Conservative endoscopic surgery in inverted papilloma. Preliminary report

[Inverted papilloma of the nose and paranasal sinuses : Diagnosis, treatment, and malignant transformation]

Inverted papilloma (IP) are benign tumors that show a locally aggressive behavior, a high rate of recurrence, and a potential for malignant transformation. Specific radiological signs such as hyperostosis at the origin of the IP and convoluted cerebriform patterns, as well as the typical endoscopic aspect, can lead to diagnosis and enable preoperative planning of surgical access and the extent of surgery. Endonasal endoscopic techniques are considered the gold standard and the introduction of extended surgical techniques such as the prelacrimal approach, frontal drillout, or orbital transposition facilitate complete subperiosteal resection with preservation of important physiological structures. There is a risk of synchronous and metachronous squamous cell carcinomas (IP-SCC). Research focuses on radiological criteria to differentiate benign IP from IP-SCC, genetic and epigenetic factors in the process of malignant transformation, and estimation of the risk of IP progressing to IP-SCC.

Clinical outcomes of sinonasal inverted papilloma: a retrospective analysis of 139 cases

OBJECTIVES

Sinonasal inverted papilloma has a high tendency for recurrence, local bone destruction and risk of malignant transformation. Therefore, complete resection of the tumour is required, and close follow up is essential. This article describes the clinical outcomes, recurrence rate and malignant transformation rate of sinonasal inverted papilloma.

METHODS

In this study, 139 patients diagnosed with sinonasal inverted papilloma in our hospital from December 2010 to May 2022 were retrospectively analysed. All patients underwent endoscopic surgery.

RESULTS

Sinonasal inverted papilloma occurred more often in males than in females. The mean age of patients with sinonasal inverted papilloma was 67.3 ± 5.7 years at diagnosis. The most prevalent site of origin was the maxillary sinus (50.4 per cent). The recurrence rate was 5.75 per cent, and the malignant transformation rate was 6.5 per cent.

CONCLUSION

All patients in this study underwent endoscopic surgery. Meticulous resection and regular long-term follow ups are crucial to reducing sinonasal inverted papilloma recurrence after surgery.

A miniature robotic steerable endoscope for maxillary sinus surgery called PliENT

In endoscopic maxillary sinus surgery, the maxillary sinus is accessed through the nasal cavity which constitutes a narrow and tortuous pathway. However, surgeons still use rigid endoscopes and rigid, straight or pre-bent instruments for this procedure. Resection of the uncinate process and creation of a medial antrostomy is warranted to access the pathology inside the maxillary sinus and depending on the location of the pathology (lateral, inferior or anterior wall), additional resection of healthy tissue and/or functional structures like the lacrimal duct and/or inferior turbinate is necessary to gain optimal access. In order to avoid this additional resection, a functional single-handed, steerable endoscope for endoscopic maxillary sinus surgery has been designed and built. This endoscope is, to our knowledge, the most slender active steerable endoscope ever reported for maxillary sinus surgery. The performance of the endoscope was validated by two surgeons on a cadaver. An increased field of view was found in comparison to currently used endoscopes. As a direct consequence, a reduced need for resection of healthy tissue was confirmed.

A Method Based on 3D Shape Analysis Towards the Design of Flexible Instruments for Endoscopic Maxillary Sinus Surgery

The emergence of steerable flexible instruments has widened the uptake of minimally invasive surgical techniques. In sinus surgery, such flexible instruments could enable the access to difficult-to-reach anatomical areas. However, design-oriented metrics, essential for the development of steerable flexible instruments for maxillary sinus surgery, are still lacking. This paper proposes a method to process measurements and provides the instrument designer with essential information to develop adapted flexible instruments for limited access surgery. This method was applied to maxillary sinus surgery and showed that an instrument with a diameter smaller than 2.4 mm can be used on more than 72.5% of the subjects' set. Based on the statistical analysis and provided that this flexible instrument can bend up to [Formula: see text] it is estimated that all areas within the maxillary sinus could be reached through a regular antrostomy without resorting to extra incision or tissue removal in 94.9% of the population set. The presented method was partially validated by conducting cadaver experiments.

Sinonasal inverted schneiderian papilloma presenting as a large intraoral lesion

Sinonasal inverted schneiderian papilloma (ISP) is a rare tumour, which almost exclusively arises from the mucosa lining, the nasal cavity and the paranasal sinuses. The tumour in its early stages presents as an asymptomatic mass, which may be discovered during routine examination. Large lesions usually measure a few millimetres to centimetres in size and show symptoms such as nasal blockade, recurrent sinusitis, postnasal drip, anosmia, epistaxis, facial pain and headache. Lesion presenting as a large oral mass is extremely rare and may cause diagnostic dilemma, resulting in misdiagnosis. This report describes a rare case of ISP presenting as large intraoral lesion, with wide area of facial skeletal involvement. Diagnosis and management of the pathology has also been highlighted.

