Endoscopic and endoscope-assisted resections of inverted sinonasal papillomas

Advances in chronic rhinosinusitis in 2020 and 2021

Major progress has been achieved in the understanding and clinical practice of chronic rhinosinusitis, with or without nasal polyps. These advances resulted in a better understanding of the pathophysiology, the distribution into subgroups, and consequently in a better management perspective using classical approaches and biologics. Pathomechanisms, endotypes and biomarkers, and finally innovative therapeutic approaches are themes especially for the more severe forms of chronic rhinosinusitis, those with uncontrolled severe nasal polyps. Biologicals against key type 2 cytokines are gaining ground in the long-term treatment approaches of often recurrent nasal polyps, and should be integrated in care pathways making use of classical and innovative treatment pathways. These areas of interest show a fast development and will profoundly change our disease management within a decade.

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.

Surgical management of inverted papilloma involving the frontal sinus: a practical algorithm for treatment planning

Inverted papilloma of the frontal sinus is a challenging disease. Given its rarity, only small case series are present in the literature. The objectives of the present study are to review our experience in the surgical management of inverted papillomas involving the frontal sinus and to propose a practical algorithm for selecting the most appropriate approach. Data on patients affected by inverted papilloma involving the frontal sinus and surgically treated between 2002 and 2016 were collected. The type of involvement of frontal sinus and extent of surgery performed (endoscopic endonasal, external or combined approaches) were analysed. A brief review of consistent literature was also carried out. Forty-seven consecutive patients were treated using an exclusive endoscopic endonasal approach (EEA) in 18 cases, while a combined endonasal with external osteoplastic approach was required in 29 cases. Most patients (29/47, 62%) had been treated previously, mainly by an endoscopic approach. A single intraoperative complication occurred (1/47, 2%), i.e. cerebrospinal fluid (CSF) leak, that was successfully repaired intraoperatively without any consequences. Recurrences were observed in only 2/47 cases (4%) after a mean follow-up of 43 months (range, 12-137). The management of inverted papilloma involving the frontal sinus requires great expertise and the surgical technique should be tailored to the site of attachment of the tumour, its extension and the anatomical conformation of each frontal sinus. The encouraging results obtained in this case series support the use of this practical treatment algorithm.

Endoscopic management of maxillary sinus inverted papilloma attachment sites to minimize disease recurrence

BACKGROUND

Inverted papillomas (IPs) are benign neoplasms, most commonly arising from the mucosal lining of the maxillary sinus. IPs can have single or multifocal sites of attachment. Although pedicle location is an important factor to consider in surgical planning, it is less clear whether the location or number of IP attachment sites hold any prognostic value. Herein, we aimed to determine the prognostic significance of the number and location of attachment sites of IPs originating from the maxillary sinus when managed by a pure endoscopic approach.

METHODS

This was a single-center, single-surgeon retrospective chart review. Patients with maxillary sinus IPs who were managed by endoscopic approaches only, from January 1, 2010 to June 30, 2016, were identified. Demographic data, operative technique, number and location of IP attachment sites, follow-up duration, recurrence, and presence of malignant transformation were captured.

RESULTS

Twenty-eight maxillary IP patients (61% males) were included, with a mean age of 54.9 (standard deviation (SD): 16.5) years. Approximately 36% of patients were referred from other institutions for management of recurrent IPs after failing previous surgical treatment. All patients were managed with an endoscopic approach, and all required an endoscopic medial maxillectomy to facilitate access to the maxillary sinus. At a mean follow-up of 31.1 (SD: 22.6) months, there were no recurrences identified. IPs with single (46%) and multifocal (54%) attachments were predominately to the medial and lateral walls. Maxillary IPs with multifocal attachments most frequently involved 2-3 walls of the sinus. Osteitis (36%) was commonly seen.

