Giant Sinonasal Osteoma with Orbital Extension; Endoscopic De-cavitation Technique; A Case Report

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Baban, Diyar Alaa, Ahmed Muayad, Peshraw K.Qader, Shkar N. Omer, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9234463/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Osteomas are the most common benign tumors of the paranasal sinuses (PNS). While typically asymptomatic and managed conservatively, a minority become symptomatic, requiring surgical intervention. Giant osteomas (arbitrarily defined as >3cm) are rare, and their management can be challenging due to their size and extensive involvement. We report a 48-year-old woman presenting with a two-year history of progressive left-sided nasal obstruction. Computed tomography (CT) imaging identified a giant bony mass originating from the ethmoid sinus, with significant erosion into the medial orbital wall, skull base, and nasal floor. The patient underwent endoscopic sinus surgery for resection. The patient experienced complete resolution of her symptoms post-operatively, with no complications or evidence of recurrence at follow-up. This case demonstrates that even giant, extensively erosive ethmoid sinus osteomas can be successfully and safely managed via a purely endoscopic approach. This report adds to the limited literature on giant osteomas and supports the role of endoscopic surgery as a viable first-line intervention for such complex cases. Otorhinolaryngology Osteoma Paranasal sinuses Endoscopic sinus surgery Figures Figure 1 Figure 2 INTRODUCTION Osteomas are the most common benign neoplasms of the nose and paranasal sinuses (PNS). They are of osteogenic origin and most commonly involve the frontal and ethmoid sinuses [ 1 , 2 ]. They are usually asymptomatic and found incidentally on imaging, with an estimated 3% of all CT scans of the PNS revealing osteomas. As a consequence of their slow growth, only about 10% of osteomas move on to become clinically significant and require surgery, and symptoms tend to occur earlier in those localized to the ethmoid sinuses due to the limited anatomical space [3, 4, 5]. The symptoms are most commonly frontal pressure or headache, either caused by the lesion directly or by impaired drainage, with or without associated chronic rhinosinusitis [ 6 ]. Osteomas are classified as small or large, with large osteomas defined as those with a diameter of more than 3cm or a weight of more than 110g [ 7 ]. They occur more commonly in males and have a peak incidence between the fourth and sixth decades [8]. Giant osteomas are very rare, with limited literature, leading to uncertainty about their clinical presentation and management. This paper discusses a case of giant cell osteoma of the ethmoid sinus managed with an endoscopic approach, along with an evaluation of the existing literature. CASE REPORT A 48-year-old woman presented to the Otorhinolaryngology-Skull Base Surgery clinic at Mercy Medical City, complaining of a 2-year history of progressively increasing left-sided nasal obstruction, which eventually led to complete obstruction. It was associated with a headache, left-sided anosmia, proptosis, and postnasal drip. There was no significant past medical history; the only previous surgery was a hysterectomy, and the family history was noncontributory. On examination, the mass was easily seen on elevation of the nasal tip, and a nasal speculum examination revealed a completely filled left nasal cavity by a mass of hard consistency on probing. Ophthalmological examination was normal with no defects in visual acuity, visual fields, or extraocular muscle movement. CT imaging of the PNS identified a large bony mass measuring approximately 4.955cm x 3.042cm x 4.427cm, which appeared to originate from the ethmoid sinuses. The mass demonstrated significant erosion with extension to the skull base, nasal septum, medial orbital wall, medial and anterior maxillary wall, and floor of the nasal cavity. After exploring the potential risks and benefits of specific approaches to the patient, the patient consented to endoscopic sinus surgery (ESS). The operation was performed under general anesthesia using a hypotensive technique. The face was sterilized with 10% povidone-iodine solution, and the patient was placed in a reverse Trendelenburg position. The nasal cavity was first decongested using nasal patties mixed with decongestants (8mL Xylometazoline 1%, 2 mL adrenaline solution 1/1000, and 4 mL normal saline) for 10 minutes, after which a hard nasal mass on the left side was noted, extending from the skull base superiorly to the nasal floor inferiorly. The surgical