Giant ethmoidal mucocele leading to proptosis and hypertelorism in a pediatric patient with cystic fibrosis: a case report.

BACKGROUND: Chronic sinusitis and its complications are common in patients with cystic fibrosis. Mucoceles are one of these complications and can have life-threatening consequences if left untreated. CASE: We present the case of a giant ethmoid mucocele leading to proptosis and hypertelorism in a 5-year-old child with cystic fibrosis. CONCLUSION: Chronic sinusitis and its complications are common in patients with CF. Mucoceles are a rare complication of sinusitis that can be treated surgically. As seen in this case if left untreated mucoceles can lead to orbital pathologies such as proptosis, hypertelorism. To the best of our knowledge, we report the first case report of giant ethmoidal mucocele leading to proptosis and hypertelorism in a patient with cystic fibrosis.

Change in Warthin's tumor incidence: a 20-year joinpoint trend analysis.

PURPOSE: The incidence of Warthin's tumor (WT) has increased worldwide. In this study, we aimed to evaluate the incidence of WT in our hospital, which provides health care for an extremely large population. METHODS: We retrospectively evaluated 573 patients, comprising 345 males and 228 females, who all experienced parotid tumor for the past 20 years. Patients with WT that were operated in the last 20 years were evaluated according to the number of patients per year to determine the annual WT increase trend. RESULTS: In the distribution of WT over the years of surgery, the ratio of WT to all tumors irregularly changed. Furthermore, the total number of parotidectomies per year increased in time. We investigated whether WT had any increasing trend over the years. The annual percentage change (APC) of WT was calculated, and according to the segmented regression analysis, the APC was insignificant (APC = 4.3, 95% CI = - 3.6-12.9, P = 0.300). CONCLUSION: The incidence of WT has increased across the world. However, in our study, no significant APC was observed according to the segmented regression analysis.

Cervical Tracheal Resection and Anastomosis for Postintubation Tracheal Stenosis.

In this study the authors evaluated the outcomes of tracheal resection and anastomosis in postintubation tracheal stenosis. The authors also aimed to identify clinical and radiological factors associated with restenosis. Thirty-four consecutive patients were included in the study. Patients with subglottic stenosis who underwent procedures involving cricoid cartilage and patients with other etiologies were excluded from the study. Univariate analysis was performed to determine the risk factors for restenosis. Receiver operating characteristic (ROC) curves were generated for the diameter of the narrowest part of the trachea (Dst) and the distance between cricoid cartilage and stenosis (Dcs). Of the 34 patients, 31 (91.1%) patients were successfully decannulated. Nineteen (55.8%) patients had complications. After univariate analysis, Dst (P = 0.001), Dcs (P = 0.001), smoking (P = 0.007) and grade of the stenosis (P = 0.003) were significantly associated with restenosis. The sensitivity and specificity were 90.9% and 77.3%, respectively, when the cutoff value for Dst was 4 mm. Sensitivity and specificity were 72.7% and 100%, respectively, when the cutoff value for Dcs was 10 mm. Tracheal resection and anastomosis is an effective surgical method for treating postintubation tracheal stenosis. In our series, 91.1% of the patients with postintubation tracheal stenosis were successfully decannulated. Restenosis was the most common complication. The diameter of the narrowest part of the trachea (Dst), the distance between cricoid cartilage and stenosis (Dcs), smoking and grade of stenosis were significantly associated with restenosis.

Outcomes of cochlear implantation in children with and without inner ear malformations.

OBJECTIVE: To evaluate the auditory functions and progress of speech development in children with and without cochlear anomalies who underwent cochlear implantation due to prelingual profound sensorineural hearing loss (SNHL). METHODS: This study was conducted at Gaziantep University Faculty of Medicine Ear-Nose-Throat Department, between October 2006 and December 2007. A total of 69 children (aged 6 to 24 months) diagnosed with profound SNHL were included. Patients were divided into two groups with respect to the presence of inner ear anomalies: Group-1 consisted of 41 children without inner ear anomaly, whereas Group-2 was composed of 28 patients with inner ear anomalies. The auditory performance was assessed using Listening Progress Profile Test (LPPT) and Monosyllabic Trochee Polysyllabic Test (MTP), the subsections of Evaluation of Auditory Responses to Speech (EARS) test battery. RESULTS: Preoperative LPPT scores were 5 (12%) in both groups. Mean LPPT values after fitting in Group-1 and Group-2 on 1st, 3rd and 6th months were 18.5 (44.1%) and 19 (45.6%); 27 (64.2%) and 28 (67.3%); 31 (75%) and 34 (83%), respectively. Postoperatively, MTP scores in Group-1 and Group-2 were 7.5 (62%) and 7.7 (64%) for 3-words set; 10.4 (58%) and 10.6 (59%) for 6-words set; 14.3 (60%) and 14 (59%) for 12-words set, respectively. The rate of stimulation for electrodes was 1345 q/u (quick/unit) in Group-1 and 1310 q/u in Group-2. No statistically significant difference was detected between groups for variables under investigation. CONCLUSION: Cochlear implantation is an effective treatment in children with prelingual profound SNHL. Auditory performance and advancement of speech are similar for children with and without inner ear anomalies.