CONCLUSION

IPs originating from the maxillary sinus frequently had multifocal attachments, but this did not impact disease recurrence. Despite the surgical challenges of accessing all of the maxillary sinus walls, IPs originating from the maxillary sinus can be effectively managed via a pure endoscopic approach.

Association of Krouse Classification for Sinonasal Inverted Papilloma With Recurrence: A Systematic Review and Meta-analysis

Importance

The risk factors for the recurrence of sinonasal inverted papilloma are still unclear.

Objective

To investigate the potential association between the Krouse classification and the recurrence rates of sinonasal inverted papilloma.

Data Sources

The EMBASE and MEDLINE databases were searched for the period January 1, 1964, through September 30, 2016, using the following search strategy: (paranasal sinuses [Medical Subject Headings (MeSH) terms] OR sinonasal [all fields]) AND (inverted papilloma [MeSH terms] OR (inverted [all fields] AND papilloma [all fields]).

Study Selection

The inclusion criteria were (1) studies including sinonasal inverted papilloma only and no other forms of papillomas, such as oncocytic papilloma; (2) minimum follow-up of 1 year after the surgery; and (3) clear report of cases (recurrence) and controls according to the Krouse classification system or deducible from the full-text article. Literature search was performed by 2 reviewers. Of the 625 articles retrieved in the literature, 97 full-text articles were reviewed. Observational cohort studies or randomized controlled trials were included, and the following variables were extracted from full-text articles: authors of the study, publication year, follow-up data, and number of cases (recurrence) and controls (no recurrence) in each of the 4 stages of the Krouse classification system.

Data Extraction and Synthesis

The Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines were followed. Odds ratios (ORs) and 95% CIs were estimated, and data of included studies were pooled using a random-effects model.

Main Outcomes and Measures

The main outcome was recurrence after surgical removal of sinonasal inverted papilloma according to each stage of the Krouse classification system.

Results

Thirteen studies comprising 1787 patients were analyzed. A significant increased risk of recurrence (51%) was highlighted for Krouse stage T3 disease when compared with stage T2 (pooled OR, 1.51; 95% CI, 1.09-2.09). No significant difference in risk of recurrence was found between Krouse stages T1 and T2 disease (pooled OR, 1.14; 95% CI, 0.63-2.04) or between stages T3 and T4 (pooled OR, 1.27; 95% CI, 0.72-2.26).

Conclusions and Relevance

Inverted papillomas classified as stage T3 according to the Krouse classification system presented a 51% higher likelihood of recurrence. Head and neck surgeons must be aware of this higher likelihood of recurrence when planning and performing surgery for sinonasal inverted papilloma.

Sinonasal Inverted Papilloma: Risk Factors for Local Recurrence After Surgical Resection

Objectives:

Sinonasal inverted papillomas (SIP) present a potential for recurrence years after the surgery, but most studies report short-term follow-up, and risk factors for recurrence are still debated. Furthermore, several classifications are described, and no consensus exists regarding which one should be used. The aims of this study were to report our long-term results, investigate for potential risk factors for recurrence, and compare the existing 8 staging systems.

Methods:

Over a 28-year period, 110 patients with a diagnosis of SIP were enrolled. The median follow-up time was 55.6 months.

Results:

In multivariate Cox regression modeling, history of previous surgery was the only variable associated with recurrence (hazard ratio = 4.91, 95% CI, 1.80-13.39). Recurrences occurred up to 60 months after the surgery. Among the 8 staging systems, none proved to be associated with recurrence.

Conclusion:

The only factor associated with recurrence of SIP was prior surgery, probably corresponding to an incomplete initial resection. Due to late recurrences, an extended follow-up of at least 5 years is mandatory. In the absence of a classification predicting prognosis, Krouse’s staging system should be used to homogenize studies’ report since it is the most widely used.

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.

