Tailored endoscopic surgery for the treatment of sinonasal inverted papilloma

Sinonasal Inverted Papilloma and Squamous Cell Carcinoma: Contemporary Management and Patient Outcomes

Simple Summary

Inverted papillomas are benign sinonasal tumors that can recur or become cancerous. The mainstay of treatment is surgical resection. We summarize the biology of inverted papillomas and review surgical outcomes in an effort to define the current treatment strategy.

Abstract

Inverted papillomas (IP) are the most common sinonasal tumor with a tendency for recurrence, potential attachment to the orbit and skull base, and risk of malignant degeneration into squamous cell carcinoma (SCC). While the overall rate of recurrence has decreased with the widespread adoption of high-definition endoscopic optics and advanced surgical tools, there remain challenges in managing tumors that are multiply recurrent or involve vital neurovascular structures. Here, we review the state-of-the-art diagnostic tools for IP and IP-degenerated SCC, contemporary surgical management, and propose a surveillance protocol.

Endoscopic Modified Danker's Approach for Management of Sinonasal Inverted Papilloma: Our Experience

Sinonasal inverted papilloma (SNIP), Inverting papilloma, Schneiderian papilloma etc. It is a benign tumor with incidence nearly 70% of all sinonasal papilloma and 0.5-4.0% of all sinonasal neoplasms. The most common site of origin is lateral nasal wall and common presenting symptom is nasal obstruction followed by epistaxis. On histopathology examination, it is characterized by invagination of neoplastic epithelium into underlying stroma. With the advent of technology, the endoscopic modified dankers approach became the surgical approach of choice. The present study was undertaken to study its role in management of SNIP with reference to rate of recurrence and malignancy. An observational study was conducted in a tertiary health center in which 40 biopsy proven cases of SNIP, operated by endoscopic assisted modified Danker's approach between September 2008 and January 2019 with minimum follow-up period of 6 months were analyzed. Male:Female ratio was 2.33:1. The most common symptom was nasal obstruction (97.5%) followed by rhinorrhoea (87.5%). Using various imaging and diagnostic measures, lateral nasal wall was found to be the most common site of origin. Out of total 40 cases, 9 (27.5%) patients had recurrence, of these, 6 were benign and remaining 3 had malignancy as confirmed by biopsy. Most of the cases of SNIP can be managed endoscopically, although extensive lesions or the lesions with malignant transformation, external approach may be needed so expertise in both endoscopic and conventional techniques is needed. Although most of the recurrences occurred in first 2 years, but life time follow-up is advisable.

Can Computed Tomography Findings Predict the Recurrence of Sinonasal Inverted Papilloma?

OBJECTIVE

To evaluate the correlation between the ability to predict the attachment site of sinonasal inverted papilloma by computed tomography and the long-term surgical outcome.

STUDY DESIGN

Retrospective cohort study.

SETTING

Five tertiary medical centers.

METHODS

Study patients underwent attachment-oriented resection of inverted papilloma. The primary outcome was tumor recurrence.

RESULTS

Among 195 patients eligible for the study, focal hyperostosis was recognized on computed tomography in 65% (n = 127), in 71% of primary cases (n = 101), and in 50% of revision procedures (n = 26). There was a trend for a higher incidence of squamous cell carcinoma among the patients without detectable hyperostosis (P = .051). Location of hyperostosis coincided with the actual tumor attachment site in 114 patients (90%). Discordance between these parameters did not differ significantly (P = .463) between 11 primary and 2 revision cases. The overall rate of recurrence was 9.7% (n = 19), with a mean time to recurrence of 20 months (range, 7-96 months). The rate of recurrence did not correlate with any of the following: tumor stage, surgical approach, presence of squamous cell carcinoma, whether the surgery was primary or revision, and the presence or location of focal hyperostosis on computed tomography. Inverted papilloma recurred significantly more often (38.5%) when the intraoperative findings of the tumor attachment site did not match the location of hyperostosis observed on computed tomography (odds ratio, 6.5; 95% CI, 1.78-23.66).