Treatment of Congenital Choanal Atresia via Transnasal Endoscopic Method.

OBJECTIVES: Congenital choanal atresia (CCA) is a very rare abnormality of the nose, but in the case of bilateral presence, it becomes a life-threatening malformation. Various surgical treatment options, such as transpalatal, transseptal, and open rhinoplasty techniques, as well as the transnasal approach, have been defined for the repair of CCA. In this study, the authors intended to evaluate the outcomes of transnasal endoscopic surgery for CCA, and stent implementation's impact on surgical success. METHODS: Patients who were admitted to the Otorhinolaryngology Department of Gaziantep University and patients who had not undergone CCA surgery before were included in the study. Patients who underwent transnasal endoscopic choanal atresia surgery (TECAS) were advised to have regular nasal endoscopic examinations performed at check-ups; after a 6-month follow-up period, surgical results were evaluated concerning whether stenosis had occurred or not. RESULTS: Of the 48 patients who underwent TECAS after a minimum 6-month follow-up period, 34 of patients revealed no stenosis, so the overall surgical success rate was 70.8%. Fourteen (29.2%) patients who underwent TECAS developed stenosis and required revision surgery. CONCLUSIONS: Transnasal endoscopic choanal atresia surgery is the most preferred approach for CCA repair and has many advantages, such as excellent vision, shorter operative time, minimal bleeding, and minimum complication. Despite advances in endovision systems and surgical instruments, stenosis is the most challenging problem after TECAS, so new treatment strategies should be developed to prevent stenosis.

Oxidative stress in otosclerosis.

OBJECTIVES: Otosclerosis is a disease involving abnormal bone turnover in the human otic capsule that results in hearing loss. Several hypotheses have been suggested for the etiopathogenesis of otosclerosis; however, its etiology remains unclear. METHODS: This study evaluated the correlation between otosclerosis and levels of paraoxonase-1 (PON1), arylesterase, total antioxidant status, total oxidant status (TOS), oxidative stress index (OSI), total sulfhydryl (-SH) groups, lipid hydroperoxide, and ceruloplasmin in the serum of otosclerosis patients and healthy subjects with respect to oxidative stress. RESULTS: In our study, TOS and OSI levels were higher in the otosclerosis patients than in the controls. The PON1 levels showed that oxidative stress was severe, and as a result, antioxidants were consumed and depleted. DISCUSSION: When an imbalance between oxygen free radical production and antioxidative defense mechanisms occurs, reactive oxygen species levels may increase, which in turn may damage cells and tissues through the peroxidation of phospholipid membrane structures. The body initially responds with increased antioxidant production, but if the oxidative stress is severe, decreased antioxidant levels may result. This study reports expression levels of oxidative stress species in otosclerosis patients.

Masking Treatment and its Effect on Tinnitus Parameters.