approach, as illustrated in Fig. 1 , revolved around a decavitation technique using a high-speed diamond burr. The core of the mass was drilled until fully weakened, leaving only a shelf of bone attached to its origins, including the ethmoid, skull base, medial orbital wall, where part of the mass impinged into orbital tissue, and the medial maxillary wall. Once sufficient core debulking was achieved, the lesion was gently mobilized from its superior, medial, and lateral attachments and displaced into the nasal cavity. Due to the large size of the remaining mass, en bloc removal was not feasible. Therefore, controlled drilling and fragmentation of the residual mass were performed under direct endoscopic visualization until the lesion was reduced into multiple manageable pieces, which were then extracted transnasally and sent for histopathological study to exclude any uneventful pathology. Subsequently, uncinectomy using backbiter cutting forceps was performed, a middle meatal antrostomy was performed, and the natural ostia were enlarged posteriorly to improve drainage and ventilation of the maxillary sinus, which was filled with thick mucus that was aspirated. The nasal cavity and skull base were then examined carefully to confirm full removal of the mass and to rule out the presence of any cerebrospinal fluid leak, orbital injury, and nasolacrimal duct injury. Hemostasis was secured using a bipolar cautery. After complete removal of the mass from the nasal cavity, a silastic nasal splint was inserted on both sides and fixed with 2/0 silk suture to prevent postoperative synechiae and adhesions. The splint was removed on the 10th postoperative day, and examination revealed no adhesions between the nasal septum and lateral wall, the maxillary sinus ostium was patent, and there were no signs of CSF leakage. The patient reported resolution of her headache, nasal obstruction, and other associated symptoms. Another follow-up was scheduled 4 weeks later, during which a CT scan was performed, further confirming complete resection of the osteoma with no subsequent complications, as shown in Fig. 1 . The histopathological report was cortical-type bone (white arrow) with multiple Haversian-like canals (red arrow) and small, band-looking osteocyte (yellow arrow), consistent with a diagnosis of osteoma, as demonstrated in Fig. 2 . DISCUSSION Osteomas are the most common benign tumors of the PNS and are usually diagnosed incidentally [ 1 ]. They are generally asymptomatic, but some of them grow to be symptomatic in the third or fourth decades, with the most common presentation, as was the case in this study, being a headache, with other symptoms being nasal obstruction, pain, rhinosinusitis, and ocular symptoms such as diplopia and proptosis [ 9 ]. It may also lead to intracranial complications via local spread, such as a brain abscess, most commonly from the frontal sinus, then followed by the ethmoid, sphenoid, and maxillary sinuses [ 10 ]; however, no such complications were reported in this current report. If asymptomatic and small, these lesions may be left alone and only followed up periodically; the only exception to this rule is sphenoid sinus osteomas, due to their close association with the visual pathways. Other indications for surgical intervention include the presence of significant symptoms, significant enlargement noted radiographically, extension beyond the sinus, filling of more than 50% of the sinus, near the frontal sinus ostium, and cosmetic deformity [ 9 , 11 ]. The indications in the current case report were significant symptoms, filling more than 50% of the ethmoid and maxillary sinuses, with extension beyond the sinuses into the Orbit. The surgical treatment of paranasal sinus osteomas remains controversial. However, endoscopic removal is suitable for most cases and is generally advantageous over an external nasal approach, as it is minimally invasive, has less morbidity and postoperative pain, allows earlier mobilization, improved cosmetic appearance, and allows clear visualization with excellent magnification [ 12 ]. According to the study by Christos Georgalas [ 6 ], osteomas of the ethmoid sinus can be safely managed endoscopically, but anterior extension to the nasolacrimal duct may require a combined approach, and lateral extension beyond the midline on the orbital roof was also considered a limitation of an endoscopic approach. Many literatures [ 4 , 13 , 14 ] highlight the difficulties in resecting frontal sinus osteoma in toto by endoscopic technique, especially tumors involving the frontal sinus with lateral extension beyond the midorbital line, and consider the external approach as the