Different options for treatment of inverting papilloma of the nose and paranasal sinuses: a report of 41 cases

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.

Lateral Rhinotomy Approach to Inverted Papilloma

The successful surgical management of inverted papilloma requires total tumor extirpation. This article will review the technique of lateral rhinotomy and indications for its use. Prevention of complications will be stressed. Literature review focusing on the efficacy of this procedure will be presented. A brief review of midfacial degloving will also be included. Its use for limited, noninvasive lesions will be described. Lateral rhinotomy remains the gold standard against which all other procedures must be compared.

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.

[Invasive sinonasal papilloma with intracranial invasion: Case report and bibliographic review]

INTRODUCTION

Inverted papilloma is a locally-aggressive benign neoplasm of the paranasal sinuses with a high potential for recurrence and malignancy. Intracranial extension is infrequent, and dural penetration even more so, typically associated with recurrence of the disease or its degeneration into squamous cell carcinoma.

CLINICAL CASE

A 32-year-old female patient consulted us for an exophytic lesion in her right nostril and exophthalmos, associated with headache, anosmia and dysgeusia. Craniofacial and brain CT and brain MRI demonstrated a lesion in the right nostril, extending into the aerial sinuses, orbital lateral wall and anterior fossa, with osteolysis and intracranial invasion towards the right frontal region. A mass effect and brain compression were noted. A histological diagnosis of inverted papilloma was made initially. Upon later resection of the lesion by double access, with reconstruction of the anterior cranial fossa, a definitive diagnosis was made of inverted papilloma of the Schneiderian type, with areas of atypical transformation in situ. Post-operatively, the patient has had a favorable course, with full upper airway patency and neither complications nor signs of recurrence after four years of follow-up.

CONCLUSIONS

Intracranial invasion of this pathology is extremely uncommon. When it exists, the tumor has a high potential for local recurrence. Consequently, complete excision of the lesion determines the patient's prognosis.

Malignant transformation of sinonasal inverted papilloma and related genetic alterations: a systematic review

Schneiderian papillomas are uncommon tumors which may develop within the nasal cavity and comprise three well-defined histological types: sinonasal inverted papilloma (SNIP), exophytic papilloma, and oncocytic papilloma. It is well known the rate of Schneiderian papilloma may also present a malignant degeneration and SNIP represents the most important subgroup in consideration of its frequency and malignant propensity. Although HPV infection is always considered the first event favoring the development of SNIP, however, it is not established as an eventual connection between viral actions and malignant transformation. In fact, different molecular mechanisms are suspected to play a crucial role in this process and, currently, many authors agree that only by improving our knowledge about these mechanisms it will be possible to achieve new and effective targeted therapies. So the aim of this study was firstly to systematically review the literature focusing on different biomarkers that could be implicated in the stages of SNIP malignant degeneration. Secondly, a systematic review with meta-analysis was performed to better define the incidence of sinonasal malignancies originating from Schneiderian papilloma (SNIP, exophytic papilloma, and oncocytic papilloma). Twenty-nine studies comprising a total of 3177 patients were statistically analyzed. Results showed a 9% (95% CI = 7-11) overall rate of malignant transformation from Schneiderian papilloma. In conclusion, this analysis confirmed that the potential malignancy of Schneiderian papilloma should not be underestimated. On the other hand, our review showed the paucity of studies investigating the molecular alterations which may be related with the malignant transformation of SNIP.

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.

Nasal endoscope: an armamentarium in the management of sinonasal inverted papilloma

Sinonasal inverted papillomas (SIP) are unique group of locally aggressive benign neoplastic lesions arising from mucosa of sinonasal tract with potential for recurrences and known association with squamous cell carcinoma in 5-15 % of cases. This study was conducted was to assess the efficacy and usefulness of the nasal endoscope in treating SIP. We reviewed 28 biopsy proven cases of SIPs that were treated at our hospital between June 2009 and September 2013. Average patient age was 46 years. Fourteen were treated by transnasal endoscopic excision of tumor with noted recurrence of 21.43 %. Thirteen were treated by endoscopic assisted open surgery which had 23 % recurrence. Three patients had malignant inverted papillomas, of whom two (7 %) were found to have synchronous squamous cell carcinoma and one (3.6 %) had metachronous squamous cell carcinoma. No evidence of recurrence was found in rest during our follow up. The endoscopic approach is the preferred method for the treatment of the majority of inverted papillomas. Powered instrumentation is extremely useful to achieve good results. Although significant number of cases was done by external approach by lateral rhinotomy, the endoscopic assistance is required to ensure complete removal of the tumour to reduce the recurrence rates. Close follow up of the patient for a longer period of time is necessary for the early detection of recurrence and to allow for surgical salvage.

Carcinoma ex-Schneiderian papilloma (malignant transformation): a clinicopathologic and immunophenotypic study of 20 cases combined with a comprehensive review of the literature

