The endoscopic management of sinonasal inverted papillomas

Camera sheath with transformable head for minimally invasive surgical instruments

INTRODUCTION

This paper presents a camera sheath that can be assembled to various minimally invasive surgical instruments and provide the localized view of the instrument tip.

MATERIAL AND METHODS

The advanced transformable head structure (ATHS) that overcomes the trade-off between the camera resolution and the instrument size is designed for the sheath. Design solutions to maintain the alignment between the camera's line of sight and the instrument tip direction during the transformation of the ATHS are derived and applied to the prototype of the sheath.

RESULTS

The design solution ensured proper alignment between the line of sight and the tip direction. The prototype was used with the curved micro-debrider blades in simulated functional endoscopic sinus surgery (FESS). Deep regions of the sinus that were not observable with the conventional endoscopes was accessed and observed using the prototype.

CONCLUSIONS

The presented camera sheath allows the delivery of the instrument and camera to the surgical site with minimal increase in port size. It may be applied to various surgeries to reduce invasiveness and provide additional visual information to the surgeons.

Case Report: Oncocytic Schneiderian Papilloma Originating From the Sphenoid Sinus

A rare case of oncocytic Schneiderian papilloma originating from the sphenoid sinus characterised, for 3 years, by non-specific symptoms of severe headache, a block of nasal breathing, and deprecating sense of smell was presented by an elderly female patient. Sphenoid sinus functional endoscopic sinus surgery (FESS), with a one-block tumour excision, through an endonasal approach, with a histological study of removed tumour masses, were performed on the patient. Long observation in the post-operative period was necessary, considering the risk of recurrence and malignancy of oncocytic Schneiderian papilloma (OSP). Although the oncocytic papilloma of the sphenoid sinus is rare, non-specific symptoms make this pathology easily misdiagnosed. Thus, any isolated unilateral process in the paranasal sinuses with long-existing symptoms must be given careful attention due to the chance of this process being an inverted papilloma with malignization. CT scan indicating a unilateral opacification of paranasal sinuses with local calcifications is a typical manifestation, and endoscopic sphenoidotomy can be recommended as a treatment of choice.

A miniature robotic steerable endoscope for maxillary sinus surgery called PliENT

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

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

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

Surgical outcomes of sinonasal inverted papilloma: a 17 year review

Introduction

Inverted papillomas represent one of the most common benign neoplasic lesions located in the sinonasal tract. Owing to the local erosive behavior, tendency to recur and the potential for malignant transformation, surgical management of inverted papillomas is often challenging.

Objective

This study aimed to analyze the surgical outcomes of patients with inverted papillomas, according to the Krouse staging and the different surgical approaches.

Methods

Retrospective study of patients diagnosed with sinonasal inverted papillomas who underwent surgical treatment between 2000 and 2016 at a tertiary referral hospital. Cases with follow-up less than 12 months were excluded. The rate and the time of recurrence were the main outcomes. Values of p < 0.05 were considered statistically significant.

Results

Thirty-six cases with mean age of 60 years, predominantly male (72%), were included. The follow-up period ranged from 1 to 16 years, with an average of 4.5 years. Krouse T1 Stage corresponded to 11.1%; T2 occurred in 50% of cases; while T3 and T4 Stages accounted for 30.6% and 8.3% of patients, respectively. Most cases were approached by an endoscopic technique alone (83.3%), with a recurrence rate of 13.3%. Patients treated via a combined or open approach revealed a recurrence of 16.7%. No differences in the recurrence rate were reported when comparing endoscopic surgery with the open or combined techniques. Krouse Stage T3 had a significant association with inverted papillomas recurrence (p = 0.023). All inverted papilloma relapses occurred up to 2 years post-operatively. One case of malignant transformation was recorded (2.7%).

Conclusion

Endoscopic surgery did not increase the recurrence rates and can be a safe and efficient alternative to open or combined techniques. The recurrence of inverted papillomas seem to be related to the persistence of the disease and tend to occur early after primary surgery. Krouse T3 Stages may be associated with a higher recurrence of inverted papillomas.

Inverted Papilloma: New Classification and Guidelines for Endoscopic Surgery

Background

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

Methods

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

Results

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

Conclusion

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

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.

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.

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.

Bilateral inverted papilloma: A report of two cases and review of the current literature

Inverted papilloma is locally aggressive tumour which typically presents as a unilateral nasal polyp. Whilst it has a malignant potential it rarely transforms and in its benign form the main concern originates from its locally aggressive nature and substantial propensity to recur. Bilateral disease can also be due to inverted papilloma, sometimes due to direct extension of the tumour, but it can also occur as two distinct lesions. Here we report two cases of bilateral involvement, review the current literature and highlight some important issues on the management and follow-up of this well known neoplasm.