gold standard. Major controversies still exist in the management of frontal sinus osteomas, but a study conducted by Duncan C. Watley[ 15 ], which reviewed the existing literature, revealed that out of 477 surgically resected tumors, endoscopic surgery alone was the most common approach (44.9%), followed by an open (36.9%) and combined approach (18.2%). The study had proposed a new grading system, which suggested that Grade A frontal osteomas (simple or broad stalk, no floor attachment, favorable anatomy, no extrasinus involvement) should be endoscopically resected, Grade B osteomas (broad attachment, minimum attachment to floor, unfavorable anatomy, minimum extrasinus involvement) may require a combined approach, and Grade C (completely filling sinus, extensive floor attachment, unfavorable anatomy, extensive extrasinus involvement) usually require an open approach. They concluded that the decision should not be made on absolute criteria, but rather a more tailored approach should be taken for each case, considering factors such as tumor attachment, surgical expertise, and anatomical feasibility. As for our operative approach, as mentioned previously, it was done with a naso-endoscopic approach using an intra nasal high speed drill, this is the same approach used by Hung-Meng Huang [ 16 ], in which the trans-nasal endoscopic approach was successful in all seven patients that participated in the study, with the only post operative complication noted being mild periorbital ecchymosis in one patient with orbital extension of the osteoma, however no such complication was reported in this case report study. They had also stated advantages of the intranasal drill such as easier hemostatic control, minimal excision and no cosmetic complications. A study conducted by Paolo Castelnuovo [ 13 ] also underlined the possibility of removing giant osteomas with an endoscopic approach using intranasal angled drills by cavitating the lesion and subsequently extracting the residual, however it was stated that its disadvantage was difficult management of intraoperative complications such as hemorrhages and lesion margins not being well controlled, and also the extensive surgical training required along with sophisticated tools. The ability to manage postoperative complications is a key to the success and improvement of endoscopic surgery, and even though no complications were reported in this study, they still occur despite meticulous surgical technique. Some of these occur immediately, such as bleeding and crusting, some can occur early, such as synechiae and infection, and some occur later, such as ostial stenosis and disease recurrence [ 17 ]. This leads to postoperative evaluation being crucial using nasal endoscopy and even CT scanning for recognition of such complications and early intervention; however, it should be stated that routine paranasal CT scanning for osteomas is not justified due to their low rate of recurrence, and periodic endoscopic evaluation is sufficient [ 18 ]. CONCLUSION This case report successfully demonstrates the efficacy of a purely endoscopic approach for the management of a giant ethmoid sinus osteoma. Despite the lesion's significant size and erosive nature, involving critical structures such as the skull base and Orbit, it was completely resected using a technique of central core decavitation and controlled fragmentation with a high-speed diamond burr. The procedure resulted in the complete resolution of the patient's symptoms without any postoperative complications. This outcome reinforces several key points in the management of paranasal sinus osteomas. It conveys that an endoscopic approach is a viable and highly effective first-line surgical option for ethmoid sinus osteomas. The technique offers the well-documented advantages of minimally invasive surgery, including minimal morbidity, no external scar, and excellent visualization. Ultimately, this case adds to the growing body of literature supporting endoscopic resection as the cornerstone of surgical management for ethmoid sinus osteomas. Declarations The patient consented to participate and publish their clinical case. Compliance with Ethical Standards: Acknowledgments: No funding was received for this study Conflicts of interest: The authors declare that they have no conflicts of interest. Ethical approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent: For this type of study, formal consent is obtained. References Alkhaldi AS, Alsalamah S, Tatwani T. A Case of Giant Ethmoid Sinus Osteoma. Cureus. 2021 Sep 16; ‌Boffano P, Roccia F, Campisi P, Gallesio C. Review of 43 Osteomas of the Craniomaxillofacial Region. Journal of Oral and Maxillofacial Surgery. 