Intranasal endoscopic prelacrimal recess approach for maxillary sinus inverted papilloma

Purpose

This study aims to determine the indications and effectiveness of transnasal endoscopic prelacrimal recess approach (PLRA) in patients with maxillary sinus inverted papilloma (IP).

Methods

We retrospectively analyzed 71 patients treated in our institution for maxillary sinus IP between August 2008 and April 2015. 20 patients underwent endoscopic surgery via PLRA. All the patients who had postoperative follow-up for 3 years were enrolled. Demographic data, surgical technique, location of IP attachment, intra- and postoperative complications, follow-up duration and recurrence were recorded.

Results

The outpatient follow-up period was 3–10 years after surgery. Recurrence of IP was seen in 6 (8.5%) of 71 patients, including 1 patient in the PLRA group. The recurrence rate was 5% in the PLRA group. Six of 71 patients experienced postoperative complications, but none was observed in the PLRA group.

Conclusion

Transnasal endoscopic PLRA is a minimally invasive, safe and effective method for maxillary sinus IP. The indication for PLRA is tumor pedicle located on the antero-inferior or infero-lateral wall or at multiple attachment sites of the maxillary sinus.

Comparison of Open versus Endoscopic Resection of Inverted Papilloma

Background

Lateral rhinotomy with medial maxillectomy has served as the standard for surgical management of inverted papilloma (IP) in the pre–endoscopic era; since the late 1980s, endoscopic techniques have emerged as the minimally invasive alternative. The objective of this study was twofold: (1) to compare operative parameters, complications, and recurrence rates and (2) predictive factors for recurrence for open versus endoscopic cases of IP resection.

Methods

Retrospective data analysis was performed on 68 patients with histopathologically confirmed IP treated at a tertiary care medical center from January 1983 to May 2005. Parameters for comparison included operative time (OT), estimated blood loss (EBL), length of hospital stay (HS), complications, and recurrence rate. Predictive factors for recurrence including open versus endoscopic cases, primary versus secondary IP, and tumor by Krouse stage were analyzed.

Results

The average age at time of presentation was 57.4 years with a male/female ratio of 2.2:1. Forty-nine patients underwent endoscopic resection, 13 patients underwent open resection, and 6 patients underwent limited open resection. Average OT and EBL were statistically similar for the three groups, whereas the average HS was statistically shorter (p = 0.002) for the endoscopic group. Biopsy-proven recurrence was noted in 11 (22%) endoscopic cases, 5 (39%) open cases, and 3 (50%) limited open cases. After reresection, all patients were free of disease. Mean follow-up was 16 months, 56 months, and 69 months for the endoscopic, open, and limited open groups, respectively. Analysis of predictive factors indicated that the surgical approach and primary versus secondary IP, regardless of approach, did not statistically impact recurrence rate. Chi-square analysis illustrated that patients with advanced-stage IP had a higher risk of recurrence (p = 0.002), regardless of surgical technique.

Conclusion

In this series, endoscopic resection of IP was associated with shorter HS and equivalent EBL and OT compared with the open groups. The overall recurrence rate was lower in the endoscopic group with acceptable morbidity compared with the open and limited open groups. Thus, the endoscopic approach may serve as a superior alternative to the open approaches for successful extirpation of IP.

Challenges in the Management of Sphenoid Inverted Papilloma

Background

Inverted papilloma (IP) arising in the sphenoid sinus is extremely rare. Management of sphenoid sinus IP is especially challenging because of the paucity of sinonasal symptoms on presentation and the inherent surgical risks associated with the anatomic location of the sphenoid sinus.

Methods

We performed a retrospective review of medical records of all patients with IP arising within the sphenoid sinus.

Results

A total of five patients were identified. All patients were managed with endoscopic resection. The most common presenting symptom was headache (three patients). The mean follow-up period was 37.6 months (range, 10–79 months). Two patients with erosive skull base lesions adjacent to the internal carotid artery were managed with a staged endoscopic resection. Only one patient developed a recurrence after 38 months and underwent revision endoscopic resection.

Conclusions

Endoscopic management of sphenoid IP allows maximal resection with minimal morbidity and facilitates endoscopic postoperative surveillance. Complete preoperative radiological assessment of tumor extent is essential. Preoperative medical therapy can help normalize inflamed mucosa and minimize intraoperative bleeding. For large erosive IP, surgical risks may be minimized by considering a staged resection and using computer-aided surgery.

