they are usually originates from the frontal and ethmoid sinus and much less frequently seen in the maxillary and sphenoid sinuses .
although the lamina papyracea is a part of ethmoid bone , a giant osteoma originated from the lamina papyracea is very uncommon .
headache , proptosis , epiphora , diplopia , dizziness , facial deformity , face pain and cerebral complications are possible symptoms .
paranasal sinus tomography showed an osseous lesion , the size of 4x 3 cm , arising from the right lamina papyracea .
they can be treated successfully by endoscopic approaches without any recurrence and complication despite its size .
they are usually originates from the frontal and ethmoid sinus and much less frequently seen in the maxillary and sphenoid sinuses ( 2 ) .
however the giant osteomas of the ethmoid and frontal sinuses are very rare , with only a few dozen cases reported in the literature ( 4 ) .
an osteoma of the paranasal sinus is usually asymptomatic and found incidentally on imaging examinations .
ethmoid sinus osteomas often show symptoms at an early stage while osteomas range in size from 2 to 30 mm because of the limited anatomical space ( 4 ) .
most common symptoms are ; blunt face pain , congestion , rhinorrhea , anosmia , sinusitis and orbital symptoms include diplopia , proptosis , exophthalmos and changes in vision ( 5 ) .
osteomas may be associated with rhinosinusitis and mucoceles and these can increase the cranial and orbital complications ( 5 ) . while osteomas usually range in size from 2 to 30 mm , an osteoma with a diameter > 30 mm or weighing > 110 g is considered a 
the symptomatic osteomas are treated surgically by external approach , endoscopic or both ( 1 , 2 ) . endoscopic approaches are preferred recently because of its advantages .
we report a case of a giant osteoma of ethmoid sinus and its treatment by endoscopically .
a 65 year old woman , presented with stuffiness and headache , referred to our clinic .
she has had these symptoms for three years and increasing for three months especially at the right side of her face .
the patient had no associated symptoms such as ; epistaxis , rhinorrhea , diplopia , cerebral or the other opthalmologic symptoms .
anterior rhinoscopy showed bilateral inferior conchal congestion and a mass at posterior of the right inferior concha .
a solid mass with smooth surface that extend to the choana was found in right nasal cavity on endoscopic examination ( figure 1 ) .
other physical examinations were normal . a paranasal sinus computerized tomography ( ct ) scan revealed a 4x3 cm lesion of osseous density arising from the right lamina papyracea and extending to the choana , posterior ethmoid air cells and frontal reses ( figure 2 ) . except from the lamina papyracea , there were no insertion of the mass to the lateral wall .
there was a soft tissue density in the right maxillary sinus secondary to the ostium obstruction . pre - operativ endoscopic view pre - operative computerized tomography an endoscopic excision planned under general anesthesia .
the bony medial orbital rim were cut by a drill without excision of the lamina papyracea and the mass was mobilized .
after removal , the giant osteoma was found to measure ~ 432 cm ( figure 3 ) .
meroceles were got out two days later , there was no hemorrhage and the patient was discharged .
the histopathologic report confirmed a diagnosis of osteoma with osteoblastic and osteoclastic activity . an endoscopic examination and
ct showed that the patient was disease - free 9 months postoperatively ( figure 4 ) .
osteomas are the most common benign tumors of the paranasal sinuses , usually found in the frontal sinus ( 57 - 80 % ) and less often in the ethmoid sinus , also lamina papyracea , ( 20 % ) , maxillary sinus ( 6.3 % ) or sphenoid sinus ( 4.9 % ) ( 1 , 2 , 4 ) .
osteomas are slow - growing neoplasms and affect 0.43 - 1 % of the population with a male dominance and in fourth decade ( 2 , 7 ) .
the tumors larger than 30 mm in diameter are considered giant tumors ( 6 ) .
our patient was 65 year old , female and the size of the tumor was 4x3x2 cm .
we thought that the osteoma was originated from the lamina papyracea because of the insertion of the mass .
cortical variant , sponge variant and mixed type ( both cortical and sponge ) ( 8) .