Endoscopic modified medial maxillectomy for treatment of inverted papilloma originating from the maxillary sinus

Endoscopic approaches have become an alternative to external approaches in the treatment of sinonasal inverted papillomas (IPs) in recent years. The aim of this study was to analyze the outcomes of endoscopic modified medial maxillectomy preserving the nasolacrimal duct and the inferior turbinate in selected IP cases. Medical charts of patients diagnosed with IP originating from the maxillary sinus between July 2008 and August 2013 were reviewed. Eight patients who had undergone endoscopic modified medial maxillectomy were included in the study. Attachment of IP was located on the medial wall of the maxillary sinus in all cases. The nasolacrimal duct was preserved in all of the patients. The inferior turbinate was completely preserved in 5 patients, and the anterior part of the inferior turbinate was preserved in 3 patients. The mean follow-up period of the patients was 30.8 months (12-60  mo). None of the patients had recurrence or major complications. The postoperative complaints were minor hemorrhagic discharge and crusting for the first few weeks. Endoscopic modified medial maxillectomy preserving the nasolacrimal duct and the inferior turbinate provides good surgical and functional outcomes in selected IP cases.

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.

Sinonasal inverted papilloma: prognostic factors with emphasis on resection margins

Objective We review our institution's experience with the treatment of inverted papilloma (IP) with emphasis on the implications of surgical margins for disease control. Design Retrospective chart review of patients with IP treated at the University of Michigan from 1996 to 2011. Setting Tertiary care center. Participants Patients undergoing surgical resection with curative intent for IP. Main Outcome Measures Overall survival, disease-specific survival, and locoregional control were used as main outcome measures. Results We studied 129 patients including 19 with carcinoma arising from IP. Disease-free rates at 2, 3, and 5 years were 79.7%, 77.9%, and 61%, respectively. Overall, 10 of 18 recurrences were detected > 2 years from follow-up, with recurrences detected up to 8 years from surgery. For benign disease, obtaining tissue margins outside of the primary specimen for margin control did not affect disease control rates. Conclusion IP is a disease that requires significant follow-up periods beyond 2 years. For IP without carcinogenesis, acquiring margins outside of the tumor specimen did not appear to affect disease control rates in this study. No clear predictors of malignancy were seen in this study, which highlights the need for further research to predict this phenomenon.

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.

Retrospective analysis of 26 cases of inverted nasal papillomas

Inverted papilloma (IP) comprises 0.5-4% of benign nasal tumors. The importance is shown by local aggressiveness, a high recurrence rate and the possibility of malignant transformation. The treatment is controversial, but endoscopic approaches tends to be the choice today.

Aim

To describe clinical, epidemiological and treatment of IP cases in a tertiary hospital.

Methods

Retrospective study consisting of chart reviews of 26 patients diagnosed with IP; evaluation of tumor location, clinical staging, follow up, tumor recurrence, malignancy, type of surgery and postoperative complications.

Results

There were 13 men and 13 women, the mean age was 57.8 years. The mean follow up time was 29.4 months; the recurrence rate was 7.6%. There was a preponderance of T3 and T4 tumors and a 3.8% malignancy rate. All patients underwent surgical treatment, mostly endonasal endoscopic surgery.

Conclusion

IP is an uncommon nasal tumor that originates mainly in the lateral nasal wall, but it also affects the paranasal sinuses. Advances in endoscopic surgery are gaining room due to lower invasiveness and success rates similar to traditional external techniques for completely resecting the tumor. There is a lower recurrence rate, and endoscopy a definitive treatment for malignancy cases in this study.

Inverted papilloma of the nasal cavity and paranasal sinuses: a Korean multicenter study

OBJECTIVES/HYPOTHESIS

The study group for sinonasal tumors at the Korean Rhinologic Society analyzed the results of the Korean multicenter experience for sinonasal inverted papilloma (IP) surgeries.

STUDY DESIGN

Multicenter cohort study and retrospective analysis.