Inverted Papilloma: New Classification and Guidelines for Endoscopic Surgery

Background

Surgery is the gold standard in the management of inverted papilloma (IP); however, the approach and extent of the surgical procedure are still controversial. Moreover, there is still no universal staging system of IP to plan surgery and/or evaluate results. We performed a retrospective study.

Methods

A new classification depending on the origin of the lesion was used to plan surgery in 70 cases of IP. Conservative transnasal endoscopic excision was performed in lesions arising from the nasal septum and lateral nasal wall (type I IP, 42 cases) and radical transnasal endoscopic medial maxillectomy was performed in lesions arising from the maxillary sinus (type II IP, 28 cases).

Results

Excluding cases with a follow-up of <2 years, follow-up for periods ranging between 2 and 13.3 years with a median of 78 months showed recurrence in a single case of type I (3.2%) and 2 cases of type II (9.5%).

Conclusion

The new classification system, based on the origin of IP, is a simple tool for grading IP. It can be used to define cases suitable for conservative excision or radical medial maxillectomy. Both could be performed transnasally and endoscopically.

Minimally Invasive Treatment of the Nasal Inverted Papilloma

Background

The purpose of this work is to evaluate our results in the treatment of the nasal inverted papillomas with an endoscopic approach using a retrospective case series.

Methods

Between 1993 and 2000 we treated 27 patients with nasal inverted papillomas. All patients underwent endoscopic nasal surgery under general anesthesia. None of the inverted papillomas extended outside of the paranasal sinuses. All tissue samples underwent polymerase chain reaction and hybridization in situ to detect genetic sequences of the human papilloma virus and Epstein Barr virus.

Results

The study population consisted of 16 men and 11 women with a median age of 52 years (range, 22–77 years). Ten patients (37%) had undergone a previous nasal surgery. The median follow-up was 5 years (range, 2–8 years). None of the patients presented with bilateral nasal involvement or a synchronous carcinoma. Seven patients underwent an additional surgical approach (two endoscopic approaches via a Caldwel-Luc approach, four sublabial approaches via a Caldwel-Luc approach, and one external ethmoidectomy). There were no surgical complications. Two patients (7%) had recurrent papilloma 4 and 6 years after surgery and again underwent endoscopic resection. The amplification both by polymerase chain reaction and hybridization in situ for human papilloma virus and Epstein Barr virus were negative in the specimens from all patients.

Conclusions

According to the literature and our own experience, we believe that the initial surgical management of primary and recurrent inverted papillomas limited to the nasal cavity and paranasal sinuses should be endoscopic sinus surgery.

Transection of Nasolacrimal Duct in Endoscopic Medial Maxillectomy: Implication on Epiphora

OBJECTIVE

Management of the nasolacrimal system is usually recommended during medial maxillectomy via external approach because of reported higher rates of postoperative epiphora. Association of the endoscopic medial maxillectomy (EMM) with epiphora, however, is not clearly stated. In this study, we attempted to evaluate whether patients develop epiphora after simple transection of the nasolacrimal duct during EMM.

PATIENTS AND METHODS

Medical records of 26 patients who underwent endoscopic tumor resection for inverted papilloma (IP) were retrospectively reviewed. Patients who underwent EMM with nasolacrimal canal transection were included and recalled for lacrimal system evaluation. Twelve patients were eligible for inclusion and fluorescein dye disappearance test (FDDT) was performed for each patient. Patient demographics, tumor data, surgical procedures, and follow-up time were recorded.

RESULTS

Of the 12 patients included in the study, 6 underwent canine fossa transantral approach concurrently with EMM. The mean duration of follow-up was 21.1 months (range, 6-84 months). Eight patients were graded as 0, whereas 4 patients were graded as 1 according to FDDT. All test results were interpreted as negative for epiphora. All patients were completely symptom free of epiphora.

CONCLUSIONS

Epiphora after EMM with nasolacrimal canal transection among patients with sinonasal tumors appears to be uncommon. Therefore, prophylactic concurrent management of nasolacrimal system including stenting, dacryocystorhinostomy (DCR), or postoperative lacrimal lavage are not mandatory for all patients.