there was no trauma or infection history in our patient . because of the large size of the tumor , the embriologic theory is considered in our patient .
when they become symptomatic , it is often related to the location of the tumor .
proptosis , epiphora , diplopia , dizziness , facial deformity , face pain and cerebral complications are the other possible symptoms ( 4 , 5 , 6 ) .
although some studies suggest that asymptomatic static lesions may be observed , surgical removal is indicated in cases with orbital matrix compression and displacement ( 10 ) .
if the mass localised near the nasofrontal ductus or filled the 50% of the frontal sinus , they operated the patients even asymptomatic ( 11 ) . according to savic and djeric , asymptomatic osteomas should be operated if they extend beyond the frontal sinus boundaries , if they can be demonstrated to be enlarging on repeated radiological examinations , or if they are located near the frontonasal duct ( 12 ) .
endoscopic surgery , external approach or both are the main treatments for symptomatic osteomas of the sinuses .
the choice must consider several factors such as tumor location , extension , dimension and the experience of the surgeon .
yiotakis and cheng reported that the main treatment is external approach but endonasal surgery may performed ( 4 , 13 ) .
reported that a transcutaneous paranasal approach offers the advantages of increased exposure of affected structures as well as accurate recognition and preservation ( 14 ) .
savic and djeric used the ostoplastic flap technique at 34 patients , external ethmoidectomy at 4 patients and lateral rhinotomy at 3 patients ( 12 ) .
lund et al . reported a combined approach was chosen in seven cases ( 15.6% ) and osteomas in three cases ( 6.7% ) were resected completely via endoscopic intranasal surgery ( 15 ) .
first time , menezes and davidson used the endoscopic approach in these tumors ( 9 ) .
after that , there are several reports of successful removal of large ethmoid osteomas with intraorbital extension , treated endoscopically .
huang et al . have presented a case of ethmoid osteoma extended into the orbit , which was removed endoscopically after drilling and elevation ( 1 ) .
naraghi et al . have described a case of large ethmoido - orbital osteoma dissected via endoscopic approach without drilling , with minimal complications ( 16 ) .
more researchers reported the endoscopic treatment of paranasal sinus osteomas and its advantages ( 17 , 18 ) . in our patient ; we performed transnasal approach despite its large size .
the limitation of blood loss , reduced postoperative morbidity with a shorter hospitalization time and no incision scar are the advantages of an endoscopic surgery .
giant osteomas of paranasal sinuses , especially originated from the lamina papyracea , are rare .
they can be treated successfully by endoscopic approaches without any recurrence and complication . the minimal blood loss , short hospitalization and excellent cosmetic view are the choice of endoscopic approach .
 introduction : osteomas are slow- growing , benign tumors . 
 they are the most common neoplasms of the paranasal sinuses . 
 they are usually originates from the frontal and ethmoid sinus and much less frequently seen in the maxillary and sphenoid sinuses . 
 although the lamina papyracea is a part of ethmoid bone , a giant osteoma originated from the lamina papyracea is very uncommon . 
 an osteoma of the paranasal sinus is usually asymptomatic . 
 headache , proptosis , epiphora , diplopia , dizziness , facial deformity , face pain and cerebral complications are possible symptoms . 
 the treatment of the paranasal osteomas are controversial.case report : a 65 year old patient that applied with stuffiness and headache to our clinic . 
 she has had a smooth mass in the right nasal cavity . 
 paranasal sinus tomography showed an osseous lesion , the size of 4x 3 cm , arising from the right lamina papyracea . 
 the mass excised endoscopically and reported as osteoma histopathologically . 
 there was no complication . 
 after 9 months , there was no recurrence.conclusion:giant osteomas of paranasal sinuses , especially originated from the lamina papyracea are rare . 
 they can be treated successfully by endoscopic approaches without any recurrence and complication despite its size . 
Introduction:
Case report:
Conclusion:
1. INTRODUCTION
2. CASE REPORT
3. DISCUSSION
4. CONCLUSION