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 order 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 complication 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]. transformation is even less clear [5, 23]. Frontal sinus involvement has been reported to occur Surgical resection is the treatment of choice, with in 1.1%–16%, although most reports cite a rate of procedures that provide “adequate exposure” being 18 1%–5% [33]. Occurring in all age groups, this tumor advocated. Radiation is reserved for patients who are most commonly occurs in the fifth to seventh poor surgical candidates, malignant lesions, or unre- decades of life. The male to female predominance sectable disease with associated morbidity. Recur- ranges from 3 : 1 to 5 : 1 [11,16]. Caucasians appear to rence rates have been cited at 25%–50% and are usu- be affected more commonly than African-Ameri- ally attributed to incomplete surgical removal [2,17]. Benign Tumors of the Frontal Sinuses Chapter 18 157

Management of Benign Lesions damage, the potential for postoperative complica- of the Frontal Sinus tions is significant. The first decision is whether to resect or observe a lesion.Although the indications for resecting a lesion Preoperative Evaluation that is causing frontal sinusitis from obstruction or has intracranial extension are clear, the timing of ad- dressing smaller lesions is more controversial. Argu- In all tumors of the frontal sinus and skull base, care- ments have been made that small osteomas should be ful preoperative evaluation is critical. Preoperative resected when found due to their inevitable growth, high-resolution computed tomography (CT) is the while others advocate a more conservative approach study of choice to delineate the bony anatomy and [35, 36]. Smith and Calcaterra have suggested that a any associated distortion, the extent of the tumor lesion that occupies more than 50% of the sinus vol- within the sinus cavity, as well as extension of tumor ume or obstructs the frontal outflow tract should be beyond the confines of the sinus. Coronal and axial resected [34]. With this in mind, the conservative images are mandatory, though sagittal images are al- management with close observation and imaging at so of great value for frontal sinus lesions. Magnetic regular (i.e. 6-month) intervals may be appropriate resonance imaging (MRI) with enhancement is also in the reliable patient. This conservative approach is useful for delineating tumor from retained secretions perhaps best suited for the asymptomatic lesions that (typically bright on T2-weighted images) but is less are laterally located. However, lesions that have a helpful in the management of bony and fibro-os- high likelihood of causing obstruction of the frontal seous lesions. With any dehiscence of the skull base infundibulum should be managed more aggressively. including the posterior table of the frontal sinus, Management decisions must be based on the individ- however, MRI is essential to evaluate for the possibil- ual circumstances, taking into account the patient’s ity of meningocele or meningoencephalocele. Pa- age, comorbidities, and the potential morbidity of tients with involvement of the orbit should have a the procedure required to remove the lesion. thorough preoperative visual assessment, and pa- Approaches to these lesions are divided into endo- tients with intracranial extension should be evaluat- scopic, open, or a combination of both. Key considered by a neurosurgeon. Furthermore, the possibility of ations in deciding an approach are the exact location a CSF leak must be discussed with the patient, and and size of the lesion. plans for a lumbar drain should be made pre-opera- Historically, trephination procedures as well as tively when appropriate. A thorough endoscopic ex- Lynch procedures have been commonly used to man- amination is also critical to delineate anatomy and to age these lesions [4, 35, 36]. These techniques are of- fully evaluate for active infection.Any acute infection ten well suited for small, inferior-medial lesions due should be treated aggressively with broad-spectrum to limited visualization provided by these approach- antibiotics due to the risk of postoperative intracra- es.Visualization may be inadequate in osteomas with nial extension. a broad attachment to the posterior table of the frontal sinus, where a greater risk of intracranial penetration and subsequent CSF leak exists [1]. Additionally, there is a well documented risk of frontal stenosis Surgical Treatment of Bony that exists after performing the Lynch procedure [8, and Fibro-osseous Tumors 11, 30], a risk that increases with time. of the Frontal Sinus: Open Approaches Osteoplastic flaps have been presented as an alternative and were popularized by Goodale and Mont- Controversy surrounding the treatment of these le- gomery [13,14].Via a brow,mid-brow,or coronal inci- sions centers on the timing of resection as well as the sion, the lesion may be approached in a unilateral or approach utilized. As stated previously, due to the bilateral manner [25]. This may be combined with delicate anatomy of the frontal recess and the ten- frontal sinus obliteration in lesions that are very dency for stenosis following circumferential mucosal large, where significant mucosal disruption of the si- 158 Brent A. Senior, Marc G. Dubin