CONCLUSION

Detectability of focal hyperostosis on preoperative computed tomography does not affect the long-term outcome of inverted papilloma resection.

Surgery of Inverted Papilloma of the Maxillary Sinus via Translacrimal Approach-Long-Term Outcome and Literature Review

There are several differential diagnoses of unilateral sinus disease. One of these is inverted papilloma (IP) of the maxillary sinus, which is a common benign tumor with a substantial rate of malignant transformation. In general, endoscopic endonasal techniques for addressing the tumor are favored nowadays instead of classical external approaches. The aim of this retrospective study was to investigate the long-term outcome of inverted papilloma treated endoscopically via the prelacrimal approach. We reviewed 17 patients with primary or recurrent IP of the maxillary sinus that were treated via the prelacrimal endoscopic endonasal technique. After a median follow-up period of 45.9 months (3.8 years), none of the 17 included patients showed signs of recurrent disease and no serious complications were reported. Hypoesthesia of the incisors was reported by four patients and was resolved with time in one. All of the maxillary sinuses could be fully visualized with the flexible endoscope. IP is an important differential diagnosis in the clinical finding of unilateral nasal polypoid lesions. The prelacrimal approach is an effective and safe method in the treatment of IP with limited patient morbidity.

[Inverted papilloma: a study of 13 cases in the Oto-Rhino-Laryngology at the National University Hospital of Fann]

Introduction

Inverted Papilloma (IP) is a rare benign tumour of the nose and paranasal sinuses histologically characterized by invagination of the outer layer of the epithelium in the underlying chorion. Its most distinctive feature is a strong local aggressiveness, a tendency to recur and an unpredictable risk of association with epidermoid carcinoma. The purpose of this study was to report the epidemiological, clinical, paraclinical data as well as to assess the outcomes of endoscopic endonasal surgery.

Methods

We conducted a retrospective study on a series of 13 patients whose data were collected in the Oto-Rhino-Laryngology at the National University Hospital Center of Fann, from 1^st January 2012 to 31^st December 2017. All patients followed up for inverted papilloma confirmed by anathomopathological examination were included in the study.

Results

The average age of patients was 44 years, the sex-ratio was 2.25. All patients had nasal obstruction; 53% of them had rhinorrhea followed by epistaxis in 30% of cases. Right-sided symptoms were reported by 69% of patients, left-sided symptoms by 23% and bilateral symptoms by 7% of patients. Anterior rhinoscopy showed endonasal mass in all patients. All patients underwent CT scan; the MRI was performed in a single patient. Endoscopic resection of IP was performed in 10 patients (76.9%) while external approach was used in 23% of cases. Surgery helped to clarify where the tumor had originated: in 46% of cases in the maxillary sinus, in 15% in the lower nasal turbinate, in 15% in the mid-turbinate, in 7% in the ethmoid bulla and in 7% in the lateral wall of the nasal fossa. One patient had recurrence after an average period of 26 months. Malignant transformation to squamous cell carcinoma occurred in one patient.

Conclusion

Inverted papilloma is a very aggressive tumor. CT scan is essential to highlight its spread, especially to bone. The advent of endoscopic surgery has revolutionised treatment, providing excellent results. But, there is nevertheless a risk of recurrence after surgery which motivates an indication for long term monitoring.

Preoperative Staging and Surgical Approaches for Sinonasal Inverted Papilloma

Objectives:

We sought to determine the value of preoperative staging by magnetic resonance imaging (MRI) assessment in the surgical management of sinonasal inverted papillomas (IPs).

Methods:

Preoperative MRI staging was used to assess 22 patients with IPs. In addition to the Krouse staging system, T3 cases were categorized as subgroup T3-B if tumors extended into the frontal sinus or the supraorbital recess; otherwise, they were categorized as T3-A. Standard endoscopic sinus surgery (ESS) was the first choice for T1 and T2 cases. Endoscopic approaches, including ESS combined with endoscope-assisted transantral approach and endoscopic medial maxillectomy, were considered in T3-A cases, and external approaches were considered in T3-B cases. Patients were followed for a minimum of 1 year after surgery.

