Under general anesthesia, surgical excision was performed through a transcolumellar and infracartilaginous incision. The nasal skin was elevated through the dissection in the supraperichondrial plane, and around the keystone area, dissection proceeded in the subperiosteal plane. A hard, pedunculated mass fixed to the bone was visualized and removed via osteotomy. The excised tumor was 0.7 × 0.5 cm in size (Fig. 3A). Biopsy confirmed a peripheral osteoma (Fig. 3B). After tumor removal, structural stability of bony and cartilaginous nasal framework was preserved and symmetry of the nasal dorsum was acquired (Fig. 1B).
On the contrast-enhanced facial CT scan 6 months later, no remnant lesion or recurrence was observed (Fig. 2B).
Osteoma is a benign, slowly growing osteogenic tumor, arising from the proliferation of compact or cancellous bone. Among them, peripheral osteoma arises from the periosteum, and its pathogenesis is multifactorial: true neoplasia, hamartoma, and reactional mechanism including trauma or infection. Iatrogenic injury to the periosteum during surgery or laser treatment could also provoke a peripheral osteoma.
Osteomas frequently develop in the craniofacial region, particularly in the paranasal sinus and mandible. They can cause asymmetry, malocclusion, headache, neuralgia, paresthesia, and ophthalmic symptoms in case of intraorbital extension.[7,8] However, an osteoma arising from the nasal bone is quite rare, and is less likely to present with the above symptoms. An osteoma of the nasal bone is usually painless and asymptomatic, and causes irregularity of the nose.[5,6]
CT is the criterion standard diagnostic tool, and shows a radiopaque mass with demarcated boundaries. Magnetic resonance imaging (MRI) could be useful in intracranial or intraorbital involvement. In addition, multiple osteoma with intestinal polyposis should point toward the diagnosis of Gardner syndrome.
In incidentally detected, asymptomatic osteoma, treatment is not mandatory. However, if it is symptomatic or grows rapidly, surgical excision should be recommended. Osteoma of the paranasal sinus can be treated with external or endoscopic surgery. Endoscopic surgery in these cases is well established. However, no standard surgical procedure is available for cases of osteoma of nasal bone because of its uncommon occurrence. It can be excised through a direct skin incision right above the lesion, or using open rhinoplasty incision: transcolummellar incision with infracartilaginous extensions.[5,6] The former is simple and straightforward but results in postoperative scarring. Hence, it is suitable for persons who are insensitive to esthetic outcomes, like the elderly population. The latter is delicate and more time-consuming, yet it could effectively hide the scar. In young or female patients, excision using the open rhinoplasty technique is more favored.
In the case of an osteoma of the nasal bone, chronic osteoma can compress the abutting structures: the nasal bone or nasal cartilages that form the shape of the nose. Furthermore, while resecting the osteoma, iatrogenic injury could occur to these structures. Either of them causes instability or asymmetry of the nose. Using the open rhinoplasty technique during osteoma excision in the nose, the surgeon can correct the asymmetry and reinforce the weakened part with various procedures: columellar strut graft, spreader graft, and so on.
Peripheral osteoma of the nasal bone is an occasional case. However, applying the open rhinoplasty technique, a surgeon could not only easily hide the operative scar, but also revise the functional and esthetic outcomes simultaneously during an excision.
Conceptualization: Jae Ha Hwang.
Supervision: Kwang Seog Kim, Sam Yong Lee.
Writing – original draft: Jae Ha Hwang, Dong Gyu Lee.
Writing – review & editing: Jae Ha Hwang.
Jae Ha Hwang orcid: 0000-0001-6992-8067.
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Keywords:Copyright © 2019 the Author(s). Published by Wolters Kluwer Health, Inc.
Nose; osteoma; rhinoplasty