METHODS

In total, 939 patients diagnosed with sinonasal IP treated between 1998 and 2007 at 17 university hospitals were enrolled. Demographic data and information about previous surgeries, the origin and involved site of the tumor, the surgical approach, follow-up duration, recurrence, and the presence of malignancy were collected. There were 361 patients whose follow-up was <12 months who were excluded, and 578 patients were included for recurrence analysis.

RESULTS

The mean follow-up duration for recurrence analysis was 41.0 months, and 15.7% (91/578) had recurrences, with a mean time to recurrence of 32.6 months. However, the group whose follow-up was longer than 3 years had a higher chance of tumor recurrence. Patients whose IPs involved the frontal sinus or the medial wall of the maxillary sinus had higher recurrence rates. There was no significant difference in recurrence rates according to stage or surgical approach. In the T3 stage of Krouse, the T3-A stage of Furuta, and group B of the Citardi staging system, the endoscopic approach alone resulted in higher recurrence rates.

CONCLUSIONS

Generally, there were no significant differences in recurrence rates according to clinical stage or surgical approach. Given the rate of delayed recurrence, follow-up of >3 years is required. Moreover, surgeons should always consider combined approaches to reduce the chances of recurrence.

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.

Sinonasal inverted papilloma: narrative review

BACKGROUND

Sinonasal inverted papilloma is a benign condition with the potential for recurrence and malignant change. Over the past few decades, numerous studies and reviews have addressed different aspects of this condition.

OBJECTIVE

To amalgamate the current literature on inverted papilloma, in order to review the evidence and consider the gaps in current knowledge.

METHODS

Retrospective, narrative review.

RESULTS

The reported incidence of inverted papilloma varies between centres and is affected by selection bias. The exact aetiology of inverted papilloma is not fully understood. Currently, there is no reliable histological or biological marker to predict the probability of recurrence or malignant transformation. There is no universally accepted staging system available for sinonasal inverted papilloma. Complete surgical removal of the tumour is the mainstay of treatment, but the method of choice depends on the extent of the disease, the skill of the surgeon and the technology available.

CONCLUSION

In order to compare different studies and to enable meta-analysis of the literature, there should be a universally accepted staging and classification system for sinonasal inverted papilloma. Further research on the aetiology of sinonasal inverted papilloma, and on biological markers for its recurrence and malignant transformation, is required. To enable meaningful future research, we would encourage multicentre participation with a consensus on management.

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.

[Four hands surgery in endoscopic sinus surgery--our experience]

Endoscopic surgery in chronic sinusitis became a gold standard since Stammberger and Kennedy describe there technique in '80 s. During last 20 years an enormous progress has been done in that field. Tumors of the nose and paranasal sinuses became a target for endonasal surgery, alternatively to open approaches. This surgery is more bloody, needs more tools, so the next step was to introduce the second surgeon into endoscopic sinus surgery and the four hands technique has born. Three models of four hands technique are present in the literature. Since November 2006 at the ENT department at Medical University in Poznań 24 patients have been operated on with this technique out of wich 12 suffered from tumors and 12 patients have been diagnosed with chronic sinusitis. This paper describe the surgical technique and our experience based on this 24 operations.

[Endoscopic surgery for selected tumors of the nose and paranasal sinuses--practical sense of the four hands technique]

Endoscopic sinus surgery is a gold standard in chronic sinusitis since middle '80. More and more attention is put on endosnasal tumor removal with the endoscopic technique. Two major pathologies are present in the literature, the inverted papilloma and the angiofibroma. Other tumors are rare. In the ENT Department of Poznań Medical University, endoscopic removal of tumors of the nose and paranasal sinuses is done with the four hands technique. Since November 2006 to July 2007 12 cases were operated in our institution. Fully endoscopic removal was performed in 7 cases. In 2 cases an endoscopic assisted surgery was performed. In 3 cases a convertion to open surgery was necessary. Endoscopic approach to nonmalignant tumor of the nose and parana sal sinuses is an alternative to open surgery of tumor of the nose and paranasal sinuses. The four hands technique is very helpful and leads to extend limits of this surgery. Performing an endoscopic surgery of tumor one has to be prepared to make an intraoperative convertion to open surgery.