OBJECTIVE: Tinnitus is described as the perception of sound without any external acoustic stimulation. Any pathology of auditory pathways or any system of the human body may result with tinnitus. The pathophysiology of tinnitus accompanying the disorders of auditory system is not fully understood and there is not any particular effective treatment method has been specified. Tinnitus masking therapy has been reported as an effective treatment modality in the treatment of tinnitus. In this study, the results of tinnitus masking treatment on the parameters were evaluated prospectively. PATIENTS AND METHODS: Patients with normal physical examination was enrolled in the study. Blood tests (complete blood count, biochemical analysis of lipid profile, and thyroid hormones), pure tone audiometry, tympanometric measurement of the middle ear pressure and stapedial reflexes were performed, Sixty six patients with normal results of blood tests and normal hearing thresholds with type A tympanogram were included. Tinnitus sufferers questionnaires (socio-demographics, clinical information, Tinnitus Handicap Inventory (THI), Beck Depression Inventory (BDI) was filled, audiological tests were performed, tinnitus parameters (frequency, intensity, minimal masking levels, residual inhibition) were measured. After four weeks of the treatment the questionnaires were repeated. RESULTS: Masking treatment for tinnitus patients resulted with significant decrease in Tinnitus Handicap Inventory and VAS scores. After four weeks of the masking treatment the questionnaire was repeated. Twenty patients did not respond to treatment. CONCLUSION: Masking therapy is one of the most effective methods of treatment for tinnitus patients. Masking therapy, that is not invasive and cost-effective has an important place in the treatment of tinnitus. Especially in a short time provides a significant reduction in tinnitus parameters.

Predictive factors for malignancy in patients with persistent cervical lymphadenopathy.

The aim of this study was to identify clinical factors that can predict malignancy in patients with persistent cervical lymphadenopathy. This retrospective study included 575 patients with persistent cervical lymphadenopathy who underwent surgical excision. The patients were divided into two groups according to their ages: group 1 (≤18 years) and group 2 (>18 years). Multiple logistic regression models and univariate analysis were performed to determine the association between clinical factors and malignancy. Male gender [odds ratio (OR) 4.184, 95 % confidence interval (CI) 1.823-9.602, p = 0.001], increased age (OR 1.072, 95 % CI 1.001-1.148, p = 0.046), left-sided lesions (OR 3.423, 95 % CI 1.407-8.329, p = 0.007), and larger lymph node size (OR 1.445, 95 % CI 1.021-2.044, p = 0.038) were significantly associated with malignancy in group 1. Male gender (OR 3.761, 95 % CI 2.361-5.992, p = 0.001), increased age (OR 1.015, 95 % CI 1.003-1.027, p = 0.018), duration of the disease (OR 0.770, 95 % CI 0.668-0.888, p = 0.001), and the presence of B symptoms (OR 4.996, 95 % CI 2.862-8.721, p = 0.001) were significantly associated with malignancy in group 2. The sensitivity and specificity of the models were 84 and 61.5 % for group 1 and 77.9 and 67.9 % for group 2, respectively. Increasing age and male gender were found to be associated with malignancy in all age groups. Larger lymph node size and left-sided lymphadenopathy were significant predictors of malignancy in children. Presence of B symptoms was found to be associated with malignancy in adults. Our results indicated that increasing duration of lymphadenopathy and the presence of bilaterality render the lymph node more likely to be benign in adults. No significant association was found between the involved neck site and malignancy for all age groups.

Isolated sphenoid sinus disease: An overlooked cause of headache.

OBJECTIVES: The aim of this study was to evaluate patients who underwent endoscopic sphenoid sinus surgery for isolated sphenoid sinus disease. We also investigated the impact of sphenoid sinus surgery on headache intensity. MATERIAL AND METHODS: Twenty-one consecutive patients who underwent endoscopic sphenoidotomy for isolated sphenoid sinus disease were included in the study. Diagnosis of isolated sphenoid sinus pathology was based on history, physical examination, and radiologic evaluation. All patients had headache with various localizations. Pre- and postoperative headache intensity of patients was scored using a visual analogue scale (VAS). RESULTS: The most common location of headache was the vertex (24%). The preoperative and postoperative mean VAS scores for headache were 8.24 ± 0.94 and 2.67 ± 1.49, respectively. Statistical comparison revealed a significant improvement in headache intensity (p < 0.01). Polyps (33.3%) were the most common pathology, followed by inflammation (23.8%). CONCLUSIONS: The most common presenting symptom of isolated sphenoid sinus disease is headache. In this study, we demonstrated that headache induced by isolated sphenoid disease can be relieved by endoscopic sphenoidotomy. Sphenoid sinus disease should be considered in the differential diagnosis of patients presenting with subacute or chronic headache.

Effectiveness and Safety of Selective Neck Dissection in Lymph Node-Positive Squamous Cell Carcinoma of the Head and Neck.