Results:

Preoperative MRI staging and postoperative staging were coincident in 21 of the 22 patients (95%). All 8 T2 cases were treated by an endoscopic approach. Of 10 T3-A cases, 9 (90%) were treated by an endoscopic approach and 1 (residual case) was treated by an external approach. All 3 of the T3-B cases underwent an external approach. One T4 case with malignant transformation underwent an external approach followed by radiotherapy. After a median follow-up period of 22 months, none of the 22 patients had had a recurrence. No major complications were observed after endoscopic approaches, but epiphora or hemorrhage requiring transfusion occurred in 3 of the 5 patients (60%) who underwent external approaches.

Conclusions:

Preoperative staging of IP by MRI is useful for selecting cases that can be managed by endoscopic approaches, resulting in lower rates of tumor recurrence and morbidity.

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.

Comprehensive review on endonasal endoscopic sinus surgery

Endonasal endoscopic sinus surgery is the standard procedure for surgery of most paranasal sinus diseases. Appropriate frame conditions provided, the respective procedures are safe and successful. These prerequisites encompass appropriate technical equipment, anatomical oriented surgical technique, proper patient selection, and individually adapted extent of surgery. The range of endonasal sinus operations has dramatically increased during the last 20 years and reaches from partial uncinectomy to pansinus surgery with extended surgery of the frontal (Draf type III), maxillary (grade 3-4, medial maxillectomy, prelacrimal approach) and sphenoid sinus. In addition there are operations outside and beyond the paranasal sinuses. The development of surgical technique is still constantly evolving. This article gives a comprehensive review on the most recent state of the art in endoscopic sinus surgery according to the literature with the following aspects: principles and fundamentals, surgical techniques, indications, outcome, postoperative care, nasal packing and stents, technical equipment.

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.

Skull base inverted papilloma: a comprehensive review

Skull base inverted papilloma (IP) is an unusual entity for many neurosurgeons. IP is renowned for its high rate of recurrence, its ability to cause local destruction, and its association with malignancy. This paper is a comprehensive review of the reports, studies, and reviews published in the current biomedical literature from 1947 to September 2010 and synthesize this information to focus on its potential invasion to the base of the skull and possible intradural extension. The objective is to familiarize the clinician with the different aspects of this unusual disease. The role of modern diagnostic tools in medical imaging in order to assess clearly the limits of the tumors and to enhance the efficiency and the safety in the choice of a surgical approach is pointed out. The treatment guidelines for IP have undergone a complex evolution that continues today. Radical excision of the tumour is technically difficult and often incomplete. Successful management of IP requires resection of the affected mucosa which could be achieved with open surgery, endoscopic, or combined approach. Radio and chemotherapy were used for certain indications. More optimally research would be a multicenter randomized trials with large size cohorts.

Inverted papillomas and benign nonneoplastic lesions of the nasal cavity

BACKGROUND

Benign lesions of the nasal cavity represent a diverse group of pathologies. Furthermore, each of these disorders may present differently in any given patient as pain and discomfort, epistaxis, headaches, vision changes, or nasal obstruction. Although these nasal masses are benign, many of them have a significant capacity for local tissue destruction and symptomatology secondary to this destruction. Advances in office-based endoscopic nasendoscopy have equipped the otolaryngologist with a safe, inexpensive, and rapid means of directly visualizing lesions within the nasal cavity and the initiation of appropriate treatment.

METHODS

The purpose of this study is to review the diagnosis, management, and controversies of many of the most common benign lesions of the nasal cavity encountered by the primary care physician or otolaryngologist.

RESULTS

This includes discussion of inverted papilloma (IP), juvenile angiofibroma, squamous papilloma, pyogenic granuloma, hereditary hemorrhagic telangiectasia, schwannoma, benign fibro-osseous lesions, and other benign lesions of the nasal cavity, with particular emphasis on IP and juvenile angiofibroma.

