Endoscopic and combined approaches in the surgical management of frontal and ethmoidal sinus osteomas: a novel decision-making flowchart

PURPOSE: Paranasal sinus osteomas are benign but potentially symptomatic lesions whose management remains heterogeneous despite recent advances. Choosing between a purely endoscopic or a combined approach can be challenging, particularly for larger lesions. This study aims to present our institutional experience in the surgical management of paranasal sinus osteomas and to propose a flowchart that integrates clinical and radiological findings and modern technologies, including intraoperative navigation and patient-specific cutting guides, to assist clinicians in selecting the optimal surgical approach. METHODS: A retrospective review was conducted on patients who underwent surgical resection of frontal and ethmoidal sinus osteomas at the Maxillofacial Surgery Unit of the University of Naples "Federico II" between January 2020 and April 2024. Patients were classified according to anatomical grading and surgical approaches were categorized as endoscopic or combined. Demographic data, radiological features, surgical details, and postoperative outcomes were analyzed. Based on these findings, our flowchart was developed. RESULTS: 22 patients (13 males, 9 females; mean age = 51.5 years) were included. 9 (41%) were Type I, 7 (32%) Type II, and 6 (27%) Type III osteomas. Endoscopic surgery was performed in 16 cases (73%), while combined approaches were required in 6 cases (27%), exclusively for Type III lesions. No major postoperative complications or recurrences were observed during a mean follow-up of 40.3 months (20-68 months). CONCLUSIONS: Endoscopic treatment is effective for most fronto-ethmoidal osteomas, while combined approaches remain indicated for large or extended lesions. This flowchart offers a guide for selecting endoscopic or combined approaches, enhancing safety and outcomes.