Options in the management of inverting papilloma involving the frontal sinus

Staged Endoscopic and Combined Open/Endoscopic Approach in the Management of Inverted Papilloma of the Frontal Sinus

Background

The endoscopic management of inverted papilloma has gained increasing popularity over the last 10 years. Although early concerns over an increased risk of recurrence seem to have been allayed, the appropriate management of lesions involving the frontal sinus and frontal recess still has to be determined.

Methods

We performed a retrospective review of the results of all patients with inverted papilloma from 2000 to 2004.

Results

A total of 18 patients were treated between October 2000 and January 2004. Six patients had frontal sinus involvement at the time of initial evaluation. One of these patients had isolated frontal sinus involvement. These patients were managed with either initial endoscopic resection with determination for the need for an additional procedure at the time of endoscopic resection (n = 5) or open/endoscopic approach for isolated frontal sinus involvement (n = 1). Of the five patients who had their disease managed endoscopically, three patients were determined at the initial procedure to need an osteoplastic flap and, subsequently, were managed successfully with a combined approach. One other patient was initially successfully managed endoscopically but ultimately required an osteoplastic flap for definitive management. The fifth patient was managed entirely endoscopically with multiple procedures. All patients treated with this protocol remain disease free with an average follow-up of 13.3 months.

Conclusion

The limitations of endoscopic resection of inverted papilloma of the frontal recess can be managed with staged procedures. Initial endoscopic resection of ethmoid/maxillary disease with subsequent open treatment of the frontal sinus has been successful in our experience.

Surgical management of frontal sinus inverted papilloma: a systematic review

OBJECTIVES/HYPOTHESIS

Surgical management of frontal sinus (FS) inverted papilloma (IP) remains a significant challenge. This study systematically reviews the FS IP literature to delineate outcomes based on surgical strategy.

STUDY DESIGN

Systematic review.

METHODS

Cases for inclusion were identified by literature query for the terms frontal sinus and inverted papilloma between 1995 and 2010. Cases reported with sufficient outcomes data, defined as specific surgical approach and disease-free follow-up, were included. Statistical analysis was performed to identify significant risk factors for recurrence. The reported length of follow-up for each surgical approach was analyzed as an indicator of the strength of the reported literature for each approach.

RESULTS

Fifty-seven cases were identified in 13 studies, with 49 cases deemed adequate for additional analysis. Twenty-four cases (49%) were primary, and 25 (51%) were secondary (residual or recurrent disease) IP. Bilateral FS involvement was reported in eight cases (16.3%). Surgical approaches employed included endoscopic frontal sinusotomy (EFS) in 21 (42.9%), endoscopic modified Lothrop (EML) in 10 (20.4%), osteoplastic flap in 13 (26.5%), and endoscopic trephination and EFS in five (10.2%) patients. The overall rate of recurrence was 22.4%. Mean follow-up time was 27 months.

CONCLUSIONS

The recent reported literature of FS IP demonstrates high prevalence of recurrent and bilateral cases. Although statistical analysis of this accrued data is unable to delineate the best surgical approach for FS IP, more aggressive approaches frequently employed for secondary or bilateral disease may facilitate better disease control.

Lateral frontal sinus access in endoscopic skull-base surgery

BACKGROUND

The modified endoscopic Lothrop (MELP) or Draf III procedure can provide extended endoscopic access to the frontal sinus. The ability to access the entire frontal sinus entirely endoscopically is often debated and there is little published data to predict access based on tumor location.

METHODS

MELP was performed in 10 cadaver heads. Access was defined as the ability to contact the bone under vision with the head of a 70-degree diamond burr. Access was assessed in 3 areas: the orbital roof and the anterior and posterior walls of the frontal sinus. Endpoints were defined in millimeters from medial orbit and lateral quartile zones.

RESULTS

Complete lateral access was excellent anterior and posterior in 95% of sinuses (mean 15.5 ± 7.8 mm and 15.4 ± 7.7 mm, respectively). Access to the orbital roof was limited (10.3 ± 4.6 mm; p = 0.01 comparing anterior and posterior). For sinuses pneumatized beyond the midorbital point, only 10% of lateral orbital roofs were contacted. Orbital roof access correlated with the anteroposterior (AP) distance between the olfactory fossa and outer periosteum of the frontal beak (r = 0.6, p < 0.01).