2012 May;70(5):1093–5. CHENG KJ, WANG SQ, LIN L. Giant osteomas of the ethmoid and frontal sinuses: Clinical characteristics and review of the literature. Oncology Letters. 2013 Mar 8;5(5):1724–30. Cokkeser Y, Bayarogullari H, Kahraman SS. Our experience with the surgical management of paranasal sinus osteomas. European Archives of Oto-Rhino-Laryngology. 2012 Mar 18;270(1):123–8. ‌Kurys-Denis E, Zamecka M, Kruk-Bochonko J, Krupski W. Giant osteoma of the paranasal sinuses and right Orbit in a patient with trauma history in CT imaging. Journal of Pre-Clinical and Clinical Research. 2014 Jul 9;8(1):48–50. Georgalas C, Goudakos J, Fokkens WJ. Osteoma of the Skull Base and Sinuses. Otolaryngologic Clinics of North America. 2011 Aug;44(4):875–90. Kim SH, Lim DS, Lee DH, Kim KP, Hwang JH, Kim KS, et al. Post-Traumatic Peripheral Giant Osteoma in the Frontal Bone. Archives of Craniofacial Surgery. 2017 Dec 20;18(4):273–6. ‌8. Dong Hoon Lee, Se Hee Jung, Tae Mi Yoon, Joon Kyoo Lee, Young Eun Joo, Sang Chul Lim. Characteristics of paranasal sinus osteoma and treatment outcomes. Acta oto-laryngologica. 2015 Feb 26;135(6):602–7. Cho A, Jung Y, Park JH, Jeong Y, Cho HJ. Clinical Manifestations and Surgical Treatment Outcomes of Paranasal Sinus Osteoma. Journal of rhinology [Internet]. 2022 Mar 28 [cited 2025 Aug 26];29(1):19–25. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC11524381/ Farah RA, Poletti A, Han A, Navarro R. Giant frontal sinus osteoma and its potential consequences: illustrative case. Journal of Neurosurgery: Case Lessons. 2021 May 24;1(21). Sofokleous V, Maragoudakis P, Kyrodimos E, Giotakis E. Management of paranasal sinus osteomas: A comprehensive narrative review of the literature and an up-to-date grading system. American Journal of Otolaryngology. 2021 Sep;42(5):102644. Naraghi M, Arash Kashfi. Endonasal endoscopic resection of ethmoido-orbital osteoma compressing the optic nerve. American Journal of Otolaryngology. 2003 Nov 1;24(6):408–12. Castelnuovo P, Valentini V, Giovannetti F, Bignami M, Cassoni A, Iannetti G. Osteomas of the Maxillofacial District. Journal of Craniofacial Surgery. 2008 Nov;19(6):1446–52 Chiu AG, Ioana Schipor, Cohen NA, Kennedy DW, Palmer JN. Surgical Decisions in the Management of Frontal Sinus Osteomas. American Journal of Rhinology. 2005 Mar 1;19(2):191–7. Watley DC, Mong ER, Rana NA, Illing EA, Chaaban MR. Surgical Approach to Frontal Sinus Osteoma: A Systematic Review. American Journal of Rhinology and Allergy. 2019 Apr 5;33(5):462–9.2. ‌16. Huang HM, Liu CM, Lin KN, Chen HT. Giant Ethmoid Osteoma With Orbital Extension, a Nasoendoscopic Approach Using an Intranasal Drill. The Laryngoscope. 2001 Mar;111(3):430– Tan BK, Chandra RK. Postoperative Prevention and Treatment of Complications After Sinus Surgery. Otolaryngologic Clinics of North America. 2010 Aug;43(4):769–79. Turri-Zanoni M, Dallan I, Terranova P, Battaglia P, Karligkiotis A, Bignami M, et al. Frontoethmoidal and Intraorbital Osteomas. Archives of Otolaryngology–Head & Neck Surgery. 2012 May 1;138(5):498. Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9234463","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":612695078,"identity":"7e7047a6-37d0-4124-abf0-3192f144d272","order_by":0,"name":"Muaid I. 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They are of osteogenic origin and most commonly involve the frontal and ethmoid sinuses [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. They are usually asymptomatic and found incidentally on imaging, with an estimated 3% of all CT scans of the PNS revealing osteomas. As a consequence of their slow growth, only about 10% of osteomas move on to become clinically significant and require surgery, and symptoms tend to occur earlier in those localized to the ethmoid sinuses due to the limited anatomical space [3, 4, 5]. The symptoms are most commonly frontal pressure or headache, either caused by the lesion directly or by impaired drainage, with or without associated chronic rhinosinusitis [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Osteomas are classified as small or large, with large osteomas defined as those with a diameter of more than 3cm or a weight of more than 110g [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. They occur more commonly in males and have a peak incidence between the fourth and sixth decades [8]. Giant osteomas are very rare, with limited literature, leading to uncertainty about their clinical presentation and management. This paper discusses a case of giant cell osteoma of the ethmoid sinus managed with an endoscopic approach, along with an evaluation of the existing literature.