CONCLUSION

A diverse array of benign lesions occur within the nasal cavity and paranasal cavities. Despite their inability to metastasize, many of these lesions have significant capability for local tissue destruction and recurrence.

New anatomic division of the orbital and sinus regions: guidance for nasal endoscopic resection of space-occupying lesions

The significance of anatomic divisions of the orbital and sinus regions in providing guidance for nasal endoscopic resection of benign space-occupying lesions was discussed. This retrospective study included 177 cases with benign space-occupying lesions of the orbital and sinus resected between 2001 and 2009. Locations of lesions were assigned to 3 anatomic categories. The 63 cases of benign lesions of the sphenoethmoid-orbital region underwent nasal endoscopic resection. In the 31 cases of benign lesions in the frontoethmoid-orbital region, surgical approaches included nasal endoscopy (n = 15) and combined endoscopic and external (n = 9) and external approaches (n = 4). In 87 cases of lesions in the axillae-ethmoid-orbital region, surgical approaches included nasal endoscopy (n = 67), combined approaches (n = 15), and external approaches (n = 5). Endoscopy facilitated the resection of both 63 cases of benign lesions of sphenoethmoid-orbital region, and 82 cases of benign lesions of the frontoethmoid-orbital and maxillae-ethmoid-orbital regions with good prognosis. However, the procedure was relatively more difficult for the other 32 cases of benign lesions of the frontoethmoid-orbital or maxillae-ethmoid-orbital regions. The feasibility of nasal endoscopic resection differs markedly according to anatomic location. Preoperative classification of the site of the lesions will help to define the indications for nasal endoscopic resection of the orbital and sinus regions.

Radiological localization of Schneiderian papilloma

BACKGROUND

It has been recently reported that the site of attachment of Schneiderian papillomas can be predicted with high accuracy on preoperative computed tomography (CT) scans using bony osteitic changes as an indicator. The objective of this study is to evaluate, in a blinded fashion, the reliability of the osteitis sign at predicting the site of attachment of Schneiderian papillomas.

METHODS

A retrospective cohort study of patients who underwent endoscopic surgical resection for inverted papilloma (IP) or cylindrical papilloma between September 2002 and September 2009 in a tertiary care rhinology center was carried out. The preoperative sinus CT scans were collected and reviewed by a fellowship-trained and experienced head and neck radiologist who was blinded to the intraoperative findings. The radiologist attempted to identify and grade bony osteitic changes in the sinuses. The radiological findings were then correlated with the actual site of attachment reported by the surgeon in the operative report.

RESULTS

A total of 34 patients were evaluated. Six (18%) patients had a single site of osteitis and 28 (82%) were found to have multiple sites of osteitis. The sensitivity and specificity of the radiological prediction based on the degree of osteitis was found to be 74% (46.5-90.3%) and 0% (0-17%), respectively. The predictive value of the radiological localization was 41%.

CONCLUSION

Osteitic changes are very common nonspecific findings on CT scans of patients with Schneiderian papillomas. Their presence as well as the degree of osteitis did not allow preoperative localization of tumor attachment.

Limitations and complications of endoscopic surgery for treatment for sinonasal inverted papilloma: a reassessment after 212 cases

BACKGROUND

The purpose of this study was to define the optimal surgical strategy for sinonasal inverted papilloma in relation to the site of origin and tumor extent.

METHODS

Retrospective analysis of patients affected by inverted papilloma treated by purely endoscopic or combined approaches at the Department of Otorhinolaryngology of the University of Brescia and Pavia-Varese from November 1991 to December 2007.

RESULTS

Two hundred twelve patients were considered eligible for this study. An exclusive endoscopic approach was performed in 198 patients (93.4%); the remaining 14 patients (6.6%) underwent an endoscopic approach combined with an osteoplastic frontal flap. Follow-up ranged from 24 to 192 months (mean, 53.8 months). A single recurrence was observed in 12 patients (5.7%). Twenty complications (9.4%) were observed.

