Inverted papilloma: a review of 53 cases

The implications of concomitant mucosal inflammation on clinical manifestations and outcomes of sinonasal inverted papilloma

PURPOSE

This study examines the impact of concomitant mucosal inflammation on clinical manifestations and long-term outcomes of Inverted Papilloma (IP).

METHODS

This retrospective cohort study was conducted in five tertiary medical centers. The included patients underwent an attachment-oriented surgical resection for IP with a minimum follow-up of 3 years.

RESULTS

Of 185 patients with IP, 65 patients (35.1%) had synchronous mucosal inflammation with polypoid changes. The mean age was 56.7 years, and 69% were males. Most tumors originated from the maxillary sinus. Age, gender, Krouse stage, and tumor attachment site did not differ between the mucosal inflammation and IP-only groups. IP recurrence rate was twofold in the patients with mucosal inflammation (15.4% vs. 7.5%, p = 0.092). However, the difference was not significant, with a similar median time to recurrence between the two groups [15.5 (3-36) months vs. 16(6-96) months, p = 0.712]. In revision cases, IP recurred only in patients with mucosal inflammation (19% vs. 0%, p = 0.07). This group had a significantly worse 5-years recurrence-free survival than revision cases without mucosal inflammation (80.6% vs. 100%, p = 0.04).

CONCLUSIONS

IP in the setting of mucosal inflammation might be associated with a higher recurrence rate, predominantly after revision surgery. Otolaryngologists should consider this during these patients' diagnosis, surgical planning, and follow-up.

Sinonasal inverted papilloma associated with small cell neuroendocrine carcinoma: A case report and literature review of rare malignancies associated with inverted papilloma

We report a rare case of sinonasal inverted papilloma (IP) associated with small cell neuroendocrine carcinoma (SNEC). To our knowledge, this is the first report to describe SNEC found during the treatment of sinonasal IP. Surgery and five cycles of cisplatin plus etoposide with concurrent intensity modulated radiation therapy were performed. Neither local recurrence nor distant metastasis was noted during 6 years of post-diagnostic follow-up. The prognosis of SNEC is very poor. Treatment planning for sinonasal IP should consider a possible association with this rare but aggressive malignancy, whose treatment is completely different from that of squamous cell carcinoma, a malignancy which is commonly associated with IP. We also performed a PubMed review of the literature to identify the incidence and pathological diagnosis of associated malignancy. Among a total of 5286 cases of sinonasal IP (61 studies), the incidence of associated malignancy was 8.02% in squamous cell carcinoma, 0.19% in transitional cell carcinoma, 0.04% in mucoepidermoid carcinoma, 0.02% in verrucous cell carcinoma and 0.02% in adenocarcinoma. The incidence of associated malignancy was significantly higher in East and Southeast Asia (11.0%) and North America (10.4%) than in Europe (3.9%) (p=0.04 and p=0.03, respectively; T-test).

Endoscopic Resection of Inverted Papilloma: University of Miami Experience

Background

The aim of this study was to evaluate the efficacy and safety of endoscopically resecting paranasal sinus inverted papillomas at a tertiary medical center.

Methods

Over a 9-year period, 51 patients with a diagnosis of inverted papilloma underwent endoscopic resection at the University of Miami/Jackson Memorial Medical Center. The study group consisted of 14 women and 37 men with a mean age of 59 years (range, 20–88 years) enrolled in a clinical data base. All of the patients were followed endoscopically at regular intervals on an outpatient basis.

Results

Endoscopic evidence of extensive papillomas involving the anterior and posterior ethmoid sinuses and at least one (usually the maxillary) dependent sinus was found in 60% of the cases. Extensive radiological disease (varying degrees of mucoperiosteal thickening or opacification of all five cavities) was evident in 50% of the cases. All but two had unilateral disease. An association with chronic inflammatory polyps (clinically and pathologically) was observed in 25 of 51 patients (49%). Follow-up ranged from 6 to 99 months (mean, 30 months). There have been seven recurrences (14%). Four of these have been managed in the office under topical anesthesia. Three recurrences were managed surgically in the operating room. All of the patients have been free of disease. Complications included an intraoperative CSF leak (three patients); temporary infraorbital hypesthesia (three patients); periorbital ecchymosis, hematoma, or cheek edema (four patients); and orbital symptoms (two patients). Carcinoma was found in four patients (8%) who received postoperative radiotherapy and remain free of disease.

