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

Management of frontal sinus and frontal recess inverted papilloma: our experience and systematic review

Objective

For frontal sinus inverted papilloma (FSIP) management, an endoscopic endonasal approach (EEA) can be combined (or not) with an external approach by an osteoplastic flap (OPF) or with a more conservative open approach. The present study aims to describe our experience in the management of FSIP, focusing on disease-related and anatomical features influencing outcomes and recurrence.

Methods

This case series of FSIP investigated anatomical and disease-related predictors of recurrence associated with EEA or a combined EEA-OPF approach. A systematic review was also performed, selecting publications on IP with the insertion point in the frontal sinus or frontal recess.

Results

Among 30 patients included, 18 underwent EEA, while 12 received a combined EEA-OPF approach. During a median follow-up of 37 months, the frontal sinus was cleared of IP in all cases except 2 in the EEA group, who presented a complex posterior wall shape of the frontal sinus. From the systematic review, a combined EEA-OPF approach was associated with a lower risk of recurrence.

Conclusions

A correct indication for a combined EEA-OPF approach is paramount and should integrate all disease-related and anatomical features, including posterior wall shape.

Bilateral sinonasal inverted papillomas originating from both sides of the frontal sinus and the left lamina papyracea: A case report

RATIONALE

The present investigation documented a case of bilateral sinonasal inverted papilloma (SNIP) that arose from both sides of the frontal sinus and ethmoid sinus. The occurrence of bilateral involvement of the nasal cavities and frontal sinus is rather infrequent.

PATIENT CONCERNS

Informed consent was obtained from the patient.

DIAGNOSIS

Bilateral SNIP.

INTERVENTIONS

The tumor was completely removed by Draf III endoscopic resection complemented by an external eyebrow arch approach, and the postoperative recovery was uneventful.

OUTCOMES

The purpose of this paper is to present a comprehensive reference for the management of bilateral SNIP that affects the frontal sinuses.

LESSONS

This study addresses the staging and surgical management of bilateral SNIP, along with a review of the factors contributing to its recurrence. The recommended treatment method involves applying the Draf III technique combined with an external nasal approach.

Unusual Locations of Inverted Papilloma

Inverted papilloma is a tumor found involving the nasal cavity and paranasal sinuses. They are not cancerous but can be locally aggressive. They are most commonly seen involving the lateral wall of nose and maxillary sinus. When the tumor involves the frontal sinus and sphenoid sinus or the post ethmoid cells it presents a surgical challenge. Inverted papilloma almost always occur unilateraly and affect mainly the maxillary sinus. Inverted papilloma arising from the sphenoid and frontal sinuses are rare. Here we present two cases; one involving a 60 year man, with inverted papilloma originating from the frontal sinus and another case where it originated from the sphenoid sinus anterior wall and posterior ethmoidalcell (Onodi cell) and was resected endoscopically.

Endoscopic Modified Medial Maxillectomy for Inverted Papilloma of the Maxillary Sinus

BACKGROUND

Sinonasal inverted papilloma (SNIP) is a benign tumor that can be surgically managed by an endoscopic approach. However, SNIP has a high recurrence rate, mainly due to incomplete resection.

AIM

This study aimed to analyze the outcomes of endoscopic modified medial maxillectomy in treating SINP originating from the maxillary sinus.

METHODS

The authors retrospectively analyzed 24 patients treated for SNIP via endoscopic modified medial maxillectomy at our institution between August 2014 and June 2019. During surgery, the mucosa involved in the tumor was stripped, and the bone underlying the tumor base was completely excised. Demographic data, surgical technique, location of SNIP attachment, complications, follow-up duration, and recurrence were recorded.

RESULTS

Twenty four patients with SNIP were identified (16 males). All patients had Krouse stage-III disease. Eleven patients presented with single attachment and 13 with multiple attachments. None of the patients had any complications during surgery. Four patients had postsurgical facial numbness around the cheek and upper lip. After a mean follow-up of 35.12 ± 14.98 months, no recurrence of SNIP was observed.

