- Skull Base Surgery Unit, Division of Neurological Surgery, Department of Surgery, College of Medicine, University of Ibadan, Ibadan, Nigeria
Amos Olufemi Adeleye
Skull Base Surgery Unit, Division of Neurological Surgery, Department of Surgery, College of Medicine, University of Ibadan, Ibadan, Nigeria
DOI:10.4103/2152-7806.74489© 2010 Adeleye AO This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Adeleye AO. A giant, complex fronto-ethmoidal ivory osteoma: Surgical technique in a resource-limited practice. Surg Neurol Int 31-Dec-2010;1:97
How to cite this URL: Adeleye AO. A giant, complex fronto-ethmoidal ivory osteoma: Surgical technique in a resource-limited practice. Surg Neurol Int 31-Dec-2010;1:97. Available from: http://sni.wpengine.com/surgicalint_articles/a-giant-complex-fronto-ethmoidal-ivory-osteoma-surgical-technique-in-a-resource-limited-practice/
Background:Unlike small and medium size fronto-ethmoidal osteomas which are amenable to surgical excision through limited craniofacial openings, giant lesions require extensive and complex craniofacial dissection, and post lesionectomy reconstruction using an array of modern-day surgical adjuncts. This is a report of our surgical technique for the successful and esthetically fair operative resection of a giant fronto-ethmoidal osteoma in a difficult practice setting.
Case Description:A 32-year-old Nigerian lady harbored a giant complex fronto-ethmoidal ivory osteoma. Deploying our understanding of modern-day advanced microsurgical anatomy and technique of skull base surgery, but under severe resource limitations, a radical total surgical resection was performed and an esthetically fair post lesionectomy reconstruction was achieved. The patient remains tumor-free in 20 months, so far, of postoperative follow-up.
Conclusions:Even under severe resource limitations, inventive adaptations of modern-day skull base surgery techniques can facilitate hitherto unusual functional and esthetically successful resection of giant osteomas of the fronto-ethmoidal sinus complex.
Keywords: Giant fronto-ethmoidal ivory osteoma, Nigeria, surgical resection
Osteomas are benign usually slow-growing osseous-fibrous neoplasm. They are quite infrequent in the paranasal air sinuses and their occurrence in these locations has been put at 0.43% in one early plain sinus radiography series and 3% in a more recent sinus computed tomography survey.[
Giant fronto-ethmoidal osteomas, lesions larger than 60 mm, are very rare indeed;[
A 32-year-old female primary school teacher presented in our clinic in 2009 with a two-year-history of recurrent generalized tonic-clonic seizures. There was a prior medical history, nine years previously, of surgical excision of a frontal extracranial mass lesion. The details of this surgical procedure and the histologic findings on the excised mass were not available for our review. Clinical and neurologic examinations revealed anosmia and a healed surgical incision below the hair line in the right frontal region. There were no other neurological deficits. Visual function and ocular mobility were preserved. Cranial computed tomography, CT, scanning showed a huge 8 cm right fronto-orbital mass lesion [Figures
Preoperative imaging, cranial CT scanning. (a) CT scanogram showing the huge highly calcified frontal-ethmoidal mass with a cresentic radiolucent mass (mucoceles) capping its posterior rim (b) the mass involved the right orbital superior rim and roof (c) the mass is associated with expansion of the adjoining diploe suggesting the differential of intradiploic dermoid and (d) there is marked compression of the frontal lobes especially on the right
The patient was positioned supine under general endotracheal anesthesia. A bicoronal scalp flap was raised with a preauricular skin incision reaching from just above the right zygomatic process to the contralateral superior temporal line. This incision was developed from behind the hair-line, separate from the previous healed below-the-hair-line frontal incision. Next a wide-base pericranial flap was developed pedicled distally. Using the Hudson brace and Cushing’s bone perforators, strategic burr-holes were placed to raise, using the Gigli saws, a cranio-orbito-nasal bone flap [Figures
Intraoperative dissection, lesionectomy and reconstruction. (a)The cranio-orbital-nasal bone flap being raised (b) the right orbit unroofed (orbital contents retracted) and intracranial extradural fronto-ethmoidectomy achieved (c) pedicled generous pericranial flap being layered on the frontal fossa floor and (d, e) the ivory osteoma shaved off the frontal-orbital-nasal bone flap and the bone flap broken pieces after autoclaving (e) frontal-orbital-nasal calvarial rigid reconstruction being facilitated with titanium skull clamps, CranioFixR (B Braun, Aesculap, Germany)
Attention then shifted to rigid reconstruction of the cranial-orbital-nasal opening. The ivory osteoma was shaved off the cranial flap using osteotome and mallet to save as much membraneous convexital skull bone as possible [Figures
The postoperative cranial CT scanning confirmed total excision of the mass, unroofing of the right orbit and good frontobasal skull calvarial reconstruction. There was also good decompression of the frontal cerebral hemispheres [Figures
Postoperative images (a, b) Axial bone window images of the immediate postoperative cranial CT scanning confirming the operative complete lesionectomy, frontoethmoidectomy, unroofing of the right orbit and the reconstructed right orbital rim and the frontal basal skull convexity (c) good cerebral hemispheric decompression and (d) clinical picture of the patient 14 months postop
Here we present our technique for the successful surgical resection of a giant and complex fronto-ethmoidal ivory osteoma using inventive modifications of some of the modern-day skull base surgery tenets in an otherwise difficult surgical practice.
Frontal osteomas are the most common of the paranasal sinuses osteomas and are either exostotic or enostotic.[
Enostotic frontal-ethmoidal osteomas on the other hand grow from either the outer or inner table of the skull into the respective sinuses or simply intracranial.[
Ultra-large lesions, or giant frontal-ethmoidal osteomas, are those larger than 60 mm in diameter and reports of such mammoth size lesions are rare in the literature.[
Many, if not all, of these enviable resources are pretty rare luxuries in our practice. What we have going for us is only a continually-challenged inventiveness to adapt modern-day practice to our resource limitations.
In this case for instance, a single cranial-nasal-orbital bone flap using adaptive deployment of the Gigli saw, osteotome and mallet to circumscribe the limits and attachments of this huge lesion was found more practical for our situation. In the same light because our only realistic option for rigid reconstruction of the post lesionectomy defect was the patient’s own cranial bone, we salvaged as much calvarial convexital bone as possible from the patient’s tumor attached cranial flap for the same-sitting cranioplasty. Previous reports of surgical resection of giant fronto-ethmoidal osteomas in similar practice as ours show patients having to leave with unsightly post lesionectomy cranial defects that were still awaiting cranioplasty for as long as two years to the time of some of the reports.[
Obviously, one main drawback of using this tumor-attached bone for this cranioplasty is the risk of recurrence. And many cases of recurrence of frontal osteomas have indeed been reported in the literature especially after not-so-radical surgery.[
Giant fronto-ethmoidal osteomas, lesions >60 mm, are uncommon. Reports of successful functional and esthetically acceptable surgical resection of such lesions in resource-limited practices are very rare indeed. One such experience has been detailed in this paper.
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