The endoscopic management of sinonasal inverted papillomas – documents

Department of Otolaryn‘olo‘y\ Sin‘apore General Hospital\ Republic of Sin‘apore

Sinonasal inverted papillomas are well known for high recurrence rates after surgery and the risk of

malignant change[ Recurrent disease occurs because of inadequate excision as a result of poor exposure

and visualization[ For these reasons\ aggressive surgery has been advocated?classically a lateral rhinotomy

and en bloc medial maxillectomy[ Endoscopic techniques have provided excellent visualization and a less

invasive approach to these tumours[ We describe 07 patients with inverted papillomas treated

endoscopically at the Singapore General Hospital since 0882[ The presentation\ sites of involvement and

diagnostic imaging are presented[ All the patients had a minimum follow!up of 07 months with a mean of

21[7 months[ One case of recurrence at the frontal recess is reported[ Endoscopic management is

appropriate for the diagnosis\ follow!up and treatment of circumscribed primary and recurrent inverted

Keywords papilloma maxillectomy endoscopic technique recurrence

Transitional cell papilloma[ The aggressive nature\ recurrence

surgical approach\ be it intranasal or external nasal surgery[

In the past\ intranasal surgery has been associated with high

recurrence rates because of incomplete excision and\ therefore\

with en bloc resection of the medial maxilla as the surgery of

choice[3?6 The advent of nasal endoscopes\ with illumination\

0Presented June 5th 0886 at the Cottle International Rhinology Cen!

laryngology\ Singapore General Hospital\ Outram Road\ Singapore

058597\ Republic of Singapore “e!mail] lincoln!chee?paci_c[net[sg#[

series with a long follow!up period may not be possible for a

single institution because of the low incidence of the disease[

ber 0885 were reviewed retrospectively[ Patient demographics\

clinical presentation\ location of tumour on endoscopy\ extent

tients were followed up endoscopically by the primary author[

strated in other studies[1\01\02 The most frequent symptom at

mon presentations “see Table 0#[ All the patients had a nasal

Most of the papillomas were traced to a wide base originating

Figure 0[ Unilateral inverted papilloma arising from left lateral nasal

wall[ MT ? middle turbinate\ IP ? inverted papilloma\ Sp ? septum[

? 0888 Blackwell Science Ltd\ Clinical Otolaryn‘olo‘y\ 13\ 50?55

were encountered in our series[ In cases of recurrent disease\

this occurred in the region of the primary lesion “Table 1#[1

All 07 patients underwent preoperative CT of the sinuses “see

Table 2#[ A localized lesion in the lateral nasal wall with no

i[e[ pansinusitis or in recurrence disease[ It is particularly

helpful in di}erentiating tumour from sinusitis00 and is well

Figure 1[ Computed tomography scan suggesting pansinus involve!

erklinger[03 One patient was treated similarly in another insti!

tution but was seen by us for recurrent disease 4 months after

his _rst surgery[ His limited recurrent disease in the frontal

only one patient “4[4)# developed a recurrence at the frontal

from multiple sites within each regional sinus were taken[ The

? 0888 Blackwell Science Ltd\ Clinical Otolaryn‘olo‘y\ 13\ 50?55

Figure 2[ Corresponding MRI di}erentiating left nasal tumour “hyp!

Histologically inverted papillomas are recognized by the neo!

plastic epithelium inverting into the underlying stroma with a

“Figure 3#[ Microscopic _ndings also suggested a wide base of

Figure 3[ Histopathological appearance of inverted papilloma[

tially the same anatomical site as the previous surgical removal

extent of disease and inadequate resection rather than histo!

logical type\ anatomical location\ mitotic activity or cellular

are better able to diagnose and trace the origin of these often

wall of the nose\ involving only the medial wall of the maxilla[

awareness\ discussion of therapeutic modalities and attention

nasal sinuses[1\04 The fact that a total spheno!ethmoidectomy\

wide meatotomy\ middle turbinate resection and frontal recess

invaluable in the postoperative monitoring and sampling “Fig!

ure 4#[ Maybe with time and experience\ the extent of resection

to be limited by site rather than the bulk of these tumours[ In

patients where the tumour originates from the lateral wall of

the maxillary sinus and the frontal sinus\ we feel that endo!

scopic surgery is contraindicated[ The only patient with recur!

