A giant, complex fronto-ethmoidal ivory osteoma: Surgical technique in a resource-limited practice

Abstract

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.

Figure 1

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

Figure 2

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, CranioFix^R (B Braun, Aesculap, Germany)

Figure 3

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