CONCLUSION

Lateral endoscopic access to the walls of the frontal sinus is excellent except for the sinus floor. Access to the orbital roof is reliable in the medial quarter only and minimal lateral to the midorbital point. The ability to predict the areas accessible by the endoscopic approach and those areas that might require ancillary approaches is important for both surgical planning and patient expectations.

Advances in endoscopic resection of sinonasal neoplasms

Management of sinonasal diseases has undergone significant change with the advent of endoscopic techniques. A wide variety of pathology can now be surgically managed with the use of endoscopes both within and beyond the sinonasal tract. Endoscopic techniques allow for excellent visualization and complete tumor resection with low morbidity. As experience continues to grow, endonasal endoscopic techniques are becoming the surgical procedures of choice for the management of a wide variety of benign neoplasms.

Perioperative and intraoperative maneuvers to optimize surgical outcomes in skull base surgery

There are many approaches to obtaining a workable endoscopic surgical field in sinus surgery. With extended sinus and transdural endoscopic surgery, a more rigid approach must be taken. There are 3 main factors that invariably lead to poor surgical outcomes in endoscopic sinus and skull base surgery: bleeding, inadequate access, and unidentified anatomic anomalies. Bleeding is arguably the most common reason for incomplete resection. An understanding of microvascular and macrovascular bleeding allows a more structured approach to improve the surgical field in extended endoscopic surgery. The endoscopic surgeon should always be comfortable in performing the same procedure as an open operation. However, converting or abandoning an endoscopic procedure should rarely occur because much of this decision making should take place preoperatively. Along with poor hemostasis, inadequate access is an important cause of poor outcome. Evaluation of the anatomy involved by pathology but also the anatomy that must be removed to allow adequate exposure is important. This article reviews the current techniques used to ensure optimal surgical conditions and outcomes.

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.

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.

Minimally invasive resection of frontal recess/sinus inverted papilloma

OBJECTIVE

Inverted papilloma (IP) in the frontal recess/sinus poses a unique surgical challenge given the inherent difficulty in endoscopic visualization and limitations in access posed by the anatomic confines of the frontal recess/sinus. The objective of this study is to evaluate the efficacy of the minimally invasive endoscopic approach for resection of frontal recess/sinus IP.

STUDY DESIGN

Retrospective chart review.

METHODS

Five patients with frontal recess/sinus IP comprised the focus of this study. Patient charts were reviewed for demographic data, tumor location and extent, histopathology, surgical treatment strategy, operative parameters (operative time, blood loss), recurrence rate, and follow-up.

RESULTS

The average age was 55 years, and all patients were men. All patients underwent computer-aided endoscopic resection of histologically proven IP as the primary surgical modality. Adjunct approaches including endoscopic frontal trephination and modified endoscopic Lothrop were performed in 1 case each. No intra- or postoperative complications occurred in the patient group. No recurrences were noted by endoscopic and/or radiographic surveillance at mean follow-up of 16.8 months.

CONCLUSIONS

The minimally invasive endoscopic approach is effective for successful resection of frontal recess/sinus IP. Adjunctive open approaches or extended frontal drill-out approaches may be required to achieve complete tumor extirpation. Careful preoperative planning coupled with meticulous surgical technique are absolute requisites for successful management of these difficult tumors.

Limits of endoscopic visualization and instrumentation in the frontal sinus

BACKGROUND

Endoscopic limitations in the frontal sinus are poorly defined. We set out to define these limits.

METHODS

Fifteen cadaveric heads underwent endoscopic frontal sinusotomies (Draf IIA, IIB, III). Areas of frontal sinus openings were calculated. Coordinates of the most distant points for instrumentation, visualization, and instrumentation with visualization in the frontal sinus were identified with the use of image guidance.

RESULTS

Twenty-eight frontal sinuses were evaluated. The mean sinus opening areas were 47.5 mm2, 105.1 mm2, and 246.4 mm2 for Draf IIA, IIB, and III. Visualization exceeds instrumentation and visualized reach (P<0.05) regardless of different frontal sinusotomies. Anterior and lateral instrumentation and visualized reach increase as the frontal sinus opening increases (P<or=0.05). For lateral visualization, Draf III>IIB>IIA (P<0.04). There is no statistical difference for superior visualization, instrumentation, and visualized reach among various sinusotomies (P>0.05).

CONCLUSIONS

Endoscopic visualization exceeds instrumentation and instrumentation exceeds visualized reach. Enlarging frontal sinus opening area increases instrumentation and visualization.