? 0888 Blackwell Science Ltd\ Clinical Otolaryn‘olo‘y\ 13\ 50?55

Figure 4[ “a\b# Six months after operation showing total ethmo!

idectomy\ sphenoidotomy and wide meatotomy for monitoring[ The

rence in our series had a tumour originating from the frontal

sinus and frontal recess[ In this situation\ exploration of the

areas such as the frontal recess and base of the skull[ Others

in recurrent disease despite traditional external surgery[09\00

Wigand[07 Present!day endoscopic sinus surgery is far di}erent

from the intranasal excision done by authors in the past using

free water content that occurs in chronically inspissated sinus

contents result in diminution of T1 weighted signal intensity[19

Figure 1[ Because of cost\ MRI is done for di.cult resections

such as extensive disease\ pansinusitis\ frontal recess and sinus

has a role in the management of inverted papillomas especially

in patients with multifocal disease\ malignant transformation\

maxillary wall[10 However\ it is associated with greater mor!

rates can also be as high as 18) as reported by Dolgin et al[11

Certainly\ a mid!facial degloving approach\ is another alter!

native[ We submit that the advent of endoscopes\ with earlier

mentation for safer resection\ acceptable recurrence rate and

control for what is essentially a benign disease\ will gradually

0[ Inverted papillomas are essentially benign\ and non!multi!

focal[ It is uncommon for the tumour to arise from the frontal

? 0888 Blackwell Science Ltd\ Clinical Otolaryn‘olo‘y\ 13\ 50?55

help further de_ne the extent of disease and aid in treatment

3[ Recurrence of tumour is a function of incomplete excision[

4[ If there is doubt about complete resection\ it can be salvaged

by converting to traditional external surgery with no reported

5[ The lower morbidity\ better functional outcome and shorter

0 WARD N[ “0743# A mirror of the practice of medicine and surgery

in the hospitals of London] London Hospital[ Lancet 1\ 379?371

1 HYAMS V[ “0860# Papillomas of the nasal cavity and paranasal

sinuses] a clinicopathological study of 204 cases[ Ann[ Otol[ Rhinol[

2 PHILLIPS P[P[\ GUSTAFSON R[O[ + FACER G[W[ “0889# The clinical

sinuses] report of 001 cases and review of the literature[ Laryn‘o!

3 SUH K[W[\ FACER G[W[\ DEVINE K[D[ et al[ “0866# Inverted papil!

loma of the nose and paranasal sinuses[ Laryn‘oscope 76\ 24?35

of inverted papilloma of the nose and paranasal sinuses[ Laryn‘o!

Inverted papilloma and squamous cell carcinoma[ J[ Otolaryn‘ol[

6 MYERS E[N[\ FERNAU J[L[\ JOHNSON J[T[ et al[“0889# Management

7 KAMEL R[H[ “0881# Conservation endoscopic surgery in inverted

8 BENINGER M[S[\ LAVERTU P[\ LEVINE H[ et al[ “0880# Conservation

surgery for the treatment of inverted papilloma[ Laryn‘oscope

00 STANKIEWICS J[A[ + GIRGIS S[J[ “0882# Endoscopic treatment of

nasal and paranasal sinus inverted papilloma[ Otolaryn‘ol[ Head

01 LAWSON W[\ BILLER H[F[\ JACOBSON A[ et al[ “0872# The role of

conservative surgery in the management of inverted papilloma[

02 CALCATERRA T[C[\ THOMPSON J[W[ + PAGLIA D[E[ “0879# Invert!

ing papillomas of the nose and paranasal sinuses[ Laryn‘oscope

04 CHRISTENSEN W[N[ + SMITH R[R[L[ “0875# Schneiderian papil!

loma] a clinicopathologic study of 56 cases[ Hum[ Pathol[ 06\ 282?

05 YAO S[F[ “0884# Histopathology of inverted papillomas and sur!

approach to tumours of the anterior skull base and orbit[ Op[

of the nose and paranasal sinuses[ Arch[ Otolaryn‘ol[ 81\ 334?338

08 SEGAL K[\ ATAR E[\ MOR C[ et al[ “0866# Inverting papillomas of

? 0888 Blackwell Science Ltd\ Clinical Otolaryn‘olo‘y\ 13\ 50?55

ically obstructed sinonasal secretions] observations on T0 and T1

11 DOLGIN S[\ ZAVERI V[\ CASIANO R[ et al[ “0881# Di}erent options

for treatment of inverting papilloma of the nose and paranasal

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