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Which is the diagnosis and approach?
¿Cuál es su diagnóstico y abordaje?

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A 51 year-old woman came by emergency for a six months precess of nasal obstruction.

She did not present any personal background of interest except for a repeated facial pain picture, consistent with a sinusitis picture, that was sporadic and that abated with the usual analgesics. A plain X-ray of the face in anteroposterior and lateral position was routinely done (Fig. 1). It showed a centrofacial lesion having osteocondensing density. After this finding, the patient was given an appointment in the out-patient clinic to continue with complementary tests that led us to the diagnosis. A computed axial tomography (Fig. 2) as well as a magnetic resonance with axial and coronal cuts (Fig. 3) were performed, this tumor being observed in the right ethmoidal level that invaded the nasal pits and obliterated the ostium of the right maxillary sinus drainage and that was accompanied by another lesion that was soft inside this sinus. The study prior to the surgical intervention was completed with a rhinoscopy.

 

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Le Fort I Osteotomy for centrofacial osteoma appoach
Osteotomía de Le Fort I para el abordaje de osteoma centrofacial

 

E. Torres Carranza¹, A. García-Perla García², R. Belmonte Caro², L. Ruiz Laza¹, 
P. Infante Cossío², J.L. Gutiérrez Pérez³

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1 Médico Residente.
2 Médico Adjunto.
3 Jefe de Servicio. Servicio de Cirugía Oral y Maxilofacial.
H.U. Virgen del Rocío. Sevilla. España

Correspondencia:
Eusebio Torres Carranza
Edificio H.R.T. Tercera planta Ampliación. Servicio de Cirugía Maxilofacial
H.U. Virgen del Rocio de Sevilla. Avda. Mamuel Siurot s/n. Sevilla. España.
e-mail: eusebiotorres@supercable.es

 

The diagnosis of nasoethmoidal osteoma accompanied by mucocele in the right maxillary sinus as a reaction to the obstruction of the ostium that drained it by the osteoma was reached based on all the tests performed.

Given the progressive clinical situation, the Craniofacial Surgery Unit of the Maxillofacial Surgery Service of the H.U.V. Rocio of Seville made the decision to operate.

The patient was placed in supine decubitus poistion and orotracheal intubation was performed.

The upper vestibule floor of the upper right first molar was cut to the left and the upper maxillary was exposed subperiostically, proceeding to mark the outline of the Le Fort I osteotomy. Four titanium miniplates were performed and placed on both sides of the pyriform ridge and in the maxillo-malar flying buttress, thus assuring the correct reposition of the fragments after the surgery. The miniplates were removed and a Le Fort I osteotomy performed according to the usual technique, ending with the performance of the down-fracture of the upper maxillary.

At this time, we performed the osteoma approach that was attached to the ethmoids by a bone pedicle, that invaded the right nasal pit and closed the maxillary sinus drainage opening (Fig. 4). The mucocele that occupied the right maxillary sinus was excised and we released the osteoma with a fine chisel and extracted it with light rotation movements to the right and left. The excised piece measured approximately 3 cm in length and 4 cm in height (Fig. 5). Once the osteoma was removed, the surgical bed was examined, observing that there were no remains of the osteoma and we performed heomostasis. The drainage was left in from maxillary sinus to right nasal opening.

Immediately after, we repositioned the maxillary in its original position, fixing it with the miniplates that we preformed at the onset of the surgery. Finally, we sutured the vestibular incision. In the postoperative check-up at six months, no occlusal sequels or complications derived from the surgical approach used were observed.

Discussion

Osteomas are benign osteogenic, encapsulated, slow growing tumors that are on skull and face bones, appearing as rounded, lobulated lesion and adapted to the cavity that contains it, and are attached to underlying structures by the bone pedicle.^1-4

Histologically, they are formed by both compact as well as trabecular bone and vascular and connective components with absence of malignant cells.^1,4-6