Frontal sinus inverted papilloma: surgical strategy based on the site of attachment

BACKGROUND

The surgical management of inverted papilloma (IP) involving the frontal sinus (FS) remains a challenge given the narrow confines of the frontal recess and the close proximity to critical structures. The objective of this study was to elucidate a surgical strategy for management of frontal sinus IP based on the site of attachment.

METHODS

A retrospective chart review was performed on 18 patients with FS IP treated at the Pusan National University Hospital and the Cleveland Clinic Foundation between 1998 and 2008.

RESULTS

The mean age was 53.8 years with a male/female ratio of 13:5. The sites of tumor attachment included the medial wall (MW; six cases), posterior wall (PW; five cases), diffuse (all walls involved; five cases), intersinus septal cell (three cases), lateral wall (two cases), and anterior wall (two cases). IP involvement was unifocal in 10 cases and multifocal in 8 cases. Unifocal IP attached to the MW or PW was managed strictly by endoscopic frontal sinusotomy (EFS) in five of six cases (83%). Multifocal IP required endoscopic modified Lothrop (EML) and/or open approaches (endoscopic frontal trephination [EFT], four, osteoplastic flap [OPF], one) in seven of eight cases (88%). One additional patient with bilateral anterior table involvement required OPF. Four (22%) patients developed recurrences. Two were managed by EML, one was managed by EFS, and one was managed by EFT and EFS. Two patients developed cerebrospinal fluid leaks that were managed endoscopically without untoward effects. All patients were free of disease at the time of last evaluation with a mean follow-up of 36.6 months.

CONCLUSION

Frontal sinus IP with MW or PW involvement can generally be managed by standard EFS. Tumors with multifocal involvement often require EML, along with adjunct EFT in selected cases. OPF can be avoided as the primary surgical approach in most patients with sinonasal papilloma of FS.

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.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

[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.

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.

Management of inverted papillomas of the nose and paranasal sinuses

PURPOSE

Inverted papillomas (IPs), although histologically benign, are aggressive lesions that may recur after an excision. The objective of this study was to compare the surgical treatment options for IPs with an emphasis on the experience of our institution with midfacial degloving (MFD) and medial maxillectomy.

MATERIALS AND METHODS

A retrospective review of the charts of patients with IP treated by MFD and medial maxillectomy was performed. An analysis of the recurrence rates of IPs in the literature for endoscopic surgery and lateral rhinotomy was also performed.

RESULTS

Ninety-eight medial maxillectomy procedures via MFD were performed for IPs with a minimum of 2 years' follow-up (median = 5.1 years). Two patients were found to have recurrences (2.1%). The literature review revealed an average recurrence rate of 15.7% for lateral rhinotomy as compared with that of 19.6% for endoscopic surgery.

CONCLUSION

Midfacial degloving balances acceptable cosmetic results with low recurrence rates. It allows for adequate exposure and resection without the scar of a lateral rhinotomy incision.

Recurrent inverted papilloma of a pediatric patient: clinico-radiological considerations

Inverted papilloma (IP) of the nasal cavity and paranasal sinuses is an uncommon pathology, especially in the pediatric population. We present a pediatric case of recurrent IP in the left nasal cavity. The physical examination of a 9-year-old girl revealed a polypoid mass filling the middle meatus in the left nasal cavity. Purulent secretion and adenoid vegetation obstructing the choanea were also noted. Coronal and axial maxillo-facial computed tomography demonstrated a mass in the nasal cavity, enlarging the left middle meatus. We discussed the imaging findings and treatment of IP and concluded that it should have been included in the differential diagnosis of nasal mass lesions in the pediatric population.

Tailored endoscopic surgery for the treatment of sinonasal inverted papilloma

BACKGROUND

This retrospective study was designed to evaluate the efficacy of tailored endoscopic surgery. Tailored endoscopic surgery aims at resecting the inverted papilloma completely with a customized surgical approach, especially when an en-bloc excision cannot be comprehensively or routinely achieved because of the immense extent of the tumor.

METHODS

Between November 1991 and March 2002, 43 patients with sinonasal inverted papillomas were treated by tailored endoscopic surgery. The average duration of follow-up for this population was 25.3 months (range, 9-150 months). A staging system developed by Krouse was adopted for tumor grading. On the basis of tailored endoscopic surgery, 15 localized lesions and 12 smaller extensive lesions (Krouse stages 1 and 2) were treated by ordinary endoscopic resection, whereas 16 larger extensive lesions (Krouse stages 3 and 4) in which the tumors were immense were subjected to sequential segmental endoscopic surgery (SSES). Seven of these 16 larger extensive lesions combined with endoscopic medial maxillectomy because of extensive encroachment of maxillary sinus antrum.

RESULTS

Four patients (9.3%) had residual disease, each requiring one revision surgery. All tumors were successfully resected. No patient required lateral rhinotomy or midfacial degloving procedure. No major complications were encountered in any of the patients. None of the patients had residual disease at the time of this writing.