\u003c/p\u003e"},{"header":"CASE REPORT","content":"\u003cp\u003eA 48-year-old woman presented to the Otorhinolaryngology-Skull Base Surgery clinic at Mercy Medical City, complaining of a 2-year history of progressively increasing left-sided nasal obstruction, which eventually led to complete obstruction. It was associated with a headache, left-sided anosmia, proptosis, and postnasal drip. There was no significant past medical history; the only previous surgery was a hysterectomy, and the family history was noncontributory.\u003c/p\u003e \u003cp\u003eOn examination, the mass was easily seen on elevation of the nasal tip, and a nasal speculum examination revealed a completely filled left nasal cavity by a mass of hard consistency on probing. Ophthalmological examination was normal with no defects in visual acuity, visual fields, or extraocular muscle movement.\u003c/p\u003e \u003cp\u003eCT imaging of the PNS identified a large bony mass measuring approximately 4.955cm x 3.042cm x 4.427cm, which appeared to originate from the ethmoid sinuses. The mass demonstrated significant erosion with extension to the skull base, nasal septum, medial orbital wall, medial and anterior maxillary wall, and floor of the nasal cavity.\u003c/p\u003e \u003cp\u003eAfter exploring the potential risks and benefits of specific approaches to the patient, the patient consented to endoscopic sinus surgery (ESS).\u003c/p\u003e \u003cp\u003eThe operation was performed under general anesthesia using a hypotensive technique. The face was sterilized with 10% povidone-iodine solution, and the patient was placed in a reverse Trendelenburg position. The nasal cavity was first decongested using nasal patties mixed with decongestants (8mL Xylometazoline 1%, 2 mL adrenaline solution 1/1000, and 4 mL normal saline) for 10 minutes, after which a hard nasal mass on the left side was noted, extending from the skull base superiorly to the nasal floor inferiorly.\u003c/p\u003e \u003cp\u003eThe surgical approach, as illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, revolved around a decavitation technique using a high-speed diamond burr. The core of the mass was drilled until fully weakened, leaving only a shelf of bone attached to its origins, including the ethmoid, skull base, medial orbital wall, where part of the mass impinged into orbital tissue, and the medial maxillary wall. Once sufficient core debulking was achieved, the lesion was gently mobilized from its superior, medial, and lateral attachments and displaced into the nasal cavity. Due to the large size of the remaining mass, en bloc removal was not feasible. Therefore, controlled drilling and fragmentation of the residual mass were performed under direct endoscopic visualization until the lesion was reduced into multiple manageable pieces, which were then extracted transnasally and sent for histopathological study to exclude any uneventful pathology. Subsequently, uncinectomy using backbiter cutting forceps was performed, a middle meatal antrostomy was performed, and the natural ostia were enlarged posteriorly to improve drainage and ventilation of the maxillary sinus, which was filled with thick mucus that was aspirated. The nasal cavity and skull base were then examined carefully to confirm full removal of the mass and to rule out the presence of any cerebrospinal fluid leak, orbital injury, and nasolacrimal duct injury. Hemostasis was secured using a bipolar cautery.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAfter complete removal of the mass from the nasal cavity, a silastic nasal splint was inserted on both sides and fixed with 2/0 silk suture to prevent postoperative synechiae and adhesions. The splint was removed on the 10th postoperative day, and examination revealed no adhesions between the nasal septum and lateral wall, the maxillary sinus ostium was patent, and there were no signs of CSF leakage. The patient reported resolution of her headache, nasal obstruction, and other associated symptoms. Another follow-up was scheduled 4 weeks later, during which a CT scan was performed, further confirming complete resection of the osteoma with no subsequent complications, as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eThe histopathological report was cortical-type bone (white arrow) with multiple Haversian-like canals (red arrow) and small, band-looking osteocyte (yellow arrow), consistent with a diagnosis of osteoma, as demonstrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eOsteomas are the most common benign tumors of the PNS and are usually diagnosed incidentally [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. They are generally asymptomatic, but some of them grow to be symptomatic in the third or fourth decades, with the most common presentation, as was the case in this study, being a headache, with other symptoms being nasal obstruction, pain, rhinosinusitis, and ocular symptoms such as diplopia and proptosis [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. It may also lead to intracranial complications via local spread, such as a brain abscess, most commonly from the frontal sinus, then followed by the ethmoid, sphenoid, and maxillary sinuses [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e10\u003c/span\u003e]; however, no such complications were reported in this current report.