CONCLUSION

Endoscopic surgery is the first choice in the treatment of inverted papilloma; only lesions with extensive involvement of frontal sinus and/or supraorbital cell may require a combined approach. A minimum follow-up of 5 years is recommended.

Inverted papilloma of the sphenoid sinus: clinical presentation, management, and systematic review of the literature

OBJECTIVES

Inverted papilloma (IP) of the sphenoid sinus is a rare neoplasm with a nonspecific and insidious presentation that is further complicated by difficult access for assessment and follow-up. In conjunction with a systematic review of the English literature, we review our experience with IP of the sphenoid sinus to better delineate the clinical presentation, prevalence, management, and recurrence of this challenging lesion.

METHODS

A systematic search strategy was developed to assess and summarize the best available evidence on sphenoid IP. A retrospective chart review of the 5-year database of one tertiary care Otolaryngology-Head and Neck Surgery practice was performed; all patients with histologically confirmed IP of the nasal cavity or paranasal sinuses were included.

RESULTS

Seventy-one patients (49 males, 22 females; mean age, 57.2 years) treated between June 2003 and January 2009 were included. Nine patients were diagnosed with IP originating in the sphenoid sinus. Two of these patients were asymptomatic, and in the remaining seven patients the most common presentation was headache (42.9%), followed by visual disturbances, hearing loss, and nasal obstruction (28.6% each). Review of the literature confirms our finding that the most common presenting symptom is headache (45.0%), followed by nasal obstruction (30.0%) and epistaxis (22.5%).

CONCLUSIONS

This is the largest reported series of sphenoid sinus IP in the English literature. We have demonstrated a predominance of neurological and visual symptoms in symptomatic patients with sphenoid IP, and suggest that these may be early manifestations of sphenoid IP, before the more common sinonasal symptoms develop secondary to extension into the nasal cavity and paranasal sinuses.

Treatment results of sinonasal inverted papilloma: an 18-year study

BACKGROUND

This article reviews our treatment results of sinonasal inverted papilloma (SNIP) over the past 18 years. A retrospective observational study was performed.

METHODS

Fifty-six patients with SNIP seen between 1990 and 2008 with follow-up of >2 years were retrospectively analyzed.

RESULTS

Forty patients (71%) had primary endoscopic resection and 16 patients (29%) had endoscopic-assisted external approaches. Ten patients (18%) had small nasoethmoid residual disease resectable under local anesthesia in the outpatient department. Eight patients (14%) had recurrences requiring revision under general anesthesia, most of which were maxillary and frontal disease requiring additional external approaches. Comparing patients with and without a history of previous surgery (36% versus 64% of all patients), the former had a higher chance of requiring external approaches during the primary resection (45% versus 29%), a higher recurrence rate (45% versus 25%), and a higher chance of external approaches for revision (44% versus 22%). All the first recurrences were at the original tumor site. Eighty-nine percent of the first recurrences were diagnosed within the first 2 years postoperation.

CONCLUSION

Thirty-two percent of our patients had recurrence after their primary resection. Recurrences in the nasoethmoid area are usually small and resectable endoscopically under local anesthesia in the outpatient department whereas those inside the maxillary and frontal sinuses are likely to require additional external approaches under general anesthesia. A minimum of 2 years of follow-up is recommended for the preliminary report on the treatment results of this condition. Lifelong follow-up is recommended for possible late recurrences and metachronous multifocal disease.

Medially originated inverted papilloma

OBJECTIVES

The objective of this study was to determine the characteristics of medially originated inverted papilloma (MOIP) and compare them with laterally originated inverted papilloma (LOIP).

METHODS

A retrospective review of the charts for a total of 83 patients with sinonasal inverted papilloma (IP) was conducted. Tumors originating from the nasal septum or the turbinates were categorized as MOIP, whereas tumors originating from the four sinuses were categorized as LOIP.