Conclusion

The endoscopic approach continues to provide at least equivalent short-term results as compared with external techniques for the removal of paranasal sinus inverted papilloma. The final cavity should allow for adequate postoperative surveillance and potential resection of recurrences in the office setting, without the need for a return to the operating room in most patients. The association of inverted papilloma with chronic inflammatory polyps and tobacco use warrants additional study.

Endoscopic Management of Extensive Inverted Papilloma

Background

Given the malignant potential and propensity for recurrence of inverted papilloma (IP) of the sinonasal cavity, complete excision is warranted. For disease extending to multiple sites, open surgical oncological procedures are associated with high morbidity and do not assure complete control of the tumor. The endoscopic approach provides excellent visualization, permits removal of diseased mucosa while preserving vital anatomic structures, and allows for excellent postoperative surveillance. Recurrences are identified early and endoscopic resection is repeated as necessary until there is no evidence of disease.

Methods

Data were prospectively collected and subsequently reviewed on 18 consecutive patients who underwent endoscopic management of extensive IP (present at more than one anatomic site) between 1999 and 2003.

Results

Fourteen men and four women with a mean age of 54 years (range, 36–74 years) were followed for an average of 29 months (range, 6–46 months) after initial endoscopic resection. Seventy-eight percent (14 patients) complained of nasal airway obstruction for more than 6 months and 22% (4 patients) were incidentally noted to have a nasal mass on endoscopy or computed tomography. Eleven patients had undergone therapeutic procedures on initial evaluation. The most common sites affected were maxillary sinus, lamina papyracea, and ethmoid sinus. Patients required an average of 1.6 endoscopic surgeries (range, 1–3 surgeries) to achieve local control; 10 patients (56%) required only one. All patients were symptomatically improved and complications were limited to one cerebrospinal fluid leak, which was repaired intraoperatively.

Conclusion

Extensive IP can be controlled using minimally invasive endoscopic procedures as long as close follow-up is maintained. Operative risk and postoperative morbidity are significantly less than observed with open procedures.

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.

Basaloid squamous cell carcinoma arising in an inverted papilloma in the nasal cavity: A case report and review

Basaloid squamous cell carcinoma (BSCC) is a histologically distinctive variant of squamous cell carcinoma comprising basal cell carcinoma and squamous cell carcinoma. BSCC is aggressive and shows a poor prognosis because of frequent lymph node invasion and distant metastases. BSCC preferentially occurs in the cervix, thymus, and esophagus and is uncommonly found in the head and neck region. BSCC in the nasal cavity or paranasal sinus is particularly rare. Inverted papilloma is an uncommon, benign tumor with a propensity to be associated with malignancy; however, BSCC arising in an inverted papilloma has never been reported. Here we report a case of a 56-year-old woman with BSCC arising in an inverted papilloma in the nasal cavity. The woman was referred to our hospital for epistaxis, nasal congestion, and dysphagia. A tumor was observed to completely occupy the left nasal cavity. The biopsy specimen was histologically diagnosed as papilloma. Computed tomography demonstrated a tumor with heterogeneous contrast effect occupying the left nasal cavity; however, extra-nasal tract extension was not observed. We performed endoscopic excision of the tumor. Microscopic findings confirmed the diagnosis of BSCC arising from an inverted papilloma. No tumor recurrence has been observed for 13 months after surgery.

