Single-Port Endoscopic Removal of Forehead Osteoma: An Otolaryngologist’s Procedure

INTRODUCTION 

Forehead osteoma is a benign tumor lesion, although mostly asymptomatic, creating significant cosmetic concerns for the patient. Traditionally, either a direct open approach with a forehead incision along the relaxed free tension line or a large coronal incision in the hair-bearing skin is made to remove forehead osteoma. However, an inevitable scar is the main issue for a direct open approach (J Craniofac Surg. 2006. doi:10.1097/00001665-200605000-00007). Additionally, there is the risk of temporary or permanent scalp paresthesia from the supraorbital or supratrochlear nerve injury.

Endoscope-assisted removal of forehead osteoma has been described, but it is not clear to many patients which surgical specialty has the appropriate training for this approach (J Craniofac Surg. 2006. doi:10.1097/00001665-200605000-00007; J Craniofac Surg. 1995. doi:10.1097/00001665-199511000-00021; Formos J Surg. 2015. doi:10.1097/SCS.0000000000005185; Ann Plast Surg. 2008. doi:10.1097/SAP.0b013e31816d829a; Ann Chir Plast Esthet. 2020. doi:10.1016/j.anplas.2019.04.004). Referrals to plastic surgeons, neurosurgeons, and general surgeons are common, but otolaryngologists have the core skill set required for this procedure. The excellent visualization from the endoscope creates success in complete removal and recontouring of the forehead without nerve injury. Moreover, the hidden incision in the frontal hairline gives excellent cosmetic outcomes.

Here, we describe our single-port endoscopic removal of forehead osteoma technique and the associated outcomes.

METHOD

A retrospective review of consecutive adult patients with forehead osteoma managed with single-port endoscopic removal of forehead osteoma was performed. Success in the primary outcomes was measured by the complete removal of the osteoma, which could not be observed by either the patient or the surgeon, and the restoration of contour without irregularities in the forehead, which also could not be seen or palpated by the patient and the surgeon. Secondary outcomes were surgical morbidity, defined as early (<90 days) or late (>90 days). Early morbidity included periorbital swelling/bruising, infection, temporary scalp paresthesia, forehead hematoma, and pain requiring additional analgesia. Late morbidity included permanent scalp paresthesia, irregularity of forehead contour, and visible surgical scarring.

Preparation

The operation was performed under general anesthesia. The surgeon operated in the sitting position at the top of the operating bed. The endoscope monitor was placed above the patient in front of the surgeon. The patient’s head was in a neutral anatomic position. The boundary of frontal osteoma was marked. The hair was divided by bush up and down above the frontal hairline without a haircut. The hair division line was perpendicular to the osteoma. The “deckled” hairline incision of 1–2 cm was drawn in the hair division line. The incision, tumor site, and endoscopic instruments’ access path were infiltrated with 1% ropivacaine and 1:100,000 adrenaline.

Surgical Technique

The deckled hairline incision was made with the 15° ophthalmic knife. Needle-point diathermy coagulation occurred to the galeal layer, setting 12. Under retraction, the surgeon blunt dissected, vertically through the galea, to the subperiosteal plane down to the subperiosteal layer. Then, a 4-mm 0° endoscope was inserted under the subperiosteal plane. The subperiosteal dissection was performed down to the osteoma’s cephalic and lateral border, extending laterally to ensure full visualization. Dissection inferior and below the border of the osteoma was facilitated with an ethmoid curette.