Sinonasal inverted papilloma: From diagnosis to treatment

Inverted papilloma is a rare sinonasal tumor that mainly occurs in adults during the 5th decade. Three characteristics make this tumor very different from other sinonasal tumors: a relatively strong potential for local destruction, high rate of recurrence, and a risk of carcinomatous evolution. Etiology remains little understood, but an association with human papilloma virus has been reported in up to 40% of cases, raising the suspicions of implication in the pathogenesis of inverted papilloma. Treatment of choice is surgery, by endonasal endoscopic or external approach, depending on extension and tumoral characteristics. Follow-up is critical, to diagnose local relapse, which is often early but may also be late. The seriousness of this pathology lies in its association with carcinoma, which may be diagnosed at the outset or at recurrence during follow-up. It is important to diagnose recurrence to enable early treatment, especially in case of associated carcinoma or malignancy. A comprehensive review of the international literature was performed on PubMed and Embase, using the following search-terms: "sinonasal" [All Fields] AND ("papilloma, inverted" [MeSH Terms] OR ("papilloma" [All Fields] AND "inverted" [All Fields]) OR "inverted papilloma" [All Fields] OR ("inverted" [All Fields] AND "papilloma" [All Fields])). We reviewed all articles referring to sinonasal inverted papilloma published up to January 2015. The present article updates the state of knowledge regarding sinonasal inverted papilloma.

Evolution in the treatment of sinonasal inverted papilloma: pedicle-oriented endoscopic surgery

BACKGROUND

In the literature, the global endoscopic sinus surgery (ESS) success in the treatment of sinonasal inverted papilloma (IP) is 95%. This study was designed to describe a conservative endoscopic approach, based on research of the tumor's pedicle and treatment concentrated on its site of attachment, and to compare the results of this technique with the outcome of standard endoscopic treatment.

METHODS

Retrospective analysis of the patients treated in our institution for paranasal inverted papilloma (IP), between 2002 and 2011 with a minimum of 18 months follow-up was performed. Group A received a standard ESS including whole sinus demucosization (maxillary, ethmoid, frontal, or sphenoid sinus) and bony wall drilling. Group B patients instead underwent pedicle-oriented endoscopic surgery (POES); in this group, bony demucosization and drilling were selectively conducted around the site of pedicle attachment of the tumor.

RESULTS

The cohort included 73 patients (median age, 60.5 years; median follow-up, 58 months). Group A/group B consisted of 37/36 patients. IP persistence-recurrence for group A/group B was 0/1 cases. Oncological success for global endoscopic/group A/group B was 98.6% (72/73)/100% (37/37)/97.2% (35/36). We noticed a significant difference in surgical operative time and postoperative complication rate among the groups, in favor of POES technique.

CONCLUSION

Our data confirm the efficacy of the endonasal endoscopic treatment for sinonasal IP. Moreover, the even more conservative endoscopic treatment proposed (POES) seems to offer good control of the disease, shorter operating times, avoidance of unnecessary surgery with respect to uninvolved structures, and permits a follow-up aimed at the site of the pedicle attachment.

[Importance of tumor origin determination in selecting suitable surgery for treating inverted maxillary sinus papillomas]

We report the clinical outcomes for 28 subjects treated for inverted maxillary sinus papilloma between 2003 and 2007 involving preoperative imaging determination of tumor origin. Tumor origin often determines whether endoscopic endonasal or transmaxillary surgery is to be done. Endoscopic endonasal surgery was conducted for tumors originating in the posterior maxillary sinus in 17 patients and endoscopic transmaxillary surgery for tumors originating in the anterior maxillary sinus in 11 patients. Recurrence was seen in only 1 whose tumor originated in the superior sinus wall and had spread wide by to the lateral and posterior walls. Endoscopic endonasal resection was initially conducted and the recurrent tumor extracted by endoscopic transmaxillary surgery. The tool essential for successful tumor removal is complete surgical resection so as our study demonstrates, the preoperative determination of tumor origin is important in selecting of the most appropriate surgical procedure.

Preoperative magnetic resonance imaging for localization of the origin of maxillary sinus inverted papillomas

PURPOSE

It is essential to precisely localize the origin of an inverted papilloma within the maxillary sinus by preoperative imaging so that the lesion can be excised as thoroughly as possible. In the present study, we evaluated the use of preoperative magnetic resonance imaging (MRI) for pinpoint localization of the origin of inverted papillomas.

MATERIALS AND METHODS

The subjects were patients with an inverted papilloma of the maxillary sinus. Given the known histopathological features and pattern of growth of this tumor, we obtained preoperative MRIs in an attempt to localize its origin.

RESULTS

When different interpretation methods were applied to the preoperative MRIs, there was up to an 85.7% correlation with the surgical results for localization of the tumor origin.

CONCLUSIONS

We were able to demonstrate a high rate of agreement between diagnostic imaging and the actual surgical findings in identification of the origin of inverted papillomas.