Canine fossa approaches in endoscopic sinus surgery - our experience

OBJECTIVE

To define the role of canine fossa approach when standard endoscopic endonasal sinus surgery technique fails.

STUDY DESIGN

Retrospective review of all endoscopic sinus surgeries performed from 1992 to 2007.

RESULT

Out of 1612 endoscopic sinus surgeries for various indications, CFA was used in 80 patients (4.96%) and among this 15 had bilateral procedure.The various diseases which required CFA were allergic fungal sinusitis (AFS), Fungal ball, Chronic invasive aspergillosis,antro choanal polyp, inflammatory polyp, Mucocoele and Maxillary cyst,inverted papilloma and Juvenile Nasopharyngeal Angiofibroma (JNA). Eight patients had minor complications (cheek swelling-6, facial pain-2 ) which resolved in 5 days.

CONCLUSION

Canine fossa approach offers an ancillary approach to failed standard endoscopic endonasal technique thereby avoiding other more invasive procedures.

External vs endoscopic approach for inverted papilloma of the sino-nasal cavities: a retrospective study of 136 cases

CONCLUSION

Endoscopic removal, with or without external technique, can be performed in a majority of inverted papilloma cases. This method has subsequent recurrence rates that are comparable to those of more aggressive external techniques and it is more cost efficient with less morbidity.

OBJECTIVES

To analyze the clinical outcomes of our 21-year experience (1986-2006) in treating inverted papillomas using different treatment modalities.

PATIENTS AND METHODS

The patients were divided into a conventional surgery group (CSG) and an endoscopic surgery group (ESG) and were staged according to the system developed by Krouse. A retrospective assessment was performed.

RESULTS

The recurrence rates were 4.3% in ESG and 9.5% in CSG. There was no significant difference in the recurrence rates according to the treatment modality used and the Krouse stage in the two groups. Mean operation time was 72.93+/-18.51 min in the ESG and 112.02+/-56.52 min in the CSG. Mean period of hospital stay was 4.66+/-1.75 days in the ESG and 9.54+/-4.79 days in the CSG. The complication rate was 3.2% in the ESG and 33.3% in the CSG. There was a significant difference in the operation time, length of hospital stay, and complication rate in the two groups.

[9-years results of the functional endoscopic sinus surgery in ENT department in Poznań--from microscope to four hands technique]

Surgical procedure is used in chronic rhinosinusitis and aims at restoring proper drainage and ventilation. For this reason the surgery of this region is referred to as functional and in English literature is termed as FESS. It supplanted classical method of Caldwell-Luc or Denker. In the study nine years experience in the Department of Otolaryngology, Head and Surgery University of Poznań in the treatment of chronic sinusitis has been presented. 1463 patients treated with FEES were analyzed. Moreover, the method of selecting patients for the surgery, the diagram showing surgeries performed step by step as well as a list of various surgeries and intraoperative complications were presented. This work is the first part of the study. In the other part the results of the treatment based on the questionnaires sent to patients will be presented.

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).

Clinical outcomes of endoscopic and endoscopic-assisted resection of inverted papillomas: a 15-year experience

BACKGROUND

The endoscopic resection of sinonasal inverted papillomas (IPs) has been well described. However, the majority of published reports in the literature are small case series with limited clinical follow-up. The aim of this retrospective study was to review the experience with the endoscopic and endoscopic-assisted resection of IPs at a major academic tertiary care facility and assess long-term outcomes.

METHODS

A retrospective review of endoscopic and endoscopic-assisted resections of IP was performed. Charts were reviewed for standard demographic data, operative technique, adjuvant approaches, complications, and postoperative follow-up times.