The aim of this study was to investigate the effectiveness and safety of selective neck dissection in patients with lymph node-positive head and neck squamous cell carcinoma to determine regional control and survival rates. Eighty patients with lymph node-positive head and neck squamous cell carcinoma who underwent selective dissection were included in the study. Regional control, survival rates, and factors affecting survival were analyzed. Regional control was 90%, disease-specific survival was 93.4%, and the overall survival rate was 87.25%. T stage, N stage, age, and extracapsular spread were included in hazard regression models. None of the factors were statistically significant. Selective neck dissection is an effective and oncologically safe treatment option in selected cases. T stage, N stage, and extracapsular spread had no significant impact on disease-specific survival.

Incidence and predictors of malignancy in children with persistent cervical lymphadenopathy.

OBJECTIVE: The aim of this study was to analyze the clinical and histopathologic aspects of persistent cervical lymphadenopathies in children. METHODS: This retrospective study included 98 children who underwent surgical excision for persistently swollen cervical lymph nodes between 2001 and 2013. Lymph nodes greater than 1.5 cm that persisted for more than 4 weeks and were unresponsive to an initial antibiotic treatment were considered "persistent". The largest lymph node with an abnormal ultrasonographic appearance was selected for surgical biopsy. The patients were divided into 2 groups according to the histopathologic outcome: benign or malignant. RESULTS: No significant differences were found between the groups regarding the mean size and mean duration of the swollen cervical lymph nodes (p = 0.147 and p = 0.446, respectively). The area under the ROC curve was 0.567 (95% confidence interval = 0.463-0.667, p = 0.259) for lymph node size and 0.507 (95% confidence interval = 0.404-0.609, p = 0.909) for the duration of the cervical lymphadenopathy. There was no significant difference in the presence of B symptoms between the two groups (p = 0.519). No significant difference was found between benign and malignant groups regarding bilaterality (p=0.913). CONCLUSIONS: The findings of our study demonstrated that the size and duration of cervical lymphadenopathy, bilateral or unilateral involvement and the presence or absence of B symptoms are not indicators of malignancy. We found a high incidence of malignancy in pediatric cervical lymphadenopathy cases in contrast to other current studies.

Management of upper aerodigestive tract amyloidosis.

OBJECTIVES: The aim of this study was to discuss the treatment options for upper aerodigestive tract amyloidosis. METHODS: Four patients with histologically confirmed amyloidosis were included in the study. All patients underwent surgical treatment. Three patients had laryngeal amyloidosis, and 1 patient had tonsillar amyloidosis. RESULTS: Two of the cases of laryngeal amyloidosis were successfully treated with a combination of surgery and radiation therapy. One case of laryngeal amyloidosis was treated with surgery alone. The tonsillar amyloidosis was removed by tonsillectomy. None of the cases showed systemic involvement. Long-term follow-up of the patients showed no recurrence or evidence of systemic disease. CONCLUSIONS: Surgical resection is the primary treatment for patients with upper aerodigestive tract amyloidosis. Radiation therapy is especially effective in cases of recurrent amyloidosis with submucosal involvement. Pedunculated polypoid lesions may be treated with surgery alone, and in cases of recurrence, irradiation following the surgical removal should be considered. Tonsillectomy is usually sufficient for treating tonsillar amyloidosis.

Pediatric endonasal endoscopic dacryocystorhinostomy.

OBJECTIVE: Nasolacrimal duct obstruction is a relatively common problem among children. Although spontaneous resolution is possible and various conservative treatment options are available, dacryocystorhinostomy is recommended for persistent epiphora. The aim of this study was to report our experience of performing 83 procedures of pediatric endoscopic dacryocystorhinostomy. METHODS: This retrospective study included 71 children who underwent endonasal endoscopic dacryocystorhinostomy between 2000 and 2011. Thirteen of these children had bilateral procedures. The diagnosis of nasolacrimal duct obstruction was based on the presence of eye discharge, the patient's history obtained from his or her parents and the results of testing the patency of the nasolacrimal canal by irrigating the lacrimal sac. The procedure was considered to be successful if the patient's eye discharge was completely resolved and the dacryocystorhinostomy ostium was patent at end of the postoperative first year. RESULTS: Eighty-three dacrycystorhinostomy procedures were performed in 71 children. There were 35 (49.3%) male and 36 (50.7%) female patients. The age of the patients ranged between 11 months and 14 years, with a mean of 8.9 years. The mean follow-up period was 27.1 months (range of 14-84 months). The overall success rate for primary endoscopic dacryocystorhinostomy was 92.7%. No major complications were encountered in any of the surgical procedures. CONCLUSION: Pediatric endonasal endoscopic dacryocystorhinostomy is a safe and effective procedure to correct nasolacrimal system obstruction in cases that are unresponsive to conservative treatments. It has a high success rate and a low incidence of complications.