CONCLUSIONS

Tailored endoscopic surgery is a safe and effective treatment that obviates the need for more extensive surgery for the management of inverted papilloma. Proper preoperative evaluations, intraoperative determination of extent and attachment of the tumor, close endoscopic follow-up, and expert application of endoscopic techniques are the keys to the successful use of tailored endoscopic surgery.

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

OBJECTIVE

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

STUDY DESIGN

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Endoscopic surgery for recurrent inverted papilloma

OBJECTIVES/HYPOTHESIS

Inverted papilloma of the nose and paranasal sinuses is noted for its high rate of recurrence. The feasibility of endoscopic treatment for inverted papilloma has been shown in the literature; however, reports discussing the efficacy of endoscopic surgery for recurrent diseases are rare. The study determined the effectiveness of endoscopic surgery for recurrent inverted papilloma and described when endoscopic medial maxillectomy was indicated.

STUDY DESIGN

Retrospective.

METHODS

Seventeen patients with recurrent inverted papilloma were treated over a 10-year period. Krouse's staging system was used for tumor grading. Because of the extent of the tumor in the majority (70.6%) of the patients, en bloc resection could not be regularly achieved; therefore, sequential segmental endoscopic surgery was the chosen treatment. Some diseases that extensively involved the maxillary sinus were treated by the combination of endoscopic medial maxillectomy (EMM) and sequential segmental surgery (SSES) to extirpate the whole disease.

RESULTS

Efficacy was evaluated strictly by radiographic study. Successful treatment was accomplished in 14 (82.4%) patients. Three (17.6%) patients had residual disease; each required one revision surgery. None of the patients had recurrence at the time of writing. There were no major complications or associated malignancies encountered in the patients.

CONCLUSION

Endoscopic surgery is an effective treatment for recurrent inverted papilloma. Precise determination of the sites of tumor origin and attachment during the operation is the key to the successful treatment. Recurrent inverted papilloma tends to behave more aggressively and has a higher postoperative recurrence rate than the primary lesion. Stage III disease had a higher recurrence rate (27.3%) than that of other stages (0%).

Treatment outcomes in the management of inverted papilloma: an analysis of 160 cases

OBJECTIVE

The objective of this study is to compare the surgical options for treatment of inverted papilloma to determine the appropriate indications for conservative and aggressive management.

STUDY DESIGN AND SETTING

A retrospective review of 160 patients with a diagnosis of inverted papilloma treated by the two senior authors (w.l. and h.f.b.) between 1973 and 2001.

RESULTS

The study group consisted of 124 male and 36 female patients with an average age of 56 years. The follow-up period ranged from 10 months to 16 years (mean, 5.2 years). Seventy-eight patients (49%) had undergone prior surgery. Lateral rhinotomy was performed in 112 patients (70%), with a recurrence rate of 18%. Conservative removal was performed in 41 patients (26%), including 30 (19%) endoscopic approaches, with a recurrence rate of 12%. The remaining patients underwent midfacial degloving, osteoplastic approach, or craniofacial resection. The rate of malignant transformation was 7%.

CONCLUSION

We present the largest personal series of cases of inverted papilloma to date. Our data suggest that conservative approaches, especially endoscopic removal, can be performed on selected lesions with recurrence rates that are comparable to those of more aggressive techniques. Those inverted papillomas that recur after treatment may represent a subset of lesions with an inherent aggressiveness, for which optimal treatment has yet to be determined.

Endoscopic removal of sinonasal inverted papilloma including endoscopic medial maxillectomy

OBJECTIVES/HYPOTHESIS

Surgical excision is regarded as the treatment of choice for sinonasal inverted papilloma. Resection can be performed endoscopically or through an external approach. Debate exists about which approach to use. The study presents different endoscopic techniques for various tumor locations and reviews the results.

STUDY DESIGN

A prospective study and an integrated literature review.

METHODS

Seventeen consecutive patients with inverted papilloma who underwent endoscopic surgical excision, including medial maxillectomies and modified Lothrop procedures, were analyzed. Preoperative symptoms, computed tomography and magnetic resonance imaging findings, operative findings, tumor stage, and outcomes were recorded.

RESULTS

Thirteen male and four female patients presented with inverted papilloma between December 1993 and October 2001. Nasal obstruction was the most common presenting symptom (50%). Sixty-five percent of tumors were either stage II or stage III. Endoscopic resection was the primary treatment in 14 patients. Of the three patients who were secondarily treated endoscopically, one had recurrence and was subsequently found to have focus of squamous cell carcinoma. The overall recurrence rate was 6% and the incidence of malignancy was 6% (1 of 17). Recurrence rate for primary resections was zero (0 of 14). Five patients underwent endoscopic medial maxillectomies, and one patient with frontal sinus inverted papilloma was successfully treated with a modified endoscopic Lothrop procedure.