RESULTS

Twenty-eight (34%) and 55 (66%) cases were categorized as MOIP and LOIP. MOIP from the middle turbinate behaved more aggressively than LOIP from the ethmoid sinus (P = 0.009), but less aggressively than LOIP from the maxillary medial wall (P < 0.05). Radical procedures were implemented in 14 patients with LOIP, but not in any patients with MOIP (P = 0.002). The recurrence rates were comparable in both groups (P = 0.472).

CONCLUSIONS

The categorization of IP on the basis of tumor origin enabled a better surgical design and more accurate excision of the tumor. Although in some cases MOIP may behave more aggressively, radical procedures were indicated in only the late Krouse stage LOIP without compromising the recurrence rate.

The evolution of management for inverted papilloma: an analysis of 200 cases

OBJECTIVES

To assess the evolution of management within one institution with the largest case series and longest clinical follow-up of IP to date in the literature and to compare this management with what has been recently presented in publication.

METHOD

A case series was performed assessing sex, age, presenting symptoms, origin of lesion, staging, primary versus recurrence, radiographic findings, method of treatment, rate of recurrence, and associated malignancy.

RESULTS

Two hundred patients (average age, 57) underwent endoscopic or endoscopic-assisted resection of IP. The mean follow-up was 4.3 years (range, 9 months-19 years). Eighty percent of cases over the last decade had prior surgery before presentation. Sixty-three percent were Krouse stage T3, and 25 percent were T4. Combined approaches were used for 57 percent of the most recent 40 cases, including Caldwell-Luc, lateral rhinotomy, medial maxillectomy, trephine, or osteoplastic flap.

CONCLUSION

Inverted papilloma can be addressed endoscopically when possible, with data from this study and the current literature suggesting this is feasible in 43 percent to 66 percent of cases. This decision should be made for each individual case, and variables that will likely affect the decision to use adjuvant external approaches include significant scarring and anatomic distortion from previous surgery, high Krouse stage, and associated malignancy.

Attachment-oriented endoscopic surgical strategy for sinonasal inverted papilloma

BACKGROUND

It is well documented that inverted papillomas (IP) have a localized attachment site. Still, instead of concentrating on the attachment site, endoscopic surgeons often perform an extended resection similar to the one achieved after external surgery.

OBJECTIVE

Our objective was to evaluate an attachment-oriented endoscopic surgical strategy and to determine IP attachment diameter and location.

METHODS

A prospective study was conducted. Thirty-three consecutive patients who underwent endoscopic IP excision (2001--2007) were enrolled. Thirty patients had adequate follow-up. Attachment diameters were measured in 25/33 patients. Surgery included debulking, identifying the precise mucosal attachment site, subperiosteal dissection and excision of the attachment, frozen section control, and resection/drilling of underlying bone.

RESULTS

The mean measured attachment diameter (n = 25) was 8.4 +/- 6 mm (range, 3-23 mm). Attachment locations included maxillary sinus (39%), ethmoid sinus (21%), nasal cavity (21%), frontal sinus (6%), sphenoid sinus (6%), lamina papyracea (3%), and cribriform plate (3%). The mean follow-up (n = 30) was 40 +/- 21 months. Three patients had Krouse stage 1, 10 patients had stage 2, and 17 patients had stage 3. Nine patients had undergone previous surgeries. After attachment-oriented endoscopic surgery, three patients had persistent disease. Nasolacrimal duct stenosis was the only complication (n = 1).

CONCLUSION

Even advanced IP have small attachments. Their Identification facilitates efficacious resection with minimal morbidity.

Endoscopic management of the inverted papilloma with attachment to the frontal sinus drainage pathway

CONCLUSION

Extensive inverted papilloma (Krouse T3 lesions) with attachment to the frontal sinus drainage pathway can be treated successfully using an endoscopic approach.

OBJECTIVES

The endoscopic management of inverted papilloma (IP) has gained in popularity over the last 15 years. However, the appropriate management of lesions involving the frontal sinus and its drainage pathway still has to be determined.