CONCLUSIONS AND SIGNIFICANCE

Endoscopic modified medial maxillectomy is a safe and effective technique for treating SNIP. Recurrence can be reduced by complete excision of the attachment sites.

Safety and Efficacy of the Draf IIb Procedure: A Systematic Review

OBJECTIVES

To systematically review the literature to evaluate the indications, safety, and efficacy of the Draf IIb procedure and to evaluate the added advantages of technical factors such as stents and flaps.

DATA SOURCES

Articles published until July 2019 on Medline and Cochrane databases.

REVIEW METHODS

After a systematic review based on the 2018 PRISMA guidelines was conducted, 26 of 1533 articles were included and reviewed for indications of Draf IIb; surgical technique; use of flaps, stents, grafts, or mitomycin; complications during and after surgery; and success or recurrence rate.

RESULTS

The main indication for Draf IIb was chronic frontal rhinosinusitis (61.82%). The postoperative patency rate was 87.85%. When flaps/grafts were applied, the rate was 93.5%, but their added value was not statistically significant. Stents could be an alternative for revision surgery. Treating frontal pathologies other than chronic rhinosinusitis was also satisfying. Safety was comparable to Draf III: no perioperative complications were reported, only a few postoperative ones (eyelid ecchymosis and periorbital cellulitis in 0.2% of the cases, hyposmia in 1.55%).

CONCLUSION

When properly indicated, Draf IIb frontal drilling is a safe and highly effective surgical technique for frontal pathology treatment, with efficiency and safety comparable to the Draf III, making it a valid option when a bilateral approach is not needed. More studies are required to confirm the added values of flaps, grafts, and stents.

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.

Frontal inverted papillomas: A 25-year study

Objectives/Hypothesis

This study analyzes the treatment outcomes of frontal inverted papillomas (FIPs) in an attempt to provide guidelines for surgery selection.

Study Design

Retrospective case series.

Methods

The treatment results of 29 FIPs classified into five categories were retrospectively analyzed. The five categories are F1, tumor prolapsed into frontal sinus, tumor origin outside frontal sinus; F2, tumor origin inside frontal sinus, medial to the plane of lamina papyracea; F3, tumor origin inside frontal sinus, lateral to the plane of lamina papyracea; F4, bilateral; and F5, extrasinonasal.

Results

Of the 11 F1 cases, 73% had Draf I and 27% had Draf IIA procedures. There was one (9%) frontal recurrence and one (9%) frontal stenosis. Of the 10 F2 cases, 10% had Draf I, 40% had Draf IIA, 40% had Draf IIB, and 10% had Draf III surgery with a trephination. One patient (10%) had a frontal recurrence. Of the five F3 cases, 40% had Draf IIA surgery, 20% had external frontoethmoidectomy, and 40% had external frontal sinusotomy. The recurrence rate was 60%, and frontal stenosis rate was 60%. The two F4 cases had external frontal sinusotomies and Draf III surgery with no frontal recurrence or stenosis. The patient with the F5 had a frontal recurrence after Draf IIA surgery and external frontoethmoidectomy.

Conclusions

Draf I or IIA surgery is adequate for most F1 tumors, and Draf II surgery is adequate for most F2 tumors. F3 and F4 tumors can be managed initially by Draf III surgery with external frontal sinusotomy added when required. F5 tumors probably require combined surgical approaches.

Level of Evidence

4 Laryngoscope, 130:1622–1628, 2020

Origin site-based staging system of sinonasal inverted papilloma for application to endoscopic sinus surgery

Background

We aimed to assess the recurrence risk of sinonasal inverted papillomas (SNIPs), based on a staging system developed according to the originating site of SNIP.