Association between the self-insertion of nasal and aural foreign bodies and attention-deficit/hyperactivity disorder in children.

OBJECTIVE: To investigate whether the prevalence of attention-deficit/hyperactivity disorder (ADHD) is higher in children presenting with nasal and aural foreign bodies than in the control group. METHODS: The present study was conducted between April 2012 and December 2012 and included 60 pediatric patients presenting with self-inserted nasal and aural foreign bodies and 50 healthy controls aged between 3 and 9 years. The Conner Parent Rating Scale (CPRS) and Turgay's DSM-IV based ADHD and disruptive behavior disorders screening scale (T-DSM-IV-Scale) were used to investigate ADHD. RESULTS: The difference between the patient group and the control group was significant with respect to the abnormal scores obtained from all the subscales (p < 0.05). In children between 5 and 9 years of age, the abnormal scores were significantly higher in the patients than the controls for all the subscales (p < 0.05). However, in children between 3 and 4 years of age, there were no significant differences between the patients and the controls for the scores obtained from all the subscales (p > 0.05). No statistically significant difference was found between the patients with a previous history of self-inserted foreign bodies and those without any history of foreign body insertion (p > 0.05). CONCLUSIONS: The findings of our study demonstrated a possible association between the self-insertion of nasal and aural foreign bodies and ADHD. Clinicians should be aware of the possible presence of ADHD in children, especially in those patients between 5 and 9 years of age who present with self-inserted nasal and aural foreign bodies.

Systemic steroid versus combined systemic and intratympanic steroid treatment for sudden sensorineural hearing loss.

OBJECTIVE: The aim of this study was to evaluate the effectiveness of oral steroid treatment versus combined oral and intratympanic dexamethasone injection for idiopathic sudden sensorineural hearing loss. METHODS: This was a retrospective case review in which 30 patients in the oral steroid group and 39 patients in the combined oral and intratympanic steroid injection group were compared. RESULTS: The comparison of the initial pure tone audiometry (PTA) threshold results revealed a significant difference between the systemic steroid (SS) group and the systemic and intratympanic steroid group. The initial PTA was 74.33 ± 22.64 dB (mean ± SD) in the SS group and 87.49 ± 26.22 dB (mean ± SD) in the intratympanic steroid group. The difference in the initial PTA results was statistically significant between the SS group and intratympanic steroid group (P < 0.05, P = 0.032). The pure-tone gain in the SS group was 20.97 ± 27.47 dB (mean ± SD), and that of the group treated with both systemic and intratympanic steroids was 19.36 ± 22.16 dB (mean ± SD) (P = 0.49). CONCLUSIONS: The results of this study indicate that, in sudden sensorineural hearing loss, the administration of intratympanic steroids in conjunction with SS therapy appears to have the same effect on the restoration of hearing "as the effect obtained using SS therapy alone."

Complications and treatment of chronic otitis media.

OBJECTIVE: The aim of this study was to investigate the etiologic factors and treatment types for chronic otitis media (COM) complications. METHODS: In this study, the data from 82 patients who had been diagnosed and treated at the Departments of Otolaryngology and Neurosurgery of Gaziantep University between 1999 and 2011 for complications from COM were retrospectively reviewed. The chosen surgical procedure was based on the type of complication and the ear pathology. RESULTS: The study included 55 male and 27 female patients. Ten patients (12.2%) had intracranial complications, and 72 patients (87.80%) had extracranial complications. There were 47 patients with cholesteatoma. Radical mastoidectomy was performed on 46 patients, canal-wall-down mastoidectomy was performed on 30 patients, and canal-wall-up mastoidectomy was performed on 6 patients. Five patients underwent neurosurgical operations because of COM complications. CONCLUSIONS: Although the rate of COM complications has recently declined, it remains important to diagnose COM without delay and to use appropriate treatments for the patients because COM complications are associated with poor outcomes.

Oxidative stress in chronic otitis media.