PATIENTS AND METHODS

We performed a retrospective review of the results for patients with IP in the Otolaryngology, Head and Neck Surgery Department, Beijing Tongren Hospital from 2004 to 2007 to identify those patients with lesions involving the frontal sinus and its drainage pathway. By their appearance on nasal endoscopic examination and by computed tomography scanning, the tumors were defined using the Krouse staging system. Sinus endoscopy was used to screen for disease after endoscopic resection and the clinical outcomes were analyzed.

RESULTS

A total of nine patients (eight males and one female) were identified in which IP involved the frontal sinus and its drainage pathway. Preoperative and postoperative pathological examinations revealed IP as the diagnosis. All tumors were defined as T3 lesions. Four cases with lateral wall of frontal recess tumor attachment underwent an endoscopic Draf IIA frontal sinusotomy. Three cases with either lateral and posterior walls of frontal recess and frontal infundibulum attachment, or medial and posterior walls of frontal recess and frontal infundibulum attachment underwent a Draf IIB procedure. Two cases with posterior wall of frontal recess and frontal infundibulum attachment, or medial, lateral, and posterior walls of frontal recess and frontal infundibulum attachment underwent a Draf III procedure. All patients remain disease-free after an average follow-up period of 15 months.

Medial maxillectomy: A comparative study as a surgical procedure

OBJECTIVE: The purpose of this study was to compare the long-term results of endoscopic and conventional medial maxillectomy.

STUDY DESIGN: A prospective study.

SUBJECTS AND METHODS: This study was conducted on 28 patients. No patient had intracranial or intraorbital extension. Thirteen patients (4 with adenocarcinoma, 5 with inverted papilloma, and 4 with malignant melanoma) underwent endoscopic medial maxillectomy, and 15 patients (5 with adenocarcinoma, 5 with inverted papilloma, and 5 with malignant melanoma) underwent conventional medial maxillectomy with a postoperative follow-up of 12 to 48 months.

RESULTS: In group 1 (the endoscopic group), recurrence was seen in one case (7.6%) with malignant melanoma 3 months after the surgery and was managed by revision endoscopic removal of the disease. The overall success rate in this group was 92.4%. In group 2 (the conventional group), the disease recurred in one (6.6%) patient with malignant melanoma. The overall recurrence rate was 7.2%.

CONCLUSIONS: The precise determination of tumor origin and extent of tumor during the surgery is the key to a successful outcome.

Inverted papilloma of the nasal cavity and paranasal sinuses

PURPOSE

To discuss the treatment and outcomes of inverted papilloma of the nasal cavity and paranasal sinuses.

METHODS

Review of the pertinent literature.

RESULTS

Inverted papilloma is a benign, locally aggressive neoplasm that arises in the nasal cavity and is associated with squamous cell carcinoma in approximately 5% of patients. Squamous cell carcinoma may be present with inverted papilloma at the initial diagnosis or it may occur metachronously after prior treatment. Surgery is the primary treatment of inverted papilloma. The likelihood of local recurrence varies from less than 5% to over 50%, depending on the extent of resection. There is likely no significant difference in the risk of local recurrence after open compared with endoscopic resection. The probability of local recurrence and/or death from tumor is increased if inverted papilloma is associated with squamous cell carcinoma. The likelihood of cure is approximately 50% when malignancy is present and postoperative radiotherapy should be considered for the majority of patients. A small subset of patients with inverted papilloma present with incompletely resectable disease. Definitive radiotherapy using doses between 65 and 70 Gy will locally control gross disease in the majority of patients.

CONCLUSION

The preferred treatment of inverted papilloma is surgery; postoperative radiotherapy is added if it is associated with squamous cell carcinoma. The likelihood of local recurrence after surgery for inverted papilloma may be substantial and varies with the extent of resection. Definitive radiotherapy may be used to successfully treat patients with incompletely resectable inverted papilloma.