Methods

A total of 200 patients with SNIP were enrolled, and a staging system was developed based on the originating sites and corresponding recurrence rates of tumor in the patients. In the verification phase, 675 patients with SNIPs were enrolled as above, and the originating sites of the SNIPs were confirmed by an endoscopic sinus surgery. Cluster analysis was performed to determine the stage for each SNIP.

Results

Overall, 608 patients completed the study. SNIP recurrence rates for stages 1‐4 were 0 (n = 43), 4.0% (n = 420), 13.4% (n = 134), 36.4% (n = 11), respectively (total = 6.4%).

Conclusions

The origin site‐based classification of SNIP may aid surgeons in selecting appropriate endoscopic surgical approaches to minimize the risk of recurrence.

Mucocele formation after surgical treatment of inverted papilloma of the frontal sinus drainage pathway

BACKGROUND

Inverted papillomas (IP) inserted in the frontal sinus and/or recess may be treated by using an endoscopic endonasal or an external approach. There are still few data available on this uncommon localization of IPs.

OBJECTIVE

To report our experience in the management of IP of the frontal drainage pathway, to describe a previously unreported specific complication of this surgery, and to discuss the optimal surgical strategy.

METHODS

A retrospective study of the patients at a tertiary care center between 2004 and 2014 who were operated on for an IP with an insertion in the frontal recess and/or the frontal sinus. Clinical charts were reviewed for demographics, clinical presentation, imaging findings, surgical treatment, and outcome.

RESULTS

Twenty-seven patients were included. Patients were operated on by using a purely endoscopic approach (Draf procedure; n = 14 [51.9%]) when the IP was inserted in the frontal recess and/or the frontal sinus infundibulum (with a nasoseptal-septoturbinal flap placed on the exposed bone in four patients), or by using a combined endoscopic and open approach (osteoplastic flap procedure; n = 13 [48.1%]) when the IP invaded the frontal sinus beyond the infundibulum. There were two recurrences (7.4%), with a mean follow-up of 40 months (range, 9-123 months). During follow-up, single or multiple iatrogenic frontal mucoceles were observed in 10 patients (37%), with a mean delay of 60 months (range, 27-89 months). These mucoceles occurred both after using endoscopic (n = 3) or combined (n = 7) approaches, and required a surgical treatment in eight patients. No postoperative mucocele was observed in the four patients who had had a septal flap.

CONCLUSION

In our experience, an approach based on the localization of the IP insertion provided acceptable results in terms of the local control rate (92.6%). However, the significant rate of postoperative mucoceles indicated that specific strategies (such as local flaps) still need to be developed to avoid this iatrogenic complication.

Challenges in the Management of Inverted Papilloma: A Review of 72 Revision Cases

OBJECTIVES/HYPOTHESIS

We report on the treatment outcome of endoscopically managed sinonasal inverted papilloma, focusing on revision cases. Our aim was to identify the properties of revision cases that affect treatment outcome by comparing them to primary cases in a single center. We propose using 5-fluorouracil (5-FU) in the postoperative management of inverted papilloma.

STUDY DESIGN

A retrospective single-center case series. This study met the criteria for approval by the local medical ethics committee.

METHODS

We performed a retrospective chart review identifying patients operated on between January 2003 and September 2013. Data were collected about patient demographics, symptoms, tumor attachment site, imaging, intraoperative and pathological findings, surgical approaches, postoperative treatment, follow-up, and recurrence.

RESULTS

One hundred and twenty-one (72 revision and 49 primary) cases were retrieved with a minimum follow-up of 1 year. Revision cases have significantly higher Krouse staging (P = 0.003), different distribution of tumor attachment sites, and higher recurrence rates. The recurrence rate was 4.1% for primary cases (mean follow-up 35.5 months) and 18.1% for revision cases (mean follow-up 45 months). Eight of the recurrent cases recurred within the first year. 5-fluorouracil was applied postoperatively in 18 (5 primary and 13 revision) cases, which included one (5.6%) recurrence and one minor complication (transient periorbital swelling).