\u003c/p\u003e \u003cp\u003eIf asymptomatic and small, these lesions may be left alone and only followed up periodically; the only exception to this rule is sphenoid sinus osteomas, due to their close association with the visual pathways. Other indications for surgical intervention include the presence of significant symptoms, significant enlargement noted radiographically, extension beyond the sinus, filling of more than 50% of the sinus, near the frontal sinus ostium, and cosmetic deformity [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The indications in the current case report were significant symptoms, filling more than 50% of the ethmoid and maxillary sinuses, with extension beyond the sinuses into the Orbit.\u003c/p\u003e \u003cp\u003eThe surgical treatment of paranasal sinus osteomas remains controversial. However, endoscopic removal is suitable for most cases and is generally advantageous over an external nasal approach, as it is minimally invasive, has less morbidity and postoperative pain, allows earlier mobilization, improved cosmetic appearance, and allows clear visualization with excellent magnification [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. According to the study by Christos Georgalas [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e6\u003c/span\u003e], osteomas of the ethmoid sinus can be safely managed endoscopically, but anterior extension to the nasolacrimal duct may require a combined approach, and lateral extension beyond the midline on the orbital roof was also considered a limitation of an endoscopic approach. Many literatures [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e14\u003c/span\u003e] highlight the difficulties in resecting frontal sinus osteoma in toto by endoscopic technique, especially tumors involving the frontal sinus with lateral extension beyond the midorbital line, and consider the external approach as the gold standard. Major controversies still exist in the management of frontal sinus osteomas, but a study conducted by Duncan C. Watley[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e15\u003c/span\u003e], which reviewed the existing literature, revealed that out of 477 surgically resected tumors, endoscopic surgery alone was the most common approach (44.9%), followed by an open (36.9%) and combined approach (18.2%). The study had proposed a new grading system, which suggested that Grade A frontal osteomas (simple or broad stalk, no floor attachment, favorable anatomy, no extrasinus involvement) should be endoscopically resected, Grade B osteomas (broad attachment, minimum attachment to floor, unfavorable anatomy, minimum extrasinus involvement) may require a combined approach, and Grade C (completely filling sinus, extensive floor attachment, unfavorable anatomy, extensive extrasinus involvement) usually require an open approach. They concluded that the decision should not be made on absolute criteria, but rather a more tailored approach should be taken for each case, considering factors such as tumor attachment, surgical expertise, and anatomical feasibility.\u003c/p\u003e \u003cp\u003eAs for our operative approach, as mentioned previously, it was done with a naso-endoscopic approach using an intra nasal high speed drill, this is the same approach used by Hung-Meng Huang [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], in which the trans-nasal endoscopic approach was successful in all seven patients that participated in the study, with the only post operative complication noted being mild periorbital ecchymosis in one patient with orbital extension of the osteoma, however no such complication was reported in this case report study. They had also stated advantages of the intranasal drill such as easier hemostatic control, minimal excision and no cosmetic complications. A study conducted by Paolo Castelnuovo [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e13\u003c/span\u003e] also underlined the possibility of removing giant osteomas with an endoscopic approach using intranasal angled drills by cavitating the lesion and subsequently extracting the residual, however it was stated that its disadvantage was difficult management of intraoperative complications such as hemorrhages and lesion margins not being well controlled, and also the extensive surgical training required along with sophisticated tools.