nus occurs with tumor removal, or when involve- precise, meticulous technique. Bleeding which ob- ment of the frontal infundibulum raises concern scures the operative field will also be decreased by about postoperative frontal stenosis. Additionally, carrying out dissection in a posterior to anterior di- obliteration may be useful if CSF leak is encountered. rection. Similarly, performance of adequate injec- In most cases, however, obliteration is not necessary, tions of vasoconstrictor agents cannot be underesti- and, indeed, is avoided in order to provide for resto- mated. One percent lidocaine with 1:100,000 parts ration of function to the sinus while preserving the epinephrine is injected over the uncinate, into the ability to monitor for tumor recurrence either radio- sphenopalatine foramen and into the greater pala- graphically or by endoscopy [25]. Overall, the osteo- tine foramen bilaterally.If middle turbinate resection plastic flap approach offers excellent exposure and is planned, the head of the turbinate is also injected. the ability to preserve the native frontal recess anato- For tumors extending into the frontal recess, cautery my, however, at the expense of surgical morbidity in of the anterior ethmoid vessels is sometimes also the form of blood loss, scar, need for a hospital stay, necessary using endoscopic bipolar forceps and an- and the risk of frontal numbness, frontalis weakness, gled endoscopes. and late frontal bossing. Early identification of the lamina papyracea and The craniofacial resection has also been advocat- the skull base is critical to safely identifying and ed for extremely large lesions with significant extras- opening the frontal recess. Thorough dissection of inus extension. This technique was first advocated by normal tissue around the tumor is performed to wid- Dandy in 1922 and later by Cushing in 1938 [7]. A re- en the surgical field. Once adequate exposure of the port of eight patients with massive lesions was pre- tumor has been achieved, small tumors can be easily sented by Blitzer, who resected residual and recur- removed. With large tumors, a drill is often required rent tumors [3]. In his series with four years of fol- to debulk the tumor before it can be removed trans- low-up, he had no recurrences. nasally (Fig. 18.4). Newer microdebriders with simul-

Surgical Treatment of Bony and Fibro-osseous Tumors of the Frontal Sinus: Endoscopic Approaches

The first reported endoscopic excision of a bony tumor was provided by Menezes and Davidson in 1994 [26]. This spheno-ethmoid tumor was removed without complication and without recurrence at 1-year follow-up [26]. Seiden and Hefny then reported on a combined trephination and endoscopic approach to remove a frontal sinus osteoma via a brow incision [31]. Later, in 1996, Kennedy’s group reported on the extension of endoscopic techniques for the management of bony tumors with intracranial or intraorbital involvement [18]. Additionally, Senior and Lanza reported on the use of endoscopic techniques in isola- tion and in combination with open approaches to re- 18 move tumors with frontal sinus involvement [32]. Intra-operatively, an emphasis on techniques that minimize bleeding is critical. Nuisance bleeding de- Fig.18.4A, B. Example of a cutting drill with simultaneous suc- creases visualization and can be avoided by minimiz- tion and irrigation for use with debrider handpiece (Diego, ing trauma to adjacent nasal structures by utilizing Gyrus ENT, Memphis, TN) Benign Tumors of the Frontal Sinuses Chapter 18 159 taneous suction and irrigation coupled with angled Headache was described as dull and constant, located drill burrs at 45°–70° can greatly increase the speed over the right brow. Intensity of the pain seemed to of the tumor debulking. As with mastoid surgery, increase with episodes of sinusitis. Drainage and however, care must be taken to switch to diamond congestion were not significant complaints. burrs at the perimeter of the dissection in order to CT scan was obtained (Fig. 18.5) with findings of a minimize potential trauma to the orbital periosteum small fibro-osseous lesion of the right frontal recess or the dura. Once the tumor is sufficiently debulked, with associated mucosal thickening in the ethmoid it may be teased from adjacent structures using an- and frontal sinuses. The lesion was closely related to gled frontal curettes and probes. Often, despite the the right cribriform plate. large size of these tumors, they are only loosely at- Surgery was performed via an endoscopic ap- tached to the adjacent bone and can be separated proach.Preoperative discussions of possible CSF leak from their base using a rocking motion. Generally, and possible injury to the anterior ethmoid neuro- frontal sinus stents are not utilized unless the result- vascular bundle were had in addition to possible re- ing recess is exceptionally narrow or significant mu- currence of tumor. Intraoperatively, the tumor was cosal disruption of the frontal infundibulum has oc- rocked from adjacent structures with a curette under curred. Additionally packing is not employed unless direct vision (Fig. 18.6) and removed transnasally. a CSF leak has occurred. If a CSF leak is encountered, Because of the small size of the tumor,no drilling was it is repaired primarily in a fashion similar to that de- performed. No CSF was encountered, and no injury scribed elsewhere in this text. Large leaks, or leaks to the neurovascular bundle occurred. unexpectedly occurring high or lateral in the frontal Postoperatively, the patient experienced resolu- sinus may require obliteration of the sinus via osteo- tion of his headaches. plastic flap. Pathology confirmed the tumor to be benign oste- These techniques may be combined with a modi- oma. fied Lothrop as described by Gross et al. [15] or similarly, a trans-septal frontal sinusotomy as described by Lanza et al. [19] in order to increase frontal sinus exposure with removal of the sinus floor, intersinus septum,and superior nasal septum.They may also be used in combination with open techniques (i.e. osteoplastic flap) to increase postoperative visualization of the frontal recess for monitoring for tumor recurrence. Furthermore, trephination may be employed allowing for manipulation of the tumor from both “above and below” while providing overall improved visualization.