The origin of the osteomas is very diverse and controversial. It is related with embryological factors, hormonal factors, this being more frequent in women in puberty and post-menopausal stages, traumatic factors, and with infectious or genetic factors.^4,6 It is proposed that the risk of developing osteoma increases in areas in which tissues having different embryonic origin enter into contact. The traumatic cause was proposed after it was observed that up to 30% of the cases had a background of facial trauma in some series, above all in puberty, that would stimulate bone growth in the traumatism zone, but the relationship of the traumatism incidence and osteoma makes this theory unlikely. Chronic infection has been suggested as a possible cause of the development of osteoma since it seems to stimulate proliferation of osteoblasts, but the high rate of chronic sinusitis compared with the limited percentage of patients who develop osteoma makes us consider the infection as a secondary phenomenon more than as a primary cause.^4,6

The incidence of osteomas is about 1%-3% of the population.⁷ In most of the series in the literature, it is more frequent in men than in women by 2:1. They may occur at any age, but they are found more between the second and fifth decade of life.⁶ Craniofacial osteomas are generally located in paranasal sinuses, the most frequent site being the frontal sinus, followed by the ethmoidal, maxillary and sphenoidal one.⁴ Location in the maxillary bone and mandible is not rare.^2,3 Orbital involvement of the osteomas is rare and when it occurs it is by direct extension from the paranasal sinuses^6. They have also been described in temporal bone^8,9 as well as in extracranial zones.

They are usually asymptomatic tumors, that can take years to become symptomatic, being identified in a plain X-ray in 1% and in CT scan as a casual finding in 3%. When there are symptoms, this generally occurs in the ethmoidal locations before the frontal ones, given that the former has less space for the expansion of the osteoma. Their size is very different, even reaching large proportions, osteomas of 4 cm in length by 3,5 cm in height having been described in the literature.^3,5,10,11 The symptoms generally present as a complication of their growth⁴, and there can be dramatic pictures such as in the case of location in the internal auditory canal⁹ or when they invade the orbital or cranial fossa.¹⁰ In the case of the ethmoidals, they can grow upwards, invading the cranial fossa, laterally towards the orbit, medially towards the nasal pits, caudally towards the maxillary sinus and the symptoms would derive from the involvement of these structures. There are symptoms of anosmia, liquorrhea, headaches, obstruction of the nasolacrinal duct with epiphora, proptosis, diplopia, amaurosis fugax, transient blindness, orbital cellulitis, nasal obstruction, sinusitis, pain, esthetic deformity, etc., based on the zones affected. Cranial and ophthalmic involvement is rare.^6,11,12 Its association with mucoceles secondary to ostium obstructions of paranasal sinus drainage has been described. The association of multiple facial osteomas together with intestinal polyposis of familial origin and squamous cell carcinomas on the skin correspond with the Gardner Syndrome.⁶

Among the possible differential diagnoses of osteocondensing lesions, we could consider osteosarcomas, osteochondromas, periostic osteoblastomas, ossified periostic lipoma, ossifying myositis and exostosis. Radiologically, it has a homogeneous density, with well defined margins and without images of cortical invasion or bone destruction.^2,6

In regards to the prognosis of these lesions, their sarcomatous transformation has not been described and recurrence is rare.

Treatment is controversial and varies based on the symptoms and growth rate. Thus, the asymptomatic patient may be treated conservatively with check-ups every year to observe its growth. In the case of symptomatic lesions or those asymptomatic patients who have rapid evolution, it should be excised, trying to not harm the neighboring structures, and thus using the common open surgery methods or endoscopic methods.^3,6,10 The choice of the most adequate approach in each case is essential for good overall surgical results. Initially, it will depend on the exact anatomic site and tridimensional extension of the lesion as well as its nature. The possible options will finally depend on the global status of the patient, reconstructive planning and the experience of the surgical team.¹³

Endoscopic approach

The classical endoscopic approach is the transnasal-transseptal-transesfenoidal one. Restrictions for instrumentation are presently consigned to diagnostic procedures or resections of small and accessible lesions, in which a thorough control of the surgical field is not necessary.

It has advantages as it has limited morbidity of adjacent structures and minimum esthetic sequels as well as a rapid post-operative period, although a surgical team experienced in this technique is needed. Special attention should be given to possible complications such as visual problems and cerebrospinal fluid fistulas.^3,10

In this case, given the tumor size, this pathway was ruled out due to technical impossibility.