[A study of surgical procedures for inverted papilloma in the nasal cavity and paranasal sinuses]

Inverted papilloma, although benign, recurs frequently and may become malignant, making definitive initial resection extremely important. We evaluated surgical procedures for recurrence and sites, with special reference to management of the orbital plate of the ethmoid and lacrimal bones, in 24 patients (32 cases) with inverted papilloma of the nasal cavity and paranasal sinuses undergoing surgical resection from 2000. Nine of the 32 showed recurrence, all around the ethmoid orbital plate. Up to 2002, recurrence was noted in 7 of 17 cases (41%), so we changed surgical selection criteria. Since 2003, we have conducted partial and combined excision of the orbital plate of the ethmoid and lacrimal bones (extended operation of the extranasal ethmoid and frontal sinuses) in cases in which tumors adhered to the orbital plate, noting recurrences in only 2 of 15 cases (13%). A number of reports advocate endoscopic sinus surgery to minimize invasiveness for inverted papilloma, but partial and combined excision of the orbital plate is indispensable, in progressive inverted papilloma cases to reduce recurrent.

Endoscopic treatment of sinonasal papilloma: a 12 year review

CONCLUSION

Endoscopic surgical management is recommended as a viable treatment option for sinonasal papilloma, with comparable results to those treated by an external approach. An external approach is still indicated in cases where the papilloma is not accessible endoscopically, or where there is extrasinus invasion. Long-term follow-up is essential for recurrence detection.

OBJECTIVES

The goal of this study was to highlight our experience with endoscopic surgery for the management of sinonasal papilloma.

PATIENTS AND METHODS

A retrospective study of all patients who underwent endoscopic surgery for the treatment of sinonasal papilloma over a 12 year period at the Gui de Chauliac Hospital, Montpellier, France.

RESULTS

A total of 55 patients were included in this study; 32 patients (58%) were treated exclusively by an endoscopic approach and 23 (42%) were treated by a combined approach. Minimal follow-up was 3 years. The overall recurrence rate was 7%. All recurrences occurred at the initial site and the average delay between surgery and recurrence was 30 months (14 months to 4 years).

New staging system for sinonasal inverted papilloma in the endoscopic era

OBJECTIVES

Advanced endoscopic techniques have emerged as the preferred treatment modality for sinonasal inverted papilloma (IP); however, a staging system that provides prognostic information has not yet been developed. This study aims to develop a clinically relevant staging system for IP managed with the endoscopic approach as the primary surgical modality.

DESIGN

A systematic review of the English-language literature (1985-2006) and a single institution's experience.

METHODS

From the literature, 445 patients with IP treated by endoscopic resection were identified in 14 reports. Only patients with known IP sites and outcomes were included.

RESULTS

Patients were categorized into three groups on the basis of recurrence rates (RR): group A (IP confined to the nasal cavity, ethmoid sinus, and medial maxillary sinus), 3.0% RR (n = 234); group B (IP with lateral maxillary sinus, sphenoid sinus, or frontal sinus involvement), 19.8% RR (n = 177); and group C (IP with extrasinus extension), 35.3% RR (n = 34). Pearson's chi-square test showed statistically significant differences for all pair-wise comparisons between groups (P < .05). Mean follow-up was 39.8 months.

CONCLUSIONS

This new staging system for IP provides information about prognosis (as operationally defined by RR) for IP managed by advanced endoscopic techniques. In contrast, other staging systems for IP reflect surgeon's judgment rather than outcomes data. This new classification for IP provides important objective data for preoperative planning and patient counseling.

Endoscopic sinus surgery: where we are-and where we're going

PURPOSE OF REVIEW

Improved understanding of sinonasal mucociliary function as well as technological advancements have led to a renaissance in the management of sinonasal disease. The current techniques, and adjunctive intraoperative technologies, have allowed for a more precise and safer surgical dissection, extending this surgical application to include the routine endoscopic management of skull base lesions and sinonasal malignancies. The anatomic boundaries of the nasal endoscope continue to be redefined. This paper will review the recent advances in the field of surgical rhinology as well as discuss directions for the future.

RECENT FINDINGS

Advancements in imaging technology including image acquisition, three-dimensional reconstruction, stereotactic navigation, and CT-MRI fusion have aided in more thorough preoperative planning, enabling safer and more precise endoscopic surgical dissection. Refinement of endonasal powered instrumentation including microdebriders and high-speed suction irrigation drills have minimized trauma to normal tissues and accelerated postoperative healing. Increased experience with the endoscope has broadened the endoscopic ventral skull base exposure from the odontoid process to foramen ovale to the olfactory bulb.

SUMMARY

Endoscopic sinus surgery is no longer exclusively for the management of chronic rhinosinusitis and nasal polyposis. Sinonasal malignancies, as well as anterior skull base lesions have become part of the rhinologist's responsibility. Furthermore, selective lesions managed through traditional craniotomies may now be accessed via trans-sinonasal transcranial endoscopic routes.