RESULTS

One hundred fourteen patients (average age, 56 years) underwent endoscopic or endoscopic-assisted resection for IPs with a mean disease-free follow-up of 40 months (7-135 months). Seventeen patients developed disease after endoscopic or endoscopic-assisted resection for a recurrence rate of 15%. Average time to recurrence was 23 months. Combined approaches were used when indicated in 34% (39/114) of patients, including adjuvant osteoplastic flap, midface degloving, trephine, or Caldwell-Luc approaches. Four patients (4%) had cerebrospinal fluid leaks that were successfully repaired endoscopically.

CONCLUSION

In this large series of endoscopically resected IPs with extensive clinical follow-up, recurrences occurred an average of 23 months after the procedure. This emphasizes the importance of long-term endoscopic follow-up to detect recurrences in all patients. Endoscopic or endoscopic-assisted resection of IPs is a valid technique in this series with recurrence rates comparable with open approaches.

[Endoscopic surgery in treatment of inverted papilloma nose et paranasal sinuses in the older patient]

Inverted papilloma is a benign neoplasm of uncertain ethiology. The tumour is considered locally aggressive, its tendency to invade adjacent paranasal structures and high recurrence rate causes. In this work was described one case of 102 year's old patient with unilateral nasal obstruction since 5 month and headache. Endoscopy surgery was applied. Histological examination revealed 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.

Surgical management of sinonasal inverted papillomas through endoscopic approach

We defined a standardized approach to surgery of sinonasal inverted papillomas (IP) for adequate and safe resection. A cohort of 65 patients treated from January 1995 to December 2005 at a single institution was retrospectively analyzed (mean follow-up: 28 months; range 1-132). The extension of the tumor was evaluated on clinical findings and computed tomography (CT) scan and/or resonance magnetic imaging (RMI). External and endoscopic surgical approaches were compared according to tumor extension, rate of local recurrence. Univariate analysis was used to review the impact on disease-free survival of factors related to the histopathological findings and the treatment. Endoscopic (alone or combined with transantral approach) and external surgery were used in 46 patients (71%) and 19 patients, respectively. Endoscopic approach (34/46) was performed to control IP in the nasal fossa, the ostiomeatal complex, the sphenoid sinus. It was combined with Caldwell-Luc procedure (12/46) for tumor extent into the lateral part of the maxillary sinus. The mean time for recurrences to occur was 19 months with range of 5-35 months. The rate of local recurrence was 17.6% (6/34) in endoscopic approach alone, 8.3% in endoscopic approach combined with a Caldwell-Luc procedure and 15.8% (3/19) in external approach. Tumor extension, excision with safe margins, associated malignancy or dysplasia have no significant impact on disease-free survival regardless of surgical procedure. On the basis of imaging evaluation and peroperative view of tumor extent, we propose a surgical strategy in which endoscopic approach could be used on the first attempt by trained surgeons. RMI is very useful to determine acute extent of the disease.

Clinical and pathological analysis of recurrent inverted papilloma

OBJECTIVES

We analyzed the clinical characteristics, pathological findings, and treatment outcomes of patients with recurrent sinonasal inverted papilloma (IP).

METHODS

This retrospective study consisted of 13 patients with recurrent IP. Patient data were collected on prior treatment, sites of recurrence, surgical procedures, pathological findings, and postoperative time to recurrence.

RESULTS

Eleven of the 13 patients (85%) had recurrence in the ethmoid sinus, particularly at the lamina papyracea (n = 8; 62%). Inverted papilloma with severe dysplasia (SD) was observed in 4 patients, 3 of whom showed malignant transformation of the recurrent tumor. Craniofacial resection was performed in 2 of the 4 patients, resulting in no further recurrence. However, the tumor was not managed in the remaining 2 patients. In the 9 patients without SD, lateral rhinotomy was performed in 6 patients and endoscopic sinus surgery was selected in 3 patients who had a small tumor without scar formation. No further recurrence was observed in the 9 patients.