\u003c/p\u003e \u003cp\u003eThe ability to manage postoperative complications is a key to the success and improvement of endoscopic surgery, and even though no complications were reported in this study, they still occur despite meticulous surgical technique. Some of these occur immediately, such as bleeding and crusting, some can occur early, such as synechiae and infection, and some occur later, such as ostial stenosis and disease recurrence [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. This leads to postoperative evaluation being crucial using nasal endoscopy and even CT scanning for recognition of such complications and early intervention; however, it should be stated that routine paranasal CT scanning for osteomas is not justified due to their low rate of recurrence, and periodic endoscopic evaluation is sufficient [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThis case report successfully demonstrates the efficacy of a purely endoscopic approach for the management of a giant ethmoid sinus osteoma. Despite the lesion's significant size and erosive nature, involving critical structures such as the skull base and Orbit, it was completely resected using a technique of central core decavitation and controlled fragmentation with a high-speed diamond burr. The procedure resulted in the complete resolution of the patient's symptoms without any postoperative complications.\u003c/p\u003e \u003cp\u003eThis outcome reinforces several key points in the management of paranasal sinus osteomas. It conveys that an endoscopic approach is a viable and highly effective first-line surgical option for ethmoid sinus osteomas. The technique offers the well-documented advantages of minimally invasive surgery, including minimal morbidity, no external scar, and excellent visualization.\u003c/p\u003e \u003cp\u003eUltimately, this case adds to the growing body of literature supporting endoscopic resection as the cornerstone of surgical management for ethmoid sinus osteomas.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cspan\u003eThe patient consented to participate and publish their clinical case.\u003c/span\u003e\u003c/p\u003e\u003cp\u003eCompliance with Ethical Standards:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments: \u003c/strong\u003eNo funding was received for this study\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest: \u003c/strong\u003eThe authors declare that they have no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval: \u003c/strong\u003eAll procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent: \u003c/strong\u003eFor this type of study, formal consent is obtained.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAlkhaldi AS, Alsalamah S, Tatwani T. A Case of Giant Ethmoid Sinus Osteoma. Cureus. 2021 Sep 16;\u003c/li\u003e\n \u003cli\u003e\u0026zwnj;Boffano P, Roccia F, Campisi P, Gallesio C. Review of 43 Osteomas of the Craniomaxillofacial Region. Journal of Oral and Maxillofacial Surgery. 2012 May;70(5):1093\u0026ndash;5.\u003c/li\u003e\n \u003cli\u003eCHENG KJ, WANG SQ, LIN L. Giant osteomas of the ethmoid and frontal sinuses: Clinical characteristics and review of the literature. Oncology Letters. 2013 Mar 8;5(5):1724\u0026ndash;30.\u003c/li\u003e\n \u003cli\u003eCokkeser Y, Bayarogullari H, Kahraman SS. Our experience with the surgical management of paranasal sinus osteomas. European Archives of Oto-Rhino-Laryngology. 2012 Mar 18;270(1):123\u0026ndash;8.\u003c/li\u003e\n \u003cli\u003e\u0026zwnj;Kurys-Denis E, Zamecka M, Kruk-Bochonko J, Krupski W. Giant osteoma of the paranasal sinuses and right Orbit in a patient with trauma history in CT imaging. Journal of Pre-Clinical and Clinical Research. 2014 Jul 9;8(1):48\u0026ndash;50.\u003c/li\u003e\n \u003cli\u003eGeorgalas C, Goudakos J, Fokkens WJ. Osteoma of the Skull Base and Sinuses. Otolaryngologic Clinics of North America. 2011 Aug;44(4):875\u0026ndash;90.\u003c/li\u003e\n \u003cli\u003eKim SH, Lim DS, Lee DH, Kim KP, Hwang JH, Kim KS, et al. Post-Traumatic Peripheral Giant Osteoma in the Frontal Bone. Archives of Craniofacial Surgery. 2017 Dec 20;18(4):273\u0026ndash;6.\u003c/li\u003e\n \u003cli\u003e\u0026zwnj;8. Dong Hoon Lee, Se Hee Jung, Tae Mi Yoon, Joon Kyoo Lee, Young Eun Joo, Sang Chul Lim. Characteristics of paranasal sinus osteoma and treatment outcomes. Acta oto-laryngologica. 