Different endoscopic surgical strategies in the management of inverted papilloma of the sinonasal tract: experience with 47 patients

OBJECTIVE

To demonstrate the potentials and limitations of three different endoscopic procedures employed for treatment of inverted papilloma (IP) of the sinonasal tract.

STUDY DESIGN

Retrospective analysis of a cohort of patients treated at two University hospitals.

METHODS

From January 1992 to June 2000, 47 patients with IP underwent endoscopic resection. Preoperative workup included multiple biopsies of the lesion and imaging evaluation by computed tomography or magnetic resonance imaging. Massive skull base erosion, intradural or intraorbital extension, extensive involvement of the frontal sinus, abundant scar tissue caused by previous surgery, or the concomitant presence of squamous cell carcinoma were considered absolute contraindications for a purely endoscopic approach. Three types of resection were used: ethmoidectomy with wide antrostomy and sphenoidotomy (type 1) for IPs confined to the middle meatus, medial maxillectomy with ethmoidectomy and sphenoidotomy (type 2) for IPs partially invading the maxillary sinus, and a Sturmann-Canfield operation (type 3) for IPs involving the mucosa of the alveolar recess or of the anterolateral corner of the maxillary sinus. All patients were followed by periodic endoscopic evaluations.

RESULTS

Type 1, 2, and 3 resections were performed in 26, 15, and 6 patients, respectively. No recurrences were observed after a mean follow-up of 55 (range 30-132) months. One patient, who underwent a type 2 resection, developed a stenosis of the lacrimal pathways requiring endoscopic dacryocystorhinostomy.

CONCLUSIONS

Our experience confirms that endoscopic surgery is an effective and safe method of treatment for most IPs. The availability of different endoscopic techniques allows the entity of the dissection to be modulated in relation to the extent of disease. Strict application of selection criteria, meticulous use of subperiosteal dissection in the involved areas, and regular follow-up evaluation are key elements for success.

An evolution in the management of sinonasal inverting papilloma

OBJECTIVE

We reviewed the 15-year experience of our institution (Medical College of Wisconsin, Milwaukee, WI) in managing sinonasal inverting papilloma, examining trends in diagnosis and treatment.

STUDY DESIGN

Retrospective.

METHODS

Thirty-seven patients with inverting papilloma were treated from 1986 to 1999. Demographic data, clinical presentations, pathological findings, surgical approaches and procedures, and recurrence rates were collected retrospectively. Each lesion was categorized into one of four groups based on computed tomography scans and endoscopic findings. This categorization was developed to compare various surgical approaches for tumors in each group.

RESULTS

Thirty-one patients had complete information for inclusion in our study. Nineteen patients were treated endoscopically with an average follow-up of 50 months. Eight patients were in group I, five were in group II, six were in group III, and no patients were in group IV. The recurrence rate for the endoscopic group was 10%. Twelve patients underwent lateral rhinotomy or sublabial degloving approach with an average follow-up of 58 months. Five patients were in group I, three patients were in group II, 1 patient was in group III, and three patients were in group IV. The recurrence rate for the external group was 8%. Difference in recurrence rates (P =.85) was not observed between the endoscopic and external approach groups. Regardless of approach, patients who had primary resection had a recurrence of 0%, whereas those with secondary resection had a recurrence of 17% (P =.10).

CONCLUSIONS

Technological advancements have led to a trend of detecting sinonasal inverting papilloma before extension beyond the sinonasal region. Difference in recurrence rates was not observed between the endoscopic and the external approach groups. Recurrence rates are lower for primary resection versus secondary resection, regardless of surgical approach.

Factors in the pathogenesis of tumors of the sphenoid and maxillary sinuses: a comparative study

OBJECTIVES/HYPOTHESIS

To explain the processes that lead to the development of tumors in the maxillary and sphenoid sinuses.

STUDY DESIGN

A 32-year review of the world's literature on neoplasms of these two sinuses and a randomized case-controlled study comparing the normal mucosal architecture of the maxillary to the sphenoid sinus.

METHODS

Analysis of a 32-year world literature review reporting series of cases of maxillary and sphenoid sinus tumors. Tumors were classified by histological type and separated into subgroups if an individual incidence rate was reported. Histomorphometry of normal maxillary and sphenoid sinus mucosa was performed in 14 randomly selected patients (10 sphenoid and 4 maxillary specimens). Specimens were fixed in 10% formalin, embedded in paraffin, and stained with periodic acid-Schiff (PAS) and hematoxylin. Histomorphometric analysis was performed with a Zeiss Axioscope light microscope (Carl Zeiss Inc., Thornwood, NY) mounted with a Hamamatsu (Hamamatsu Photonics, Tokyo, Japan) color-chilled 3 charge coupled device digital camera. The images were captured on a 17-inch Sony (Sony Corp., Tokyo, Japan) multiscan monitor and analyzed with a Samba 4000 Image Analysis Program (Samba Corp., Los Angeles, CA). Five random areas were selected from strips of epithelium removed from each sinus, and goblet and basal cell measurements were made at magnifications x 100 and x 400.