Chronic otitis media usually presents with a benign tumor-like lesion of the temporal bone known as a cholesteatoma. The role of oxidative stress in the pathogenesis of chronic otitis media and cholesteatoma has not yet been fully explored. Therefore, the aim of this study was to investigate the oxidative stress markers and antioxidant enzymes in patients with cholesteatomatous and noncholesteatomatous chronic otitis media and in healthy subjects. A prospective controlled trial was performed on cholesteatomatous and noncholesteatomatous chronic otitis media patients in a tertiary referral center in a university hospital. A total of 75 subjects, including 25 cholesteatomatous and 25 noncholesteatomatous chronic otitis media patients and 25 healthy subjects participated in this study. Serum total oxidant status (TOS) and oxidative stress index (OSI) levels were significantly increased in the patient groups with or without cholesteatoma compared with the control group. Serum total antioxidant status (TAS) levels and Paraoxonase and arylesterase activity were significantly lower in the patient groups with or without cholesteatoma compared with the control group. Serum TOS and OSI levels were lower in the noncholesteatomatous group, whereas serum TAS levels were higher compared with the cholesteatomatous group. Serum arylesterase activity was significantly lower in the noncholesteatomatous group compared with the control group. The results of this study reveal that in cholesteatoma cases, the oxidative stress and antioxidant enzyme imbalance were more significant than in cases of chronic otitis media without cholesteatoma.

The polymorphisms of the MBL2 and MIF genes associated with Pediatric Cochlear Implant Patients.

OBJECTIVES: Mannose-binding lectin and macrophage migration inhibitory factor gene polymorphisms are associated with several acute/chronic autoimmune or inflammatory diseases. The aim of this study was to investigate if there was any association between mannose-binding lectin 2 (MBL2) and macrophage migration inhibitory factor (MIF) gene polymorphisms and profound congenital sensorineural hearing loss in children who underwent cochlear implantation. METHODS: A total of 62 patients with congenital hearing loss and 80 age- and sex-matched healthy controls were evaluated for codon 54 A/B polymorphisms in MBL2 and the-173 G/C polymorphism in MIF by using the polymerase chain reaction and restriction fragment length polymorphism method. RESULTS: The frequency of the BB genotype of MBL2 and MIF -173 GC genotype were statistically significantly higher in the patient group than in the controls (p=0.0127, p=0.0408, respectively). CONCLUSION: In this study, we found that a subject who is homozygous for the variant allele B of codon 54 of the MBL2and heterozygous for variant allele C of -173 MIF has a risk factor for sensorineural hearing loss.

Late metastasis of an intracranial meningioma to the hard palate.

Meningiomas are benign neoplasms that arise from cellular elements of the meninges. Although meningiomas are usually considered as benign tumors, they have a potential to become aggressive and to metastasize to the extracranial structures. Distant metastasis most commonly occurs in lung, liver, and long bones. We present an extremely rare case of a delayed metastasis of a recurrent intracranial meningioma to the hard palate 19 years after the initial diagnosis. The patient underwent surgical excision without any complication and follow-up showed no recurrence.

Paranasal sinus osteomas.

Osteoma is the most common benign tumor of the paranasal sinuses. They remain asymptomatic until the tumor reaches a certain size. Although the etiology of the osteomas is controversial, embryologic, traumatic, and infective theories have been proposed. Osteomas may be discovered at any age but are usually found during the fourth and fifth decades, and there is a male preponderance. In this retrospective study, we analyzed 25 patients with paranasal sinus osteomas who were treated surgically between 2005 and 2011. Age and sex of the patient, size and location of the tumor, clinical presentation, type of surgical approach, duration of follow-up, outcome, and any intraoperative or postoperative complications were obtained from the medical records of the patients. Diagnosis of osteoma was based on computed tomography findings and confirmed histopathologically in all cases. There were 9 men (36%) and 16 women (64%) with a mean age of 38.7 years. Tumor localization was divided as follows: ethmoid sinus in 14 patients (56%), frontal sinus in 9 patients (36%), and maxillary sinus in 2 patients (8%). Mean tumor size was 2.04 cm, ranging from 0.5 to 6.5 cm. External approach was used in 9 cases and endonasal endoscopic surgery was performed in 19 cases. Combination of endoscopic surgery and external surgery was performed in 3 cases. After at least 6 months of follow-up, all patients were symptom-free except 2 patients who underwent revision surgery. These 2 patients were also asymptomatic following revision surgery. Although there is an increasing trend to endoscopic surgery, external approach is recommended in large frontal osteomas and ethmoid osteomas with lateral extension and in case of intracranial or intraorbital involvement.