Cases: Fibro-osseus Lesions of the Frontal Sinus

Case 1: Endoscopic Resection of Tumor in the Frontal Recess Fig. 18.5. Coronal CT illustrating presence of fibro-osseous lesion in the region of the right frontal recess with adjacent mu- A 54-year-old man presented with 3 years of right- cosal thickening of the frontal sinus and ethmoid sinus. Note sided headache with recurrent episodes of sinusitis. proximity of the lesion to the cribriform plate 160 Brent A. Senior, Marc G. Dubin

the frontal sinus. New CT imaging reveals recurrence of tumor encapsulating the previously placed stent (Fig. 18.7). Surgery was performed via an osteoplastic flap. Tumor was drilled down to the roof of the orbit and posterior table of the sinus (Fig. 18.8). The intersinus septum and the floor of the sinus were removed to maintain sinus aeration. Postoperatively, pain resolved, and the patient remains asymptomatic 2 years following surgery with a patent frontal sinus.

Considerations in Endoscopic Approaches to Fibro-osseous Lesions Fig. 18.6. Endoscopic view showing curetting of the fibro-osseous lesion shown in Fig. 18.5. The lesion was gently rocked í Complete sinus surgery with wide exposure to free of its attachments allow for careful inspection of the skull base and lamina papyracea í Cautery of the anterior ethmoid artery and Case 2: Open Resection of Tumor vein using bipolar forceps if risk of injury is of the Frontal Sinus high í Use of endoscopic drills (Diego, GyrusENT, A 21-year-old woman presented with recurrent pain Memphis, TN) to debulk tumors to ease re- in the right frontal region following resection of moval and delivery out of the nose (Fig. 18.4) frontal sinus fibrous dysplasia via osteoplastic flap 3 years earlier. At the time of the original procedure, frontal sinus stent was placed to maintain integrity of

18 Fig. 18.8. Recurrent monostotic fibrous dysplasia of right fron- Fig. 18.7. Triplanar imaging of recurrent monostotic fibrous tal sinus. Access is being provided with an osteoplastic flap dysplasia of the right frontal sinus managed previously via os- frontal sinusotomy, and the tumor has been drilled down to teoplastic flap with placement of frontal sinus stent. Previous- the posterior table. The intersinus septum is being drilled ly placed stent is clearly visible down to facilitate drainage to the contralateral side Benign Tumors of the Frontal Sinuses Chapter 18 161