RESULTS

The literature review revealed that the number and variety of tumors in the maxillary sinus are much greater than those in the sphenoid. The incidence of metastatic lesions to each sinus is approximately equal. No recognized pattern of spread from any particular organ system could be determined. On histomorphometric study there were no statistically significant differences between the sinuses in the concentration of goblet cells, basal cells, or seromucinous glands.

CONCLUSIONS

Factors involved in the pathogenesis of tumors of the maxillary and sphenoid sinuses include differences in nasal physiology, embryology, morphology, and topography. There are no significant histological differences in the epithelium and submucous glands between the two sinuses to explain the dissimilar formation of neoplasms.

The endoscopic management of sinonasal inverted papillomas

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 18 patients with inverted papillomas treated endoscopically at the Singapore General Hospital since 1993. The presentation, sites of involvement and diagnostic imaging are presented. All the patients had a minimum follow-up of 18 months with a mean of 32.8 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 papillomas.

Midfacial degloving approach facilitated by endoscope to the sinonasal malignancy

Midfacial degloving is known to provide excellent exposure of the central compartment of the anterior and middle cranial fossae without facial incisions. In this study, an endoscope was adapted for midfacial degloving technique in the medial maxillectomy with ethmoidectomy in five patients with sinonasal malignancy. Meticulous and safe manipulation in the medial and inferior aspect of the orbit, sphenoid sinus and olfactory fossa can be obtained by endoscopic management without serious complications. This procedure, employing an endoscope, offers accurate and safe resection of selected cases with the sinonasal malignancy.

Inverted papilloma - an analysis of 30 cases

Clinical, radiological and surgical details of 30 patients of inverted papilloma treated between the years 1990-1995 were analysed. Inverted papilloma is a benign but locally aggressive tumour. Unilateral nasal obstruction with or without bleeding was the commonest presenting feature. More than half of the patients gave history of previous surgery. CT scan is a good modality to know the exact extent of the lesion and plan surgery. Radical surgery was done in all patients. We had recurrence in 1 patient (3.3%) and two patients had carcinomatous change (6.6%). The results are presented with brief review of literature.

Transnasal endoscopic surgery in juvenile nasopharyngeal angiofibroma

A case of angiofibroma limited to the right posterior nasal cavity, nasopharynx and pterygopalatine fossa was operated upon transnasally under endoscopic control. The tumour was completely excised without complications. Endoscopic follow-up for the next two years and contrast computed tomography (CT) excluded any residual tumour or recurrence. The advantages, limitations and possible complications of this approach are discussed. It seems that in limited lesions of angiofibroma, the option of a transnasal endoscopic approach could be cautiously considered by experienced surgeons.

Transnasal endoscopic medial maxillectomy in inverted papilloma

This study comprised 17 cases of inverted papilloma, which were divided into two groups. The first group included 8 cases that lacked maxillary sinus involvement. They were subjected to intranasal endoscopic resection with safety margin. The second group included 9 cases involving the maxillary sinus with or without nasal extension. They were subjected to transnasal endoscopic medial maxillectomy. Follow-up for an average of 43 months in group 1 and 28 months in group 2 (excluding the 5 cases with less than 2 years of follow-up) showed no recurrence. The author realized that inverted papilloma can be divided into two groups from the anatomic and behavioral points of view and accordingly should be managed differently. For those lesions without involvement of the maxillary sinus, intranasal endoscopic resection is effective; for those lesions with maxillary sinus involvement, transnasal medial maxillectomy, which could be performed safely under endoscopic control, is recommended.

Inverted papilloma: a report of 112 cases

Inverted papilloma is a benign sinonasal tumor which is locally aggressive and has a significant malignant potential. This report updates the experience of the two senior authors, who have treated 112 patients with inverted papilloma at the Mount Sinai Medical Center over a 20-year period. As clinical examination often underestimates tumor extent, preoperative radiographic assessment is of paramount importance in guiding selection of surgical therapy. Complete en bloc excision via lateral rhinotomy and medial maxillectomy was the method of treatment in the majority of patients (84%). In selected patients with limited disease, or in patients who refused en bloc excision, conservative therapy employing intranasal or transantral ethmoidectomy was performed. The recurrence rates for the two groups were 14% and 20%, respectively. Recurrent disease developed throughout the paranasal sinuses, with the maxillary antrum and ethmoid labyrinth constituting the major sites. In two patients presenting with anterior skull base erosion, craniofacial resection was undertaken to eradicate disease. The latter cases underscore the aggressive nature of the tumor if left untreated. The overall rate of squamous carcinoma in this series was 5%. Given the predilection for local recurrence, multicentricity, and the possibility of malignancy, the authors continue to recommend lateral rhinotomy and medial maxillectomy as the standard therapy for the majority of cases. Management principles as well as a review of the literature are discussed.