CONCLUSIONS

Careful management of IP around the lamina papyracea is essential during initial surgery. Recurrent IP without SD can be successfully managed by lateral rhinotomy in most cases, and by endoscopic sinus surgery in selected cases. However, more aggressive treatment, including craniofacial resection, should be considered in IP with SD, which is associated with a high rate of recurrence and malignant transformation.

[Endonasal endoscopic approach in the treatment of sino-nasal inverted papillomas]

INTRODUCTION

Sino-nasal inverted papilloma is a rare benign tumor of the nasal fossa and the paranasal sinuses for which the successful surgical treatment by an endonasal approach has been corroborated in the literature. Nevertheless, the authors aim in this study to evaluate the advantages and the limits of this approach, to analyse its failures and its recurrences, and to define the indications for using it with the external or dissimulated approach.

MATERIAL AND METHODS

42 patients presenting with a sino-nasal inverted papilloma and treated surgically over a ten year period were included in this retrospective study. The operative technique was chosen as a function of the endonasal and radiological examination results (CT scan and MRI). Follow-up was over one year for all patients.

RESULTS

Twenty eight patients were operated exclusively through an endoscopic endonasal approach. Fourteen patients were operated using a combined approach, associating either a vestibular (9 cases), a paralateral nasal (3 cases) or a fronto-orbital (2 cases) approach with endonsal endoscopy. In two cases, an associated squamous cell carcinoma was found. We observed a recurrence in 9.5% of the all cases and in 14.2% of the patients treated using a combined approach.

CONCLUSIONS

Endoscopic endonasal surgery is a validated surgical approach for the treatment of sino-nasal inverted papilloma in that total tumor removal is possible. This approach is particularly indicated in medially-situated papillomas without frontal or maxillary extension. In all other cases, associating an external or dissimulated approach is usually necessary.

Site of attachment of inverted papilloma predicted by CT findings of osteitis

BACKGROUND

The treatment of choice for sinonasal inverted papilloma (IP) is surgical resection, which typically includes identification of the site of origin with appropriate inclusion or management of this site in the surgical resection. Appropriate preoperative planning is thus of significant importance and will routinely include CT imaging and nasal endoscopy. The aim of this study was to determine whether findings of osteitis in the patients' preoperative CT images could predict the site of attachment.

METHODS

This bipartite study contained both retrospective and prospective arms. For the retrospective arm, preoperative CT images of all cases were reviewed electronically in a blinded fashion by the senior author and a prediction was made for the site of attachment. The actual site of attachment as documented in the operative note was then compared with the predicted site. A similar process was followed for the prospectively acquired patients except that the site of attachment was predicted preoperatively.

RESULTS

Twenty-eight retrospective and six prospective patients were identified as eligible for the study. Six retrospective patients were excluded because of incomplete data. In patients that were reviewed retrospectively, osteitis was seen in 20/22 patients and was used to correctly predict the site of attachment in 18/20 times. Of the prospectively acquired patients osteitis was seen in 5/6 patients with the site of attachment predicted in 4/5 patients.

CONCLUSION

In patients in whom osteitis is detectable on the preoperative CT scan, the site of origin of the IP can be predicted with a high degree of accuracy.

Benign sinonasal neoplasms: a focus on inverting papilloma

Benign sinonasal neoplasms are a pathologic and clinically varied group of tumors. Inverting papilloma is a notable member of this group, and it is renowned for its high rate of recurrence, its ability to cause local destruction, and its association with malignancy. This article aimed to familiarize the clinician with all the practical aspects of inverting papilloma and its management. The treatment algorithm for this tumor has undergone a complex evolution that continues today.

Bibliography. Current world literature. Nose and paranasal sinuses

PURPOSE OF REVIEW

Patients with advanced head and neck cancer are being treated with chemo-radiotherapy, and life is being prolonged, with or without persistent disease, for longer than was previously. Hypercalcaemia may present in patients with advanced or disseminated head and neck cancer, and, as such, these patients may present to a larger variety of clinicians for advice concerning their symptoms and illness. Modes of presentation of hypercalcaemia and treatment strategies are reviewed.