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 versus open surgical interventions for inverted nasal papilloma: a systematic review

Inverted nasal papilloma is a unique neoplasm characterised by a tendency to recur following excision, an association with malignancy and an ability to destroy bone. The coexistence with nasal polyps (not always sent for histology), the lack of a universally accepted staging system and the fact that most data on Inverted papilloma come from tertiary centres (selected cases probably the most aggressive) account for the difficulty in determining its true incidence. Treatment is surgical. The gold standard approach was an open radical procedure. The introduction of endoscopic surgery for primary or recurrent lesions has shown potential advantages. Lack of complications of open surgery together with improved access to specific nasal areas suggests that the endoscopic techniques in experienced hands and for selected lesions may be a good alternative. The aim of this review was to assess the effectiveness of the endoscopic versus open techniques for management of inverted papilloma. There is not enough evidence in the literature to support one or the other treatment option for management of inverted papilloma. There is a trend though towards endoscopic approach. Ideal management should aim at complete removal of all diseased mucosa with creation of wide cavities and long term follow-up to detect subsequent recurrence or malignant transformation.

Staging of surgical approach of sinonasal inverted papilloma

OBJECTIVE

In this study, we tried to make the staging of surgical approach of inverted papilloma (IP) and investigated the recurrence rate of IP.

PATIENTS AND METHODS

Operating staging was as follows: When the IP was limited to the middle meatus, anterior and posterior ethmoid, or sphenoethmoid recess, standard endoscopic sinus surgery (SESS) was performed. When the lesion extended from the middle meatus into the maxillary sinus or originated from the medial wall of the maxillary sinus, radical endoscopic sinus surgery (RESS) was performed. And, when the IP originated from or involved the posterolateral, anterior, inferior wall of the maxillary sinus, intraorbital involvement, extensive growth of the lesion into the frontal or sphenoid sinus, or intradural invasion, external approach with endoscope assistance (Ex+E) was performed.

RESULTS

14 (36%) patients underwent SESS, 9 (23%) patients underwent RESS, and 16 (41%) patients underwent Ex+E. Malignancy occurred in no patient, and recurrences developed in four patients (10%). One of these recurrences happened after SESS, one after RESS and two after Ex+E.

CONCLUSION

In this study, there was no significance of recurrence rate in each group. Better visualization can be obtained by combining the endonasal operation with an external procedure.

Endoscopic sinus surgery for benign and malignant nasal and sinus neoplasm

PURPOSE OF REVIEW

Endoscopic sinus surgery has become widely accepted as the standard of treatment for chronic inflammatory diseases of the paranasal sinuses unresponsive to medical treatment. With increased skill with endoscopic surgical technique, advanced technologies such as intraoperative imaging systems, and a better understanding of the complex anatomy of the paranasal sinuses and surrounding vital structures, many otolaryngologists have increasingly applied their expertise in endoscopic sinus surgery to the resection of nasal and sinus neoplasms. The following represents a review of the recent literature on the latest trends regarding endoscopic resection of nasal and paranasal sinus neoplasms.

RECENT FINDINGS

There has been an increasing popularity in the removal of nasal and paranasal sinus neoplasms through an endoscopic approach. In the recent literature, emphasis has been on the endoscopic surgery of benign tumors, especially inverted papilloma and nasopharyngeal angiofibroma. Other benign neoplasms have also been reported, but only in small case reports. There have been a few recent reports supporting endoscopic removal of malignant neoplasms as well. However, the follow-up is too short and study groups too small to make definitive conclusions.

SUMMARY

In the hand of experienced and skilled surgeons, complete endoscopic removal is attainable in most cases. Especially for the more common benign neoplasms, such as inverted papilloma and early stage angiofibroma. En bloc resection is not necessary to achieve oncologic cure. However, several factors have to be considered before selection of this surgical approach. Large tumor size, intracranial or orbital extension, and extensive frontal or infratemporal fossa involvement are relative, but not absolute limitations.