Recurrence of sinonasal inverted papilloma following surgical approach: A meta-analysis

OBJECTIVES/HYPOTHESIS

Inverted papilloma (IP) is a rare benign tumor, which is found in the sinonasal area. It is characterized by recurrence, local destruction, and malignant change. Of these, recurrence is a challenging problem to many otolaryngologists. In this study, we evaluated recurrence based on the type of surgical approach using a meta-analysis.

STUDY DESIGN

MEDLINE, Embase, and Cochrane database.

METHODS

Relevant studies were identified by searching the following databases: MEDLINE, Embase, and Cochrane through February 2016. Random-effects models were used to estimate risk ratio (RR) and 95% confidence interval (CI). The Newcastle-Ottawa scale was used to assess the quality of cohort studies.

RESULTS

Our search yielded 14 retrospective cohort studies involving a total of 696 endoscopic approaches and 444 nonendoscopic approaches. The pooled RR for IP recurrence (endoscopic vs. external approach) was 0.56 [95% CI: 0.36-0.85, I² =48.3%]. A subgroup analysis was also performed.

CONCLUSIONS

Surgical management of IP via an endoscopic approach reduces the risk of recurrence compared to an external approach. Although further data are needed, early- stage IP requires endoscopic or endoscopic-assisted surgery to reduce the risk of tumor recurrence.

LEVEL OF EVIDENCE

NA Laryngoscope, 127:52-58, 2017.

Survival Outcome of Squamous Cell Carcinoma Arising from Sinonasal Inverted Papilloma

Background:

Sinonasal inverted papilloma (IP) is a rare benign tumor of the nasal cavities and paranasal sinuses. It is destructive or bone-remodeling, tends to recur after surgical resection, and has a significant malignant potential. The present study aimed to perform a retrospective analysis of patients with squamous cell carcinoma (SCC) arising from IP, including characteristics, survival outcome, and predictors of associated malignancy.

Methods:

The medical records of 213 patients diagnosed with IP from January 1970 to January 2014 were retrospectively reviewed. Eighty-seven patients were diagnosed with SCC/IP; their clinical characteristics, treatments, and survival outcomes were analyzed.

Results:

Of the 87 patients with SCC/IP, the 5- and 10-year overall survival outcomes were 39.6% and 31.8%, respectively. Twenty-nine of these patients received surgery and 58 received combined surgery and radiation. Of the patients with stages III–IV, the 5-year survival rate was 30.7% for those treated with surgery only and 39.9% for those given the combination treatment (P = 0.849). Factors associated with significantly poor prognosis were advanced-stage, metachronous tumors, or with cranial base and orbit invasion. Age, synchronous or metachronous tumors, and pathological stage were independent risk factors for mortality, shown by multivariate analysis.

Conclusion:

Patients with SCC/IP had low overall survival outcomes. Advanced age, stage, and metachronous tumors are the main factors affecting prognosis. Treatment planning should consider high-risk factors to improve survival outcome.

Management and treatment of sinonasal inverted papilloma

AIMS

The aim of this paper is to describe the surgical experience of 35 patients with Inverted Papilloma (IP) of paranasal sinuses and its recurrence rate after a year of follow-up.

MATERIALS

A retrospective chart review was performed on patients presenting with IP of paranasal sinuses. Thirty-five patients comprised the focus of this study. For all patients was performed a pre-surgery TC, and for more 5 patients it was necessary to perform a Magnetic Resonance (MR) with gadolinium.

RESULTS

Among 35 patients selected, 18 patients underwent to open surgery, 4 patients had a combined approach with endoscopy and open surgery, while 13 patients were managed only with an endoscopic approach, with a minimum of 1 year of follow-up. Our results highlighted that the global percentage of success 12 months after the treatment was 93% and it not vary according to the tipology of the approach used if a radical excision of the lesion is achieved. More in depth, among 35 cases, only 2 patients were found to have recurrences and were treated with coronal and endoscopic approach.

CONCLUSION

It is fundamental to underline that surgery must be carried on in a radical manner to treat these tend to recur. A complete removal of the lesion and bone peripheral border filing are essential to perform a correct and definitive treatment. Also, endoscopic approach can be taken into account when tumors are localized median to a sagittal plan crossing the orbit median wall and when they did not massively compromised paranasal sinus walls.