RECENT FINDINGS

There were previously few large series of head and neck cancer patients diagnosed with hypercalcaemia, which may or may not have been related to their cancer being treated. Investigations, by way of blood/serum calcium level, may identify such patients. Patients with cancer-related hypercalcaemia have a poor prognosis, but many may respond temporarily to treatment when offered, with an improvement of their quality of life and death.

SUMMARY

Hypercalcaemia should and must be considered in all patients who have or possibly have a diagnosis of a head and neck cancer and who present unwell with symptoms of fatigue, lethargy and somnolence. Investigation must include serum calcium (corrected for serum albumin binding) and parathyroid hormone level. Patients may be treated by a combination of rehydration and bisulphonate therapy until the serum calcium is reduced to a level below 3 mmol/l. The majority of patients diagnosed with hypercalcaemia due to head and neck malignancy die of their diseases in the short term, but some may enjoy a prolongation of life with reasonable quality if diagnosed and treated aggressively.

Endoscopic management of inverted papilloma

PURPOSE OF REVIEW

Inverted papillomas are uncommon benign tumors that may occur in the sinonasal tract. Because of their tendency towards recurrence and their potential for malignant transformation, complete en bloc resection has been the standard treatment modality. With the application of minimally invasive surgical techniques in the management of sinonasal disease processes, transnasal endoscopic removal of inverted papillomas is gaining in acceptance. The following represents a review of the current literature regarding sinonasal inverted papilloma and its clinical management.

RECENT FINDINGS

The recent literature has further refined the technique of endoscopic resection of inverted papillomas by delineating essential principles and applying new technologies, such as image guidance and angled endoscopic drills. Modified approaches and methodology have been described to address tumors originating in particular anatomic locations. At the same time, new information relevant to the diagnosis and surveillance of inverted papillomas has been published, regarding the role of imaging, serum tumor markers, and human papillomavirus.

SUMMARY

Growth in experience with the endoscopic management of inverted papillomas has led to evolving technical improvements and innovations. In most tumor locations, the completeness of resection achieved by a skilled endoscopic surgeon is equivalent, if not superior, to that attained with an open approach. In some instances, an endoscopic exploration with tumor resection may help define the site of tumor attachment and direct adjunctive open procedures when indicated. Long-term outcomes studies with sizeable patient cohorts will be needed to define the role of various surgical strategies in the optimal management of inverted papilloma.

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 Resection of Sinonasal Hemangiomas and Hemangiopericytomas

INTRODUCTION

Endoscopic resection of benign neoplasms, such as inverted papilloma, has been well described. There are limited case reports of endoscopic resection of benign vascular tumors, including hemangiomas, or those with low-grade malignant potential, such as hemangiopericytomas.

METHODS

Retrospective review of sinonasal hemangiomas and hemangiopericytomas resected endoscopically at a single tertiary-care facility.

RESULTS

Three hemangiomas and 3 hemangiopericytomas were resected endoscopically with no recurrences at a mean follow-up of 22 months. Four tumors involved the skull base; 2 of these underwent preoperative embolization. One patient had a CSF leak that occurred as the tumor was removed from the cribriform plate and that was successfully repaired intraoperatively. The average size of the tumors was 5.8 cm x 2.7 cm with all tumors at least 2.5 cm in greatest dimension by computed tomography or magnetic resonance imaging. The largest tumor was 12 cm in greatest dimension. An average of 8 intraoperative frozen section margins was taken around 5 tumors, with all margins of each tumor clear on final pathology. Patients included 4 males and 2 females with an average age of 47 years.

CONCLUSION

Large vascular neoplasms of the sinonasal cavity, such as hemangiomas and hemangiopericytomas, can be safely removed using endoscopic techniques. Although these patients have a limited follow-up, it is prudent to perform long-term endoscopic follow-up in order to detect recurrences regardless of resection technique.

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.