CONCLUSION

The most important factors in preventing the recurrence of inverted papilloma are the determination of the location of the attachment and the completeness of resection in the primary endoscopic surgery. Revision cases have a higher recurrence rate, and the attachment sites are surgically more challenging. The use of 5-FU might have a place in the postoperative treatment of surgically challenging inverted papilloma.

LEVEL OF EVIDENCE

4.

Endoscopic transnasal management of inverted papilloma involving frontal sinuses

Inverted papilloma is a benign locally aggressive tumor of paranasal sinuses which has been traditionally managed with external surgical approaches. Advances in tumor imaging, surgical instrumentation and intraoperative visualization have led to a gradual shift to endonasal attachment-oriented surgery. Involvement of both frontal sinuses by inverted papilloma is rare. There are scant reports in the literature regarding this topic. We present 2 cases of the tumor involving both frontal sinuses removed by median drainage (Draf III procedure) under endoscopic guidance without any additional external approach. The whole cavity of both frontal sinuses was easily inspected at the end of the procedure. No early or late complications were observed. No recurrence was seen in 1-year or 2-year follow-up. Management of frontal sinus inverted papilloma with the endoscopic median drainage approach is feasible and seems to be effective.

The outside-in approach to the modified endoscopic Lothrop procedure

OBJECTIVES/HYPOTHESIS

Drilling in modified endoscopic Lothrop procedure (MELP) is traditionally described as commencing from the frontal recess (FR). This is challenging when the FR is involved by tumor, inflammatory disease, or scarring. The outside-in MELP, where the limits of the sinusotomy are first defined and the FR is addressed last, is described.

STUDY DESIGN

Case-control study.

METHODS

Patients undergoing MELP, using the standard or outside-in approach, for inflammatory disease or endoscopic skull base surgery were assessed. Data were collected on demographics, disease characteristics, and FR involvement. Operative time was calculated from intraoperative video recording. Time points recorded were times to frontal sinus and recess connected for outside-in MELP and completion of Lothrop cavity for both groups. Perioperative complications (infection, skin breach or contusion, surgical emphysema, orbital bleeding, cerebrospinal fluid leak, and intracranial complications) were recorded.

RESULTS

Thirty patients (67% female) with a mean age ± standard deviation of 56.0 ± 10.8 years underwent MELP (24 outside-in, six standard). Time for Lothrop completion was shorter for outside-in MELP (30.60 ± 14.10 minutes vs. 69.66 ± 64.52 minutes, P = .002). Among outside-in MELP, mean time to frontal sinus floor discovery was 8.41 ± 6.29 minutes, to recess connected 26.50 ± 12.45 minutes, and were similar regardless of pathology. The time for Lothrop cavity completion was shorter for tumor cases (24.63 ± 6.49 minutes) than for chronic rhinosinusitis without polyps (35.87 ± 20.18 minutes) and chronic rhinosinusitis with polyps (34.62 ± 11.56 minutes) (P = .05). One patient had skin edema. No other complications were recorded.

CONCLUSIONS

The outside-in MELP is technically feasible and safe. Its advantage is a wide approach to the frontal sinus with development of the Lothrop cavity en route resulting in short predictable operative times. Defining the limits of the dissection early provides a robust and efficient approach.

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.

Modified endoscopic maxillary medial sinusotomy for sinonasal inverted papilloma with attachment to the anterior medial wall of maxillary sinus

OBJECTIVES

The endoscopic management of inverted papilloma (IP) has gained in popularity over the last 15 years. However, the appropriate management of lesions involving the anterior medial wall of the maxillary sinus still has to be determined.

METHODS

We performed a retrospective review of the surgical results for patients with IP attached to the anterior medial wall of the maxillary sinus in the Otolaryngology, Head and Neck Surgery Department, Beijing TongRen Hospital. The tumors were removed by using our surgical technique of modified endoscopic maxillary medial sinusotomy, which was defined as an extended endoscopic medial maxillectomy with preservation of the nasolacrimal duct and inferior turbinate. Sinus endoscopy was used to screen for disease after endoscopic resection and the clinical outcomes were analyzed.

