Endoscopic View of Ossification of the Middle Turbinate and Ethmoid Sinus

Figure. A: Submentovertical CT of the sinuses shows the extensive flocculent calcification of the right middle turbinate with opacification of the right maxillary sinus. B: This CT view shows the extension of the ossification into the right ethmoid cells to the right lamina papyracea, but not into the orbital cavity. C: Telescopic view (4 mm, 0°) of the right nasal cavity shows the huge middle turbinate obstructing the middle meatus. D: Telescopic view shows the resection of the lateral portion of the right fibro-osseous middle turbinate.

A 78-year-old woman presented with increasing left-sided facial and periorbital discomfort of 1 year's duration. She had been treated four times during the previous year for acute sinusitis.

Nasal examination revealed a huge right middle turbinate with edema in the right middle meatus. Computed tomography (CT) of the sinuses showed what the radiologist described as extensive flocculent calcification and a soft-tissue density of the right middle turbinate with opacification of the right maxillary sinus (figure, A). These findings of ossification were described as extending into the right ethmoid cells to the lamina papyracea with no extension into the orbit (figure, B).

The patient underwent functional endoscopic sinus surgery with powered instrumentation. Intraoperatively, the right middle turbinate was found to be obstructing the right middle meatus (figure, C). The lateral portion of the right middle turbinate was resected with a microdebrider (figure, D). The turbinate had a fibro-osseous consistency, as did the tissue in the ethmoid labyrinth, which was carefully dissected with the help of a computer-aided guidance system. A middle meatal antrostomy was performed, and the right maxillary sinus was carefully drained. Postoperatively, the patient experienced no further right facial discomfort. The pathologic analysis revealed benign tissue of fibro-osseous origin.

The differential diagnosis of this tissue at the time of clinical evaluation and at the time of surgery included chronic mucocele formation with calcification, chondrosarcoma, and squamous cell carcinoma with calcification. Since the pathologic diagnosis was benign tissue of fibro-osseous origin, no further treatment was suggested.

Four types of fibro-osseous lesions are listed by the World Health Organization: fibrous dysplasia, ossifying fibromas, cementing fibromas, and cementoossifying fibromas. ¹ The more locally aggressive lesions (i.e., the fibromas) require significant surgical excision to reduce the chance of local recurrence. The surrounding anatomy of the orbit and the skull base makes the consequences of aggressive dissection in the area of the paranasal sinuses a concern. A conservative approach will yield a pathologic diagnosis and treat the functional obstruction in a safe manner. Our patient's condition improved, and she continued long-term follow-up for observation.