Transnasal endoscopic piezoelectric-assisted removal of frontal sinus osteoma.

INTRODUCTION Piezosurgery, a method of bone cutting utilizing ultrasound vibrations, widely used in oral and maxillofacial surgery, is being used in a growing number of new clinical applications. Its main advantages are preservation of soft tissues, precise bone cutting, and the possibility of use in narrow spaces. Over the past 5 years, several authors have presented their experience with the use of this tool in ENT including antromastoidectomy, stapedectomy, osteoplastic flap procedure, removal of osteomas of the frontal bone, and revision endoscopic sinus surgery. Osteomas of the paranasal sinuses are benign, slow-growing, usually asymptomatic tumors. The frontal sinus and recess are the most commonly affected sites. In most cases, surgery is not required, and radiological follow-up is performed. Indications for removal include frontal pain, rapid tumor growth, blockage of sinus drainage, involvement of more than half of the sinus volume, and intracranial or intraorbital complications. Endonasal endoscopic surgery of frontal sinus osteomas became possible due to the development of extended approaches to the frontal sinus. Draf IIb, IIb/III, and III procedures are limited mainly by individual anatomic conditions such as narrow anterior-posterior dimension of the frontal recess, not allowing the scope and burr to pass. The most common late complication of these procedures is scaring of the created ostium, which depends on the amount of removed mucosa created by the use of the burr. The use of mucosa-sparing, slim-shaped instruments allows for better visualization of the operative field, minimizes trauma, and improves late outcomes. Removal of large osteomas with currently available equipment (irrigated curved burrs) is rather time consuming. Cavitation of the lesion with burrs and then fracturing and piecemeal removal of eggshell remnants is the method of choice. The use of saw-like cutting instruments allows for creation of narrow gaps through the tumor, decreasing resection time. Another advantage of the use of piezoelectric systems is decreased risk of cerebrospinal fluid (CSF) leak and bleeding due to preservation of the dura and vessels. For these reasons, it is a promising tool for use in endonasal surgery of bony tumors of the paranasal sinuses. The purpose of this article was to present our initial experience with the use of piezosurgery for transnasal endoscopic frontal sinus osteoma removal. The patient was a 50-year-old, obese, asthmatic female complaining of severe frontal pain/headaches. She had previously undergone endoscopic sinus surgery for chronic rhinosinusitis with polyps 6 months prior with no improvement in headaches. Computerized tomography revealed osteoma type IV, according to Chiu and Kennedy classification, in her hypoplastic right frontal sinus, relatively thick frontal beak, and lower intersinus septum (Fig. 1). The maximum dimension of the tumor was 2.2 cm.