively called vil- dense bone, whereas the mature variant contains liform cancer, papillary sinusitis, Ewing’s papilloma, 156 Brent A. Senior, Marc G. Dubin Fig. 18.3. Triplanar imaging of a fibrous dysplasia lesion of the right maxillary sinus in an 11-year-old girl. Note the bulging of the cheek on the right side on the reconstructed facial image and transitional cell papilloma. Inverted papillomas cans.Presenting symptoms include nasal obstruction are characterized by a high rate of recurrence and (87%), nasal drainage, facial pain/pressure (31%), potential for transformation to squamous cell carci- epistaxis (17%), frontal headache (14%), and epipho- noma. Rates of malignant transformation have been ra (7%) [37]. Various etiologic factors have been cit- reported to range from less than 2% to 53%, with ed, although none proven. These include chronic in- most authors agreeing on a rate of approximately flammation, allergy, viral infection, and environmen- 10% [32]. Histologically they have an inverted growth tal carcinogens [9]. Recently, numerous reports have pattern with an inflammatory infiltrate of neutroph- shown the presence of Human Papilloma Virus ils and microcysts. (HPV) in inverted papilloma using polymerase chain Although inverted papilloma of the paranasal si- reaction (PCR) and in situ hybridization (ISH) tech- nuses is relatively common, the most common site of niques, though prevalence has varied wildly from origin is the lateral nasal wall resulting in involve- 0%–100%. Subtypes 6, 11, 16, and 18 have all been ment of the ethmoid and maxillary sinuses, and thus identified, although correlation with malignant isolated involvement of the frontal sinus is rare [37].

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