Sinonasal papillomas: a report of 82 cases in Copenhagen County, including a longitudinal epidemiological and clinical study

The present epidemiological and clinical study comprises 82 patients with sinonasal papillomas diagnosed from 1975 to 1993. Histology showed 58 cases of inverted papillomas including 5 cases of associated carcinoma, 19 cases of exophytic papilloma, and 5 cases of columnar cell papilloma. The incidence of sinonasal papillomas in Copenhagen County was 0.74 per 100,000 inhabitants per year. The inverted and columnar cell papillomas were typically located in the middle meatus with a varying degree of involvement of the adjacent sinuses. The exophytic papillomas were predominantly located multicentrically on the nasal septum. Good results of treatment, especially with regard to inverted papillomas, were not correlated to the aggressiveness of surgery. A lateral rhinotomy with medial maxillectomy was performed as primary surgery in 28 patients. In 50% of these patients there were recurrences. The preliminary results of endonasal endoscopic surgery revealed a high success rate, i.e., no recurrences in 5 cases so far. The septal papillomas were typically resected by a simple endonasal procedure. There were recurrences in 66% of these cases. The midfacial degloving procedure may be advocated instead of or as a supplement to the lateral rhinotomy if the tumor cannot be visualized sufficiently by endoscopy. Smoking may dispose to sinonasal papillomas.

Endoscopic surgical treatment of nasal and paranasal sinus inverted papilloma

Most of the papers written in the past regarding surgical treatment of nasal and sinus inverted papilloma recommend aggressive surgical treatment-usually a medical maxillectomy with external or transantral ethmoidectomy. However, since the introduction of endoscopic diagnostic and surgical techniques for the treatment of nasal and sinus disease, the treatment of inverted papilloma requires review. In Europe, Waitz and Wigand1 and Draf* routinely treat inverted papilloma endoscopically, reserving extensive surgery for papilloma involving the maxillary sinus or for recurrent disease. Fifteen cases of inverted papilloma of the nose and paranasal sinuses are discussed in this article. Ten cases represent inverted papilloma treated primarily with endoscopic sinus surgery; five were endoscopically treated for secondary or recurrent disease. All primarily treated patients had disease limited to the nose, nasal cavity, ethmoid, sphenoid, or medial wall of the maxillary sinus. The one patient in whom a recurrence in the maxillary sinus developed laterally underwent a medial maxillectomy for control. All patients treated endoscopically have had their disease followed for a minimum of 1 year, with an average of 3 years. Four patients in this study had traditional surgery involving medial maxillectomy and ethmoidectomy for an initial diagnosis of inverted papilloma. These patients manifested recurrent papilloma into the sphenoid sinus bilaterally in one case, frontal sinus in another, and the maxillary sinuses in two other cases, and all patients have papilloma controlled endoscopically. Endoscopic nasal and sinus diagnosis and surgery is appropriate for diagnosis, followup, and treatment of both limited and recurrent inverted papilloma, provided all patients are made aware of the possibility of recurrent and need for more extensive surgery as a result.(ABSTRACT TRUNCATED AT 250 WORDS)

Inverting papilloma of the head and neck: the UCLA update

Inverting papilloma of the nose and paranasal sinuses is a benign disease with malignant potential. This disease is characterized by multiple recurrences, especially after minimal operative therapy. Controversy exists over the most appropriate treatment for this rare tumor. This review presents an update of the UCLA experience with inverting papilloma over the past four decades along with a review of the literature. A retrospective study of 61 patients seen at the UCLA Medical Center was conducted. The mean age at presentation was 63 years, with a male-to-female ratio of 2:1. The most common symptom at presentation was nasal obstruction (71%), followed by epistaxis (27%). Seventeen percent of the patients in this series either had concurrent squamous cell carcinoma of the nose or paranasal sinuses, or it developed. Patients treated with a lateral rhinotomy and medial maxillectomy had a recurrence rate of 30 percent. Those treated with a less aggressive operation had a recurrence rate of 71 percent. Despite a trend for a more conservative sinus operation in recent literature, we continue to advocate a lateral rhinotomy and medial maxillectomy as the treatment of choice for inverting papilloma of the head and neck.