Combined Endoscopic and External Approach for Resection of a Large Ethmoido-Orbito-Frontal Osteoma in a Pediatric Patient: A Surgical Challenge

Background Osteomas are benign, slow-growing tumors commonly found in the paranasal sinuses. While typically asymptomatic, large osteomas that extend into the orbit or skull base present significant surgical challenges, particularly in pediatric patients. A combined endoscopic and external approach is often required for safe resection in such cases. Case Presentation : A 15-year-old female presented with a 4-month history of right-sided non-axial exophthalmos, with no associated symptoms such as ocular pain, nasal obstruction, or neurological deficits. Imaging studies, including CT and MRI, revealed a large ethmoidal osteoma extending into the orbit and the right frontal sinus. The lesion measured approximately 22 × 19 × 24 mm and caused mild displacement of the right globe. Due to the tumor’s location and extension into critical structures, a combined endoscopic and external surgical approach was employed. The procedure involved an endoscopic endonasal resection followed by an external approach through an incision at the internal canthus for complete excision of the orbital portion. Postoperative recovery was uneventful, and the patient showed significant improvement in exophthalmos without any complications. Conclusion Large osteomas of the ethmoid and frontal sinuses, especially those extending into the orbit or skull base, present significant surgical challenges. In such cases, a combined endoscopic and external approach is essential for achieving complete resection while minimizing morbidity and preserving function. This case underscores the importance of a multidisciplinary approach in managing complex sinonasal osteomas in pediatric patients. Early diagnosis, careful preoperative planning, and appropriate surgical techniques are crucial for optimal outcomes. This case adds to the growing evidence supporting the use of combined surgical approaches for managing large, complex osteomas in anatomically sensitive areas.