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.

Sinonasal carcinoma associated with inverted papilloma: a report of 16 cases

OBJECTIVES

To analyse the characteristics and outcome of patients with carcinoma associated with inverted papilloma, and find predictors of associated malignancy.

METHODS

The medical records of 228 patients who were diagnosed with IP between January 1990 and December 2010 were retrospectively reviewed. Out of 228 patients, 16 were also diagnosed with carcinoma. We evaluated their clinical characteristics, treatment modalities, and survival outcomes.

RESULTS

The incidence of carcinoma associated with IP was 7.0%. Fourteen were synchronous carcinomas and two were metachronous. Tumours arising inside the frontal sinus or the frontoethmoidal recess were more likely to be associated with carcinoma. Patients who had a stage of T2 or less had a much better outcome than those who had a stage of T3 or greater (disease-free period, 84.8 months vs. 5.7 months, p<0.001).

CONCLUSION

Tumours originating in the frontal sinus or frontoethmoidal recess have a tendency to be associated with carcinoma. As most (87.5%) of the carcinomas were diagnosed at the same time as the inverted papilloma, complete histological examination of the whole excised tumour is warranted because early diagnosis and treatment is essential as T2 and lower stage carcinomas had a strikingly better prognosis than T3 and higher stage carcinomas.

Preoperative staging of sinonasal inverted papilloma by magnetic resonance imaging

OBJECTIVES/HYPOTHESIS

Sinonasal inverted papilloma is a rare but locally aggressive benign tumor. Inverted papilloma tends to recur after surgical resection and is occasionally associated with squamous cell carcinoma. Radical en bloc resection by lateral rhinotomy and medial maxillectomy has been recommended for initial management; however, endoscopic sinus surgery is effective in selected cases. To determine adequate surgical approaches, a staging system for inverted papilloma based on extent and location of the tumor has been advocated. The study investigated whether preoperative assessment by magnetic resonance imaging (MRI) accurately predicts the extent of inverted papilloma.

STUDY DESIGN

Magnetic resonance imaging was retrospectively reviewed in 21 cases of inverted papilloma without knowledge of the surgical and pathological findings.

METHODS

Patients were categorized into stages based on MRI findings, according to the staging system proposed by Krouse. The involvement of inverted papilloma in each sinus was also assessed.

RESULTS

Stages graded by MRI were coincident with postoperative staging verified by surgical and pathological findings in 18 of the 21 cases (86%), which included 1 case of stage T1, 3 cases of stage T2, and 14 cases of stage T3. Two cases of stage T2 were judged as T3, and one case of T3 was judged as T2 by MRI. Positive predictive value of MRI diagnosis for tumor involvement was 68% to 89% in each sinus, and negative predictive value was more than 93%.

CONCLUSION

In most cases, MRI assessment of inverted papilloma can accurately predict the extent of tumor involvement. Preoperative staging of inverted papilloma by MRI may be useful for planning an appropriate surgical approach.

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.

Survival outcomes of squamous cell carcinoma arising from sinonasal inverted papilloma: report of 6 cases with systematic review and pooled analysis

BACKGROUND

Inverted papilloma (IP) is an uncommon sinonasal tumor. Squamous cell carcinoma (SCC) is associated with IP in about 7% of cases. To date, there has been no pooled analysis to formulate a survival outcome associated with this rare condition.

PATIENTS AND METHODS

We retrospectively reviewed the medical records of patients with IP and SCC treated at our institution during 1999-2007. Including our series, a systematic review of literature on Medline database and pooled analysis were performed to establish a survival estimate.

RESULTS

Six patients were identified. Squamous cell carcinoma was metachronous to the initial diagnosis of IP in 1 case and synchronous in 5 cases. Of 5 patients who had completed therapy at the time of this report, only 1 remained disease-free at 74 months. The median overall survival in our series was 33 months. Three patients developed distant metastases in brain, lung, bone, and liver. Literature review and pooled survival analysis consisting of 76 cases indicated a median overall survival of 126 months with 3- and 5-year survival rates of 63% and 61%, respectively.