CONCLUSIONS

Endoscopic sinus surgery is a viable treatment alternative for sinonasal inverted papilloma. Recurrence rates for primary treatment are comparable to external approaches. Close follow-up of patients is mandatory because recurrence may be associated with malignancy.

Transnasal endoscopic medial maxillectomy for inverting papilloma

OBJECTIVE

To describe the new technique of transnasal endoscopic medial maxillectomy.

STUDY DESIGN

Study design included application of the new technique in the management of five patients with inverting papilloma; retrospective review of five patients who had lateral rhinotomy with medial maxillectomy for inverting papilloma; comparison of transnasal endoscopic medial maxillectomy to open medial maxillectomy for scope of resection, margin control, operative time, and surgical access; and detailed description of transnasal endoscopic medial maxillectomy.

METHODS

Charts were reviewed and tabulated for operative time, duration of follow-up, and recurrence. Pathology reports were reviewed for number and orientation of the specimens and for margin control.

RESULTS

Operative time was shorter for patients managed with transnasal endoscopic medial maxillectomy. All patients with transnasal endoscopic medial maxillectomy had one large, well-oriented specimen with margin control. There was no recurrence in either group.

CONCLUSIONS

Transnasal endoscopic medial maxillectomy providing full access to the maxillary and ethmoid sinuses is described in detail. Transnasal endoscopic medial maxillectomy is an effective, reproducible technique with less operative time and morbidity and, possibly, better pathological tumor mapping than open medial maxillectomy for selected patients. Maxillary sinus involvement with inverting papilloma is not a contraindication for this technique. Strong illumination, superior resolution, and angled visualization, coupled with exact osteotomies, make transnasal endoscopic medial maxillectomy an efficacious technique for inverting papilloma with extension limited to the maxillary and ethmoid sinuses.

Schneiderian Papilloma of the Nasopharynx

We report a rare case of a schneiderian papilloma of the nasopharynx. Because this tumor is locally invasive, has a tendency to recur, and can undergo malignant transformation, it should be completely excised. It is possible to completely remove such a tumor in a minimally invasive way by using a combination of transnasal and transoral approaches and high-resolution angled endoscopes and other suitably designed instruments.

Endonasal approaches for sinonasal and nasopharyngeal tumors

This article reviews the published literature on endonasal approaches for sinonasal and nasopharyngeal tumors and synthesizes this information with the author's personal experience into a rational approach to patients with the following disorders: inverted papilloma, adenocarcinoma, hemangioendothelioma, olfactory neuroblastoma, carcinosarcoma, squamous cell carcinoma, melanoma, juvenile angiofibroma, chordoma, and chondrosarcoma.

Inverted papilloma: a review of 53 cases

OBJECTIVE

To assess the surgical management of patients with inverted nasal papilloma over a 14-year period.

STUDY DESIGN

Retrospective study.

SETTING

Tertiary health care center.

RESULTS

Fifty-three patients (38 males, 15 females) with an average age of 49.8 years were treated. Overall recurrence rate was 28% and a malignant association of 9% was shown. Recurrence rates varied from 27% in patients with more extensive disease involvement treated by lateral rhinotomy and medial maxillectomy, to 30% in patients with less extensive disease treated conservatively. Of the 5 patients with associated malignancy, 3 (6% of all patients) are likely to have undergone malignant transformation.

CONCLUSION

Aggressive initial management remains the therapeutic aim in this condition.

An evolution in the management of sinonasal inverting papilloma

OBJECTIVE

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

STUDY DESIGN

Retrospective.

METHODS

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

RESULTS

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

CONCLUSIONS

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

Aggressive endoscopic resection of inverted papilloma: an update

OBJECTIVE

Endoscopic resection has been proposed for sinonasal inverted papilloma (IP). Our objective was to determine the efficacy of aggressive endoscopic resection of IP.

METHODS

Retrospective analysis was performed on patients undergoing endoscopic resection of IP at the University of Virginia between 1990 and 1996. Total ethmoidectomies, wide maxillary antrostomies, frontal recess explorations, sphenoidotomies, and turbinate resection were performed as required. Once all visible papilloma was removed, residual mucosa was removed by using a diamond burr to polish bone at the site of origin.

RESULTS

Twenty-one patients were treated with endoscopic resection of IP. Only 1 of 21 patients had an adjunctive external procedure (an osteoplastic flap without obliteration). Average follow-up was 41.9 months after initial aggressive endoscopic resection at the ureterovesical angle. Recurrences occurred in 19% (4/21) of patients. One of the 4 had two recurrences. Recurrences occurred in 16 months or less, except for one noted at 35 months and another at 56 months.

CONCLUSIONS

Aggressive endoscopic resection of IP by experienced rhinologists is an acceptable treatment.