Open approach pathways

They are based on the osteoma site. Three approach pathways are suggested, transcranial, transfacial and intraoral, each one with advantages and disadvantages as well as associated morbidity.¹⁰ The transfacial approaches may be combined or with intracranial approaches, simultaneously or differed, and, thus, there are many possibilities. We can establish some basic principles for the choice of the best approach:^2,13

• Choose the shortest pathway towards the objectives, finding a way around the noble structures, also considering the possibility of future surgery.

• Perform the craniofacial osteotomies necessary to avoid excessive cerebral retraction and achieve adequate exposure of the lesion that permits the most complete resection possible. The osteotomies should try to obtain the widest bone fragments possible and should be performed with preformed osteosynthesis to assure correct anatomic reposition.

• Seek the best esthetic result possible.

Transcranial

The coronal incision is the most widely used, following a crenate pathway from ear to ear, which makes it possible to cover it with hair afterwards.

Transfrontal osteotomy

Also called Derome¹³ it is the classic transcranial pathway in which a bifrontal craniotomy is performed that makes it possible to access the anterior cerebral fossa. It's disadvantage is that the exposure of the field may be limited and the need for prolonged retraction of the brain can have serious sequels; there may also be complications such as cerebrospinal fluid fistulas, anosmia due to lesion of the olfatory nerve or lesion of the supraorbital nerve.¹⁴ This approach may be extended, associating a fronto-orbital osteotomy of the supraorbital rim to the craniotomy and both roofs of the orbits in a piece of bone. In this way, the attack angle is extended, thus increasing the approach possibilities and minimizing the retraction of the frontal lobules. In the reconstruction, an adequate dural reposition and isolation of the anterior cranial fossa that can be performed with a vascularized pericranial flap by the supraorbital pedicles is critical.

Subcranial osteotomy

Popularized by Raveh. It consists of a fronto-naso-orbital osteotomy that is extended laterally until the optic nerves.

Transfacial

It can be used alone or in combination with the above.

Transethmoidal approach

Using the paralateronasal incision of Moure or the extended one of Weber-Ferguson with their different variations that are no other than extending the incision line to the subpalpebral or supraciliary groove and even joining it to the coronal in the Labayle incision that permits an approach to the centrofacial skeleton to be able to perform the necessary osteotomies.

One of the problems of the lateral rhinotomy or the extended lateral rhinotomy of Weber-Fergusor is that, in spite of leaving minimum esthetic sequels, they can be invalidating according to the characteristics of the patient^2,15,16, and may also cause problems associated with the lacrimal duct.

Transnasomaxilar approach

Weber-Ferguson incision and its modifications to perform a Le fort II type osteotomy.

Intraoral

This is the selection of choice in our case given the esthetic requirements of the patient and the lesion accessibility.

Among the possible options, we have the transpalatine approach which is ruled out due to inaccessibility from it to the lesion.

The approach via Cadwell-Luc of the maxillary sinus given the osteoma dimensions is presumed insufficient.

In the mediofacial degloving technique, osteotomies are performed by intraoral incisions of the vestibule and intranasal fundus, this being its principal advantage, since it avoids skin scars. The modified degloving with section of septum and lateral nasal osteotomy permits good visualization of the nasal pits, paranasal sinuses and nasopharynx.¹⁷

The pedicellated hemimaxillotomy is a variant technique of the maxillotomy described by Hernández Altemir in which he performed a unilateral Le Fort I type osteotomy, the bone fragment being joined to a cheek flap obtained by a Weber-Ferguson approach with the consequent esthetic sequel.

In the case in question, preference was giving to using a maxillotomy with Le Fort I type osteotomy according to the conventional technique,^15,16 since it is an especially useful technique in large centrofacial tumors with a location in the cribiform plate. This osteotomy achieved a good field, achieved good visibility and permitted its extension, performing a saggital segmentation of the upper maxillary if necessary. Cure after the intervention is relatively rapid, with few complications and some excellent esthetic and functional results. The possible maloocclusion was avoided with the use of preformed miniplates. The other complications described in the literature are nasal bleeding, cervical emphysema or the more infrequent maxillary ischemia.¹⁶

References

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