CONCLUSION

Although the survival outcome of SCC arising from IP seems comparable with sinonasal SCCs, some patients with this disease do have a highly aggressive disease, including hematogenous distant metastasis. Overall, about 40% of patients will die of the disease within the first 3 years.

[Results of treatment papilloma of nasal cavity and paranasal sinuses]

INTRODUCTION

Papilloma of the nose and paranasal sinuses is a benign tumor originated from nose mucosa. Especially inverted papilloma tumor has a significant recurrence and malignancy potential rate. The aim of the study was the analysis of clinical and treatment outcomes of patients with papilloma of the nose and paranasal sinuses.

MATERIAL AND METHODS

The retrospective analysis was curried out on 41 patients--16 with papiloma of the nasal vestibule and 25 with inverted papilloma the nose and paranasal sinuses surgically treated in I ENT Clinic Medical University in Lodz between 1998-2004 years. We analyzed patient's complains, clinical data and surgical follow-up results.

RESULTS

The most frequent complains was increasing unilateral nasal obstruction and rhinorhea. Nasal vestibule papilloma were intranasal removed in all cases. In extended tumor nose and paranasal sinuses in 14 cases intranasal procedures, in 7 sublabial approached, in 4 lateral rhynothomy were performed. In 5 patient local recurrences was observed and in 3 neoplasmatic transformation.

CONCLUSION

The choice of surgical management should be individual with respect to tumor localization and extension of neoplasmatic process. The treatment result depends of radical tumor resection.

[Sinonasal basaloid squamous cell carcinoma in biopsies of inverted papilloma]

Basaloid squamous cell carcinoma (BSCC) is a rare tumor representing an aggressive variant of squamous cell carcinoma (SCC) and arising from a common precursor cell. BSCC rarely originates from the sinonasal tract. We report on an 83-year-old woman with BSCC after multiple resections of an inverted papilloma (IP) of the left sinonasal tract. The tumor filled the nasal cavity completely and was infiltrating the ipsilateral frontal skull base and periorbita. Because of the tumor's expansion, the patient's age, and comorbidity, surgery was not performed, but primary radiotherapy was initiated. A possible association between sinonasal BSCC and IP, as implicated by the current case, must be further investigated. In any case, IP requires consequent endoscopic and, if necessary, radiological follow-up in order to detect recurrent disease or malignant transformation.

[Surgical management of inverted papillomas of the nose and paranasal sinuses]

INTRODUCTION

Inverted papillomas require radical resection because of their high recurrence rate and expansive growth and the risk of malignant degeneration. Since the late 1980s surgical resection has been performed predominantly as an endoscopy-/microscopy-aided procedure through an endonasal approach. The extranasal approach is only used in the case of papillomas in unusual locations or ones that have expanded to an exceptional degree. The goal of the present study was a comparative evaluation of the results of this relatively new treatment strategy and of external sinus surgery in our own patients, with particular reference to the recurrence rate.

PATIENTS AND METHODS

Since 1989 a total of 80 patients have undergone surgery for inverted papilloma and have been followed up at regular intervals by means of endoscopic examinations. In any patients with a recurrence the revision operation was carried out through an extranasal approach when the papilloma was in the anterior or laterocaudal maxillary sinus or in the frontal sinus; in all other cases an endonasal approach was used for the revision surgery. The mean period of follow-up was 43 months (range 15 months to 16years).

RESULTS

In most patients (n=64, 80%) the endonasal surgical approach was used for the primary surgical treatment, while in 16 patients (20%) an extranasal approach was used initially. In 2 patients (2.6%) a squamous cell carcinoma was discovered adjacent to the papilloma. These two therapeutic special cases were not considered evaluable in the analysis of recurrences. Recurrences were seen in 14 patients (17.9%, n=78), in 11 patients after endonasal surgery (17.5%, n=11) and in 3 (20%, n=15) after extranasal resection. The majority of recurrences developed in patients with T3 papillomas.