time of surgery should also be placed on creating a í After the tumor has been shelled out and de- cavity that can easily be monitored postoperatively in bulked, it may be gently rocked and teased the clinic with angled endoscopy. Case series of en- away from adjacent structures with a Lusk doscopic resection of inverted papillomas of the maxillary ostium seeker or the Kuhn-Bolger frontal sinus were recently reported [10, 20]. curette (Karl Storz Endoscopy, Culver City, Endoscopic management of inverted papilloma CA) that either primarily or secondarily involves the frontal sinus can be considered in select cases [10]. Lesions that do not involve the lateral or anterior frontal sinus may be managed endoscopically if the Surgical Management of Inverted frontal recess is large enough. Regardless, endoscop- Papilloma: Open and Endoscopic ic assessment of inverted papilloma of the frontal sinus at the same time as endoscopic resection of eth- Traditionally, management of inverted papilloma moid/maxillary disease can accurately assess the without involvement of the frontal sinus involved lat- need for open approaches and can open the recess eral rhinotomy or midface degloving with an “en from below to facilitate postoperative surveillance bloc” resection of the lateral nasal wall and maxilla. [10]. Furthermore, as with removal of fibro-osseus In 1990, Phillips reported on recurrence rates in 112 tumors, endoscopic resection can be combined with cases of inverted papilloma resection from 1944– open approaches to ensure complete resection. Al- 1987,cases in which a variety of approaches were per- though a majority of patients may ultimately require formed. The recurrence rate with each technique an open resection of inverted papilloma that involves were: medial maxillectomy (14%), transnasal with si- the frontal sinus, a select few may be managed entire- nus exenteration (35%), and transnasal alone (58%) ly endoscopically [10]. This may be facilitated by ex- [28]. Subsequently, the increased visualization and tended endoscopic techniques in the form of a mod- surveillance associated with endoscopic techniques ified Lothrop or a trans-septal frontal sinusotomy led to the increased, albeit controversial, use of endo- [20]. scopic resection by many authors [35, 36]. Extension of inverted papilloma into the area of the frontal recess or frontal sinus presents a unique Cases: Inverted Papilloma challenge. Because endoscopic techniques provide of the Frontal Sinus limited access to much of the frontal sinus, inverted papillomas that extend into this area often require an Case 1: Recurrent Inverted Papilloma open or combined open/endoscopic approach via an of the Frontal Sinus osteoplastic flap or fronto-ethmoidectomy. The osteoplastic approach provides excellent exposure and A 46-year-old woman presented with pain, pressure, allows for an en bloc resection of a papilloma with a proptosis, and diplopia. Her history was significant cuff of normal mucoperiosteum. Obliteration after for having undergone medial maxillectomy via later- resection makes postoperative surveillance difficult al rhinotomy for an inverted papilloma of the right both clinically and radiographically and is therefore side 7 years earlier. Endoscopic examination revealed avoided if at all possible. a polypoid mass of the right ethmoid with extension Despite the limitations of endoscopy in the resec- into the right frontal sinus. CT revealed opacification tion of frontal sinus inverted papillomas, regardless of the right frontal sinus (Fig. 18.9), and MRI suggest- of the surgical approach employed,the endoscope reed the opacification to be soft tissue and not inspis- mains a critical tool in evaluation and treatment. The sated secretions. careful examination both intra-operatively and post- Surgical pathology from the earlier resection was operatively of the surrounding mucosa can increase a reviewed, confirming benign inverted papilloma. En- surgeon’s ability to remove all neoplastic disease and doscopic approach was performed. Preoperative rapidly identify recurrent tumor. Emphasis at the counseling focused on orbital injury with tumor 162 Brent A. Senior, Marc G. Dubin

evaluation if necessary. Packing is only placed if a leak is encountered and is removed 1–3 days following the lumbar drain. As with any CSF leak, a high level of suspicion for meningitis must be maintained, and the patient must be appropriately educated as to the signs and symptoms.Vaccination against S. pneu- moniae should be considered. If diplopia occurs postoperatively, early consultation with an ophthalmologist is essential. Trauma to the trochlea or extra-ocular muscles must be considered and addressed. Any orbital pain or change in vision is considered an orbital hematoma until proven otherwise. In- creased orbital pressure from an arterial bleed is managed with a canthotomy with cantholysis and an emergent ophthalmology consultation. For osteomas, recurrence is rare with complete re- Fig.18.9. Coronal CT showing opacification of the frontal sinus from recurrent inverted papilloma moval, so follow-up surveillance is less important; however, with other fibro-osseus lesion and inverted papillomas, regular and long-term surveillance is essential. The ability to identify residual or recurrent overlying the dehiscent orbit, in addition to recur- disease endoscopically is, arguably, the most signifi- rence and need for further surgery in light of the cant advantage provided by the endoscope. frontal tumor extension. Intraoperatively, tumor was freed from its attachments at the frontal ostium, without necessitating an open approach. No stenting was performed, the tumor having dilated the frontal ostium. Tumor was safely removed from the dehiscent lamina papyracea. Post-operatively, patient remains tumor free at 2 years post-op with a patent frontal sinus (Fig. 18.10).

Postoperative Considerations

Regardless of the technique used, all patients are treated with antibiotics in the postoperative period. Typically, a broad-spectrum antibiotic with good CSF penetration is chosen. If a CSF leak was encountered and repaired,a lumbar drain may be placed and the patient kept on be- drest for 3–4 days. After this time period, the drain is clamped for 24 hours and then removed if no leak is 18 present. Great care must be utilized, however, as large skull base defects may result in greater likelihood of pneumocephalus with lumbar drainage. Headache Fig. 18.10. Endoscopic view of the right frontal sinus illustrat- not responsive to pain medications should prompt a ing patency 2 years following endoscopic removal of recurrent lateral brow plain radiograph and neurosurgical inverted papilloma of the frontal sinus shown in Fig. 18.9 Benign Tumors of the Frontal Sinuses Chapter 18 163

10. Dubin M, Sonnenburg RS, Melroy CT, Ebert C, Couffey C,

Conclusions Senior BA (2004) Staged endoscopic and combined open/

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