What are the implications of a fibro-osseous lesion within the frontal sinus?

From the Guidelines

Surgical intervention is typically recommended for fibro-osseous lesions within the frontal sinus if they are symptomatic or showing growth, as these lesions can expand slowly and potentially cause complications such as sinus obstruction or mucocele formation. These benign lesions, which include osteomas, fibrous dysplasia, and ossifying fibromas, replace normal bone with fibrous tissue and mineralized material. Patients should undergo complete evaluation with CT imaging, as it best depicts osseous changes and can help distinguish bony remodeling that is more typical of slow growing or benign masses from lytic destruction seen with more aggressive malignancies 1.

Key Considerations

• CT maxillofacial enables surgical planning given its detailed depiction of sinonasal anatomy and can be used with surgical image-guidance systems when acquired with the appropriate protocol 1.
• Small, asymptomatic lesions may be monitored with periodic imaging every 6-12 months.
• For symptomatic lesions causing headaches, sinus obstruction, or cosmetic concerns, endoscopic sinus surgery or open approaches like osteoplastic flap procedures are recommended.
• Postoperatively, saline irrigations and intranasal steroids help healing, with follow-up occurring at 1 week, 1 month, and 3 months post-surgery, and subsequent CT imaging at 6-12 months to confirm complete removal.

Surgical Approaches

• Endoscopic approaches have generally become the surgical standard of care for chronic infectious sinusitis, especially if there is evidence of mechanical blockage of the ostiomeatal complex 1.
• Open surgical procedures, such as frontal sinus trephine and postoperative irrigation, are still required, depending on the extent and the location of the sinuses involved.

From the Research

Implications of Fibro-osseous Lesion within Frontal Sinus

• The presence of a fibro-osseous lesion within the frontal sinus can cause symptoms such as headaches, pain/pressure, and nasal obstruction 2
• In some cases, the lesion can lead to proptosis and diplopia, as well as associated nasal polyps 2
• The diagnosis of a fibro-osseous lesion can be incidental, with 38% of cases in one study being found incidentally 2

Management of Fibro-osseous Lesions

• An expectant management approach can be used for asymptomatic patients, with observation and serial imaging to monitor for interval growth 2
• Symptomatic patients can be treated with endoscopic sinus surgery (ESS) without resection of the lesion, with symptomatic improvement in 92% of cases in one study 2
• Resection of the lesion can be performed in patients with orbital complications, progressive growth of the lesion, or persistent symptoms 2
• Intraoperative CT-updated image-guided systems can be used to improve surgical precision and tumor control during endoscopic or endoscopically assisted surgeries for sinonasal fibro-osseous lesions 3

Diagnostic Considerations

• Preoperative radiologic diagnosis can be correlated with postoperative histologic diagnosis to guide a diagnostic algorithm 4
• Biopsy may be indicated for diagnosis in cases where the preoperative radiologic diagnosis is indeterminate or concerning for an aggressive fibro-osseous neoplasm 4
• Clinical, radiological, and histological findings should all be considered to establish differential diagnosis among fibro-osseous lesions 5

Treatment Approaches

• An endoscopic approach can be used for most cases of fibro-osseous lesions, with an external open approach being necessary in selected patients 5
• The choice of treatment approach depends on the location, extension, and histological variant of the lesion, as well as the patient's symptoms and overall health status 5