CONCLUSIONS

The recurrence rates observed after endonasal resection are comparable to those after extranasal surgery. Thus, a primary endonasal approach does not mean any prognostic disadvantage. This approach should therefore be given preference over extranasal approaches whenever possible, because there are fewer side-effects and recovery is faster than after extranasal surgery.

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).

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.

Inverted papilloma of paranasal sinuses

INTRODUCTION

Inverted papilloma (Schneiderian papilloma) is a primarily benign lesion that occurs in the nasal cavity and paranasal sinuses. Clinical problems include a tendency towards local destruction, recurrence and malignant transformation into squamous cell carcinoma. Hence, complete surgical removal is the therapy of choice and a meticulous follow-up is mandatory.

STUDY DESIGN

This is a review including a short introduction to the different histological types of nasal papilloma, their pathogenesis and the clinical and histopathological diagnosis. Staging systems, therapeutic approaches, and surgical concepts are discussed.

RESULT

The detection and definition of factors that allow a prognosis of recurrence or malignant transformation of inverted papilloma is an active field of research. The results of studies dealing with the definition of prognostic factors, that investigated immunohistochemical methods, virus detection, molecular genetics, and histomorphological studies are discussed including our own results on the prognostic value of histology. A concept for the diagnosis, management, therapy and follow-up of inverted papilloma is proposed.

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.

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.

Histopathological parameters of recurrence and malignant transformation in sinonasal inverted papilloma

CONCLUSIONS

A combination of parameters may be useful in predicting the clinical course of squamous cell carcinoma in inverted papilloma (IP). In particular, the parameters hyperkeratosis, squamous epithelial hyperplasia and high mitotic index were negative prognostic indicators.

OBJECTIVE

To define histopathological parameters which could predict the recurrence and development of squamous cell carcinoma in IP.

MATERIAL AND METHODS

We analyzed the histopathological characteristics of 39 cases of IP using the following parameters: site of origin of tumor; presence of bone invasion; presence of inflammatory polyp; ratio of endophytic to exophytic lesions; ratio of neoplastic epithelium to stroma; presence of hyperkeratosis; presence of squamous epithelial hyperplasia; mitotic index; number of mucin globules; and number of eosinophils.

RESULTS

Malignancy was related to the presence of bone invasion (p=0.039), the absence of inflammatory polyp (p=0.033), increase in the ratio neoplastic epithelium:stroma (p=0.037), increase in hyperkeratosis (p=0.030), the presence of squamous epithelial hyperplasia (p=0.044), increase in the mitotic index (p=0.029) and a decrease in the number of eosinophils (p=0.037). Multiple recurrences (without malignancy) were related to frontal sinus origin (p=0.042), increase in hyperkeratosis (p=0.041), the presence of squamous epithelial hyperplasia (p=0.044) and increase in the mitotic index (p=0.031). Clinically benign behavior was related to the presence of inflammatory polyp (p=0.010) and the absence of hyperkeratosis (p=0.008).

Markers of malignant transformation of sinonasal inverted papilloma

AIM

To measure HPV status, epidermal growth factor receptor (EGFR) and transforming growth factor-alpha (TGF-alpha) expression and Ki-67 index in exophytic papilloma (EP), inverted papilloma (IP) with dysplasia, IP with carcinoma and invasive squamous cell carcinoma (SCC).

METHODS

Forty-four patients with sinonasal papilloma and invasive SCC were selected. The nasal tissues were stained with monoclonal antibodies to EGFR, TGF-alpha and Ki-67. The results were analysed using quantitative immunohistochemical analysis. In situ hybridization studies for HPV DNA for 6/11, 16/18 and 31/33 were also performed on the tissue.

