The authors aimed to determine the best approach to paranasal osteoma excision. They conducted a retrospective study of 41 patients with paranasal sinus osteoma (PNSO) at a tertiary centre in Turkey. PNSO was present in: the frontal sinus in 26 patients (63.4%); ethmoid in 10 (24.3%); maxillary in four (9.7%) and sphenoid in one (2.4%). Four patients who were asymptomatic were managed by serial CT scanning over two to five years. There was no significant growth in these patients. Osteomas had an average 2.1cm diameter in the frontal, 3.5cm in the ethmoid, 2.6cm in the maxillary and 3cm in the sphenoid sinus. Eleven frontal sinus osteomas were completely excised endoscopically, nine via an osteoplastic flap and five via a combined approach (three patients had modification with a bicoronal incision and two patients had endoscopic approach combined with frontal trephination). Three patients operated via osteoplastic flap developed mucoceles requiring revision surgery within two years. Eight patients with an osteoma in the ethmoid were treated successfully with endoscopic excision and three of these patients had orbital extension requiring additional orbital decompression. Partial loss of vision developed in one patient with orbital extension. Two patients with an osteoma on the medial maxillary wall were successfully treated via endoscopic medial maxillectomy. One patient with extension into the infratemporal fossa was resected via combination of Caldwell-Luc and endoscopic surgery and one patient with sphenoid sinus osteoma declined surgical treatment. The authors recommend surgical excision of all ethmoid and sphenoid osteomas despite being asymptomatic due to increased risk of sight and intracranial complications. Asymptomatic frontal and maxillary osteomas can be monitored. Surgical technique depends on size, location, extent, complications and surgeon’s ability.