Schneiderian papilloma (SP) are uncommon tumors with malignant transformation even less common. The histologic criteria to define malignant transformation are not well developed nor is the immunohistochemical profile reported in a large series of carcinomas. 20 cases of malignant transformation of SP included 7 females and 13 males, aged 38-86 years (mean 60.7 years). Patients presented most frequently with a mass (n = 11) and obstructive symptoms (n = 7), present for 38.7 months (mean). Most patients had no previous history of SP (n = 13); metachronous carcinoma was identified in 7 patients an average of 34.4 months after the first diagnosis of SP, with 1-4 recurrences of SP. With a mean size of 4.1 cm, the majority of tumors involved a combination of more than one anatomic site (n = 10), followed by the maxillary sinus only (n = 5) or nasal cavity only (n = 3). Histologically, 17 were inverted and 3 exophytic type SP. There were 17 squamous cell carcinomas, 2 mucoepidermoid carcinomas and 1 sinonasal undifferentiated carcinoma, comprising from 10 to 95 % of the tumor volume. Malignant histologic features included atypical mitoses, necrosis, bone invasion, lymphovascular invasion, decreased transmigrating neutrophils, paradoxical maturation, dyskeratosis and/or perineural invasion (n = 3). Patients tended to present with advanced stage (n = 14, Stage III and IV). Immunohistochemical studies showed positive reactions in the malignancies for CK5/6 (86 %), p63 (86 %), CK7 (luminal, 50 %), p53 (83 %), and p16 (25 %). In situ hybridization detected human papillomavirus in 26 %. Surgery was often accompanied by radiation therapy (n = 13), with a mean of 2.4 years of follow-up. Five patients developed a recurrence between 0.8 and 3.3 years. Carcinomas ex-SP are less common and are associated with better outcome than previously reported. Patients tend to present with a synchronous carcinoma, developing in an inverted type SP, with squamous cell carcinoma the most common malignancy. Development of metachronous carcinomas ex-SP was always preceded by SP recurrence in this series.

Transoral treatment strategies for head and neck tumors

The introduction of transoral endoscopic surgery has initiated a fundamental change in the treatment of head and neck cancer. The endoscopic approach minimizes the intraoperative trauma. Due to the lower burden for the patient and the savings potential these methods have gained wide acceptance. These transoral accesses routes allow experienced surgeons to reduce the morbidity of surgical resection with no deterioration of oncologic results. This suggests a further extension of the indication spectrum and a high growth potential for these techniques and equipment in the coming years. For selected patients with selected tumors the minimally invasive transoral surgery offers improved oncological and functional results. In the present paper, different surgical access routes are presented and their indications discussed.

A study on the clinical profile and management of inverted Papilloma

Inverted Papilloma is a unique neoplasm characterized by its tendency to destroy bone, tendency to recur after incomplete removal and association with malignancy. The uncertainty of its clinical features and projected behaviour has resulted in an ill-defined approach to its management. This is a prospective study of 30 patients of Inverted Papilloma admitted at Regional Institute of Medical Sciences, Imphal between August 2001 to July 2003. In this study, meticulous attention is given to the clinical presentation and management in a series of 30 patients with inverted papilloma. A majority of patients were between 50-70 years (40%) with a mean age of 52.3 years. M: F Ratio=3.3:1. Commonest presenting symptoms were unilateral nasal obstruction (93.3%), nasal discharge (40%) and epistaxis (36.6%). 90% of the patients had signs of involvement of the nasal cavity with one or more sinuses and 46% showed bony erosion on C.T. Scan studies. Surgery was the treatment of choice in 90% of the cases.

Select Neoplasms of the Sinonasal Tract

The sinonasal tract (SNT) includes the nasal cavity and paranasal sinuses (maxillary, ethmoid, frontal, and sphenoid) and may give rise to a variety of nonneoplastic and neoplastic proliferations, including benign and malignant neoplasms. The benign neoplasms of the SNT include epithelial neoplasms of surface epithelial origin, minor salivary gland origin, and mesenchymal origin. The spectrum of malignant neoplasms of the SNT includes epithelial malignancies, sinonasal undifferentiated carcinoma, malignant salivary gland neoplasms, neuroectodermal neoplasms, neuroendocrine neoplasms, melanocytic neoplasm, and sarcomas. This article concentrates on some of the more common types of benign and malignant neoplasms.

Benign inverted papilloma with intracranial extension: prognostic factors and outcomes

We describe a case of benign inverted papilloma with intracranial extension treated with endoscopic resection combined with craniotomy. Intracranial involvement of inverted papilloma, in the absence of malignancy, is uncommon. We present an analysis of the literature identifying the characteristics and outcomes of benign intracranial inverted papilloma. PubMed database was searched using keywords intracranial, inverted or inverting, and papilloma. There are 17 reports of benign inverted papilloma with intracranial extension reported with a mean age of 49.2 years (range, 23 to 92 years), a female predominance, 22% of cases with an associated mucocele, and 60% recurrent disease. The most common sites of invasion are the frontal sinus or cribriform plate. The prognosis for benign intracranial inverted papilloma is dependent on the presence of dural invasion and the achievement of total resection. There are no reported recurrences after craniofacial resection with a mean follow-up of 7.9 years. Adjuvant radiation therapy has demonstrated benefit in cases of residual disease after resection. We expect that endoscopic resection, the standard treatment for sinonasal inverted papilloma, will be increasingly used in the presence of intracranial extension.

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.

[Inverted papilloma of the nose and paranasal sinuses in endoscopic surgery of the Otolaryngology Clinical Division in 4-th Clinical Military Hospital in Wrocław between years 2006-2008]

The aim of presented work is analysis of the inverted papilloma cases treated by endoscopic surgery between years 2006 and 2008. Within this period there were 180 surgeries, out of which 11 patients were diagnosed with papilloma inversum in the histopatological test of irradiated tissue. Symptoms reported by the patients, tumor loci, scope of the surgery and its efficiency are described and analyzed. The arguments supporting endoscopic surgery as a treatment modality for inverted papilloma are presented.

An unusual presentation of inverted papilloma: case report and literature review

Objective:

Inverted papilloma is a rare but locally aggressive tumour with the potential for malignant transformