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Large osteoma of the maxillary sinus accompanied by an unerupted tooth.

A 17-year-old boy presented with a 1-year history of intermittent localized pain over his right cheek. He had no history of notable facial trauma or nasal surgery, and his medical conditions were noncontributory. He had no history of sinonasal symptoms.

On examination, the right cheek protruded more than the left. No tenderness was present on palpation. Examination of the nose revealed no unusual findings such as nasal discharge or polyps. Computed tomography (CT) demonstrated (1) a bony mass that was occupying the maxillary antrum, (2) an unerupted tooth just anterior to the mass, and (3) a patent maxillary sinus ostium (figure 1). Magnetic resonance imaging (MRI) showed a dark, signal-intense mass measuring 34 x 40 x 43 mm. The mass filled the right maxillary antrum from 8 mm below the orbital floor to 20 mm below the level of the nasal cavity floor (figure 2, A and B). Contrast-enhanced, fat-suppression, T1-weighted imaging showed no significant enhancement within the mass (figure 2, C).

Surgery was indicated owing to the large size of the tumor and the need for a definitive histopathologic diagnosis. The patient was operated on under general anesthesia via the Caldwell-Luc approach. After an incision was made on the right gingivobuccal sulcus, the buccal mucoperiosteal flap was elevated. The retained tooth was removed, and the surgical specimen was processed for histopathologic examination.

The mass was removed by using an electric drill while rinsing with physiologic saline. During the operation, it was impossible to distinguish the boundary between the mass and the sinus walls, owing to the similar composition of the compact bone. Although enough mass was removed to provide an adequate cavity for the maxillary sinus, we were unable to determine if the lesion was completely removed. Histopathologic examination of the removed pieces of the mass identified it as an osteoma.

The postoperative period was uneventful. After surgery, the patient's cheek pain was relieved. For 2 years postsurgically, he visited our ENT outpatient department regularly, and he exhibited no significant tumor growth.

The reported prevalence of paranasal sinus osteomas ranges from 0.01 to 0.43%. (1) They are generally found in the frontal sinuses (60 to 70% of cases) and the ethmoid sinuses (20 to 30%); rarely are they found in the maxillary sinuses (2%).' While osteomas can occur at any age, they are most common in young adults.

Osteomas grow slowly, they are usually asymptomatic, and they are often discovered incidentally during radiologic evaluation. The presence or absence of symptoms depends on the location of the tumor and the degree of extension to surrounding structures. (2) In the case of a maxillary sinus osteoma, an anterior extension may lead to facial deformity. Moreover, its continued growth may completely obstruct the sinus ostia and lead to symptoms associated with sinusitis, such as pain, swelling, and nasal discharge. In rare cases, these lesions may even expand into the orbit.

CT of the maxillofacial region is required for patients with an osteoma to rule out Gardner syndrome, which should be considered when a patient has more than one osteoma. These patients may present with severe gastrointestinal disorders, such as rectal bleeding and abdominal pain. This autosomal dominant disorder is characterized by intestinal polyposis, multiple osteomas, cutaneous fibromas, epidermal cysts, and impacted teeth. (3) Although our patient had an impacted tooth within his lesion, he was free of the gastrointestinal symptoms associated with Gardner syndrome. Therefore, his lesion was considered to represent an isolated case of osteoma.

Management choices depend on the patient's symptoms and the location of the lesion within the paranasal sinuses. Conservative management is advocated for patients who are asymptomatic. Symptomatic osteomas definitely require surgical intervention. Indications for surgical treatment include serious cosmetic disfigurement, limitation or loss of function, a significant growth rate, or the need for a definitive histopathologic diagnosis. (4) In our case, surgical intervention was performed because of the need for a definitive histopathologic diagnosis, some cosmetic disfigurement, and the nearly complete occupation of the sinus by the lesion.

There are no guidelines on postoperative follow-up, but radiologic follow-up is recommended, especially in cases in which complete resection has not been achieved. (5) In our case, radiologic follow-up was necessary because the lesion had not been completely removed.

There are very few reports in the literature of a large maxillary sinus osteoma similar to the one in our case. (5)

References

(1.) Rajayogeswaran V, Everson JW. Endosteal (central) osteoma of the maxilla. Br Dent J 1981;150(6):162-3.

(2.) Koivunen P, Lopponen H, Fors AP, Jokinen K. The growth rate of osteomas of the paranasal sinuses. Clin Otolaryngol Allied Sci 1997;22(2):111-14.

(3.) Takeuchi T, Takenoshita Y, Kubo K, Iida M. Natural course of jaw lesions in patients with familial adenomatosis coli (Gardner s syndrome). Int J Oral Maxillofac Surg 1993;22(4):226-30.

(4.) Dalambiras S, Boutsioukis C, Tilaveridis I. Peripheral osteoma of the maxilla: Report of an unusual case. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005; 100(1):e 19-24.

(5.) Edmond M, Clifton N, Khalil H. A large atypical osteoma of the maxillary sinus: A report of a case and management challenges. Eur Arch Otorhinolaryngol 2011;268(2):315-18.

Jae-Hoon Lee, MD

From the Department of Otolaryngology, Institute of Wonkwang Medical Science, Wonkwang University School of Medicine, Iksan, Chonbuk, Republic of Korea.
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Title Annotation:IMAGING CLINIC
Author:Lee, Jae-Hoon
Publication:Ear, Nose and Throat Journal
Article Type:Case study
Date:Jul 1, 2014
Words:886
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