RESULTS

A total of 7 patients (4 males and 3 females) were identified. Pre- and postoperative pathological examinations revealed inverted papilloma as the diagnosis. All tumors were defined as Krouse III lesions. There were no complications recorded as a result of surgery. All patients remain disease free with a mean follow-up of 35.7 months (range 20-68 months).

CONCLUSION

Sinonasal IP with attachment to the anterior medial portion of the maxillary sinus can be treated successfully using modified endoscopic maxillary medial sinusotomy with preservation of the nasolacrimal duct and inferior turbinate.

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.

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.

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.

Management of Sinonasal Inverted Papillomas and Comparison of Classification Staging Systems

Background

The aim of this study was to describe treatment results in patients with sinonasal inverted papilloma and to compare recent classification staging systems.

Methods

We performed a retrospective study of 79 patients with primary paranasal sinus inverted papilloma from 1978 to 2008.

Results

The median age at diagnosis was 59 years. There were 68 men (86%) and 11 women (14%). Sixty inverted papilloma (76%) were located in the ethmoidal sinus complex, 16 (20%) were in the maxillary sinus, 2 were in the sphenoid sinus (3%), and 1 was in the septum (1%). Malignancy was simultaneously associated in four cases (5%). Intracranial extension was found in five patients (6%) and we did not find orbital content involvement. The external approach was used in 22 cases (28%) and 57 patients were treated with endoscopic nasal resection (72%). The overall recurrence rate in the total population was 21%. Recurrences were observed in 7 cases (32%) in the group of patients who received external approach and in 10 (17%) patients in the endoscopic group. Recurrences according to the Krouse system were 0% in T1 stage, 16% in T2 stage, 25% in T3 stage, and 60% in T4 stage (p = 0.05). Recurrences for groups A, B, and C stages using the Cannady staging system were 12, 26, and 60%, respectively (p = 0.039). Recurrences according to Han's system were 19% in both T1 and T2, 20% in T3, and 60% in T4 (p > 0.05).

Conclusions

Our results support the endoscopic approach as the treatment of choice when feasible in patients with inverted papilloma, combined in selected cases with external approaches. The Krouse and Cannady systems provided a good distribution of patients according to local control.

Inverted papilloma involving the frontal sinus: a management plan

Inverted papilloma is a benign but locally aggressive sino-nasal tumour. Although relatively uncommon, involvement of the frontal sinus by this tumour represents a significant surgical challenge. The objective of the study is to propose a scheme for management of inverted papilloma involving the frontal sinus, based upon the findings of the current study. All cases of inverted papilloma operated upon between July 1995 and June 2008 were retrospectively reviewed to identify cases in which the tumour involved the frontal sinus. Among 34 patients with inverted papilloma, 4 were found to have tumours involving the frontal sinus (11.76%). These patients were initially treated by endonasal endoscopic resection. At time of initial surgical excision, the tumour was found to involve the frontal sinus by expansion from the ethmoids in three of these patients. In the fourth patient, the tumour was found to be massively involving the frontal sinus mucosa. After a mean follow-up of 16.3 months, no recurrences were detected in the first three patients. In the patient with massive mucosal involvement, recurrence was detected 4 years after the initial endonasal endoscopic resection. Subsequently, an osteoplastic flap was performed to resect the tumour. Fifty months later the patient remained disease free. Surgeons managing patients with frontal sinus inverted papilloma should have a clear management scheme before embarking on surgery. The patient's consent should be obtained pre-operatively for a possible osteoplastic flap. Tumours just expanding into the frontal sinus can be managed by either endoscopic or nonendoscopic approaches. On the other hand, in tumours significantly involving the frontal sinus mucosa, an osteoplastic flap is warranted to ensure complete tumour resection.