2015 Feb 26;135(6):602\u0026ndash;7.\u003c/li\u003e\n \u003cli\u003eCho A, Jung Y, Park JH, Jeong Y, Cho HJ. Clinical Manifestations and Surgical Treatment Outcomes of Paranasal Sinus Osteoma. Journal of rhinology [Internet]. 2022 Mar 28 [cited 2025 Aug 26];29(1):19\u0026ndash;25. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC11524381/\u003c/li\u003e\n \u003cli\u003eFarah RA, Poletti A, Han A, Navarro R. Giant frontal sinus osteoma and its potential consequences: illustrative case. Journal of Neurosurgery: Case Lessons. 2021 May 24;1(21).\u003c/li\u003e\n \u003cli\u003eSofokleous V, Maragoudakis P, Kyrodimos E, Giotakis E. Management of paranasal sinus osteomas: A comprehensive narrative review of the literature and an up-to-date grading system. American Journal of Otolaryngology. 2021 Sep;42(5):102644.\u003c/li\u003e\n \u003cli\u003eNaraghi M, Arash Kashfi. Endonasal endoscopic resection of ethmoido-orbital osteoma compressing the optic nerve. American Journal of Otolaryngology. 2003 Nov 1;24(6):408\u0026ndash;12.\u003c/li\u003e\n \u003cli\u003eCastelnuovo P, Valentini V, Giovannetti F, Bignami M, Cassoni A, Iannetti G. Osteomas of the Maxillofacial District. Journal of Craniofacial Surgery. 2008 Nov;19(6):1446\u0026ndash;52\u003c/li\u003e\n \u003cli\u003eChiu AG, Ioana Schipor, Cohen NA, Kennedy DW, Palmer JN. Surgical Decisions in the Management of Frontal Sinus Osteomas. American Journal of Rhinology. 2005 Mar 1;19(2):191\u0026ndash;7.\u003c/li\u003e\n \u003cli\u003eWatley DC, Mong ER, Rana NA, Illing EA, Chaaban MR. Surgical Approach to Frontal Sinus Osteoma: A Systematic Review. American Journal of Rhinology and Allergy. 2019 Apr 5;33(5):462\u0026ndash;9.2.\u003c/li\u003e\n \u003cli\u003e\u0026zwnj;16. Huang HM, Liu CM, Lin KN, Chen HT. Giant Ethmoid Osteoma With Orbital Extension, a Nasoendoscopic Approach Using an Intranasal Drill. The Laryngoscope. 2001 Mar;111(3):430\u0026ndash;\u003c/li\u003e\n \u003cli\u003eTan BK, Chandra RK. Postoperative Prevention and Treatment of Complications After Sinus Surgery. Otolaryngologic Clinics of North America. 2010 Aug;43(4):769\u0026ndash;79.\u003c/li\u003e\n \u003cli\u003eTurri-Zanoni M, Dallan I, Terranova P, Battaglia P, Karligkiotis A, Bignami M, et al. Frontoethmoidal and Intraorbital Osteomas. Archives of Otolaryngology\u0026ndash;Head \u0026amp; Neck Surgery. 2012 May 1;138(5):498.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"University of Sulaymaniyah","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Osteoma, Paranasal sinuses, Endoscopic sinus surgery","lastPublishedDoi":"10.21203/rs.3.rs-9234463/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9234463/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eOsteomas are the most common benign tumors of the paranasal sinuses (PNS). While typically asymptomatic and managed conservatively, a minority become symptomatic, requiring surgical intervention. Giant osteomas (arbitrarily defined as \u0026gt;3cm) are rare, and their management can be challenging due to their size and extensive involvement. We report a 48-year-old woman presenting with a two-year history of progressive left-sided nasal obstruction. Computed tomography (CT) imaging identified a giant bony mass originating from the ethmoid sinus, with significant erosion into the medial orbital wall, skull base, and nasal floor. The patient underwent endoscopic sinus surgery for resection. The patient experienced complete resolution of her symptoms post-operatively, with no complications or evidence of recurrence at follow-up. This case demonstrates that even giant, extensively erosive ethmoid sinus osteomas can be successfully and safely managed via a purely endoscopic approach. This report adds to the limited literature on giant osteomas and supports the role of endoscopic surgery as a viable first-line intervention for such complex cases.\u003c/p\u003e","manuscriptTitle":"Giant Sinonasal Osteoma with Orbital Extension; Endoscopic De-cavitation Technique; A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-06 08:15:22","doi":"10.21203/rs.3.rs-9234463/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"44ab796d-e8f6-4b82-a6b8-bdebb6747cf0","owner":[],"postedDate":"April 6th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":65194328,"name":"Otorhinolaryngology"}],"tags":[],"updatedAt":"2026-04-06T08:15:22+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-06 08:15:22","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9234463","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9234463","identity":"rs-9234463","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}