RESULTS

Significant increase of EGFR and TGF-alpha was observed in IP with severe dysplasia, IP with carcinoma and invasive SCC compared to IP with mild dysplasia and control nasal mucosa. And a serial upreguration in terms of Ki-67 index in IP with dysplasia was observed. Among IP, HPV 6/11-positive was present in 42% tumour and HPV 16/18-positive was present in 31% of tumours. Among HPV 6/11 and 16/18-positive IP, significant increase of EGFR and Ki-67 index were observed.

CONCLUSION

Pre-cancerous lesions of IP exhibited elevated levels of EGFR and TGF-alpha and these expression may be associated with early events in IP carcinogenesis. HPV infection may be an early event in a multistep process of malignant formation of IP.

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.

Impact of resection of the turbinates and the lateral nasal wall on particle deposition

OBJECTIVES/HYPOTHESIS

The aim of the investigation was to determine the influence of complete resection of the turbinates and the lateral nasal wall on nasal deposition of particulate matter with an aerodynamic diameter of 10 microm or less (pm10) and its relation to nasal patency and geometry.

STUDY DESIGN

Retrospective study.

METHODS

Eight patients were enrolled in the study after unilateral sinus surgery for a unilateral inverted papilloma of the sinuses. Particle deposition from the inhaled and exhaled air was measured by means of a laser particle counter in the nasal valve area and the nasopharynx during nose-only breathing and nose-in, mouth-out breathing. The data on deposited fraction for the operated side were compared with the data for the untreated, healthy side. Rhinomanometry and acoustic rhinometry were performed.

RESULTS

Particle deposition did not differ significantly between the operated and untreated sides of the nose at both detection sites. No correlation between the deposited fraction and rhinomanometric and rhinometric values was found.

CONCLUSION

Radical resection of the turbinates does not seem to disturb particle deposition (pm10) measured in the nose to a significant degree. Factors other than impaction and sedimentation onto the mucosal surface of the turbinates seem to be sufficient for effective particle deposition after radical removal of the turbinates.

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 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.

[Inverted papilloma: treatment and evolution]

Inverted Papilloma is a frequent bening nasosinusal tumour. The high frequency of recurrences and the malignant potential are its clinical characteristics. We present our experience in a retrospective study done in the last 10 years. 10 patients with Inverted Papilloma have been treated during that period. According to the Classification made by krouse who divides the Inverted Papilloma in four stages, we found 3 in stage I, 6 in stage II and 1 in stage IV. The treatment in almost all of the patients in Stage I and II was endonasal surgery. External approach was performed for stage IV. The recurrence rate was 30% and malignization occurred in 10% of the cases. Finally, we have compared other publications, and revised the literature.

Impact of unilateral sinus surgery with resection of the turbinates by means of midfacial degloving on nasal air conditioning

OBJECTIVE/HYPOTHESIS

One of the most important functions of the nose is the climatization of inspired air. The aim of the investigation was to determine the influence of radical sinus surgery with complete resection of the turbinates and the lateral nasal wall by means of midfacial degloving as treatment for inverted papilloma on the nasal humidification and heating of inspired air.

STUDY DESIGN

Retrospective study.

METHODS

Humidity and temperature were measured in the nasopharynx during normal respiration by means of a miniaturized thermocouple device and a humidity sensor for continuous detection. Eight patients after prior unilateral sinus surgery by means of midfacial degloving for a one-sided inverted papilloma were enrolled into the study. The humidity and temperature data of the surgically treated side were compared to the values of the healthy side that was not surgically treated. Active anterior rhinomanometry and acoustic rhinometry were performed.

RESULTS

At the end of inspiration, absolute humidity and temperature values in the nasopharynx were statistically significantly lower on the surgically treated side compared with the side that was not surgically treated.

CONCLUSIONS

Radical sinus surgery with resection of the turbinates by means of midfacial degloving seems to disturb the climatization of the inspiratory air in the nasal cavity. Reduced absolute humidity and temperature may contribute to crusting, bleeding, and nasal dryness as frequent complaints of patients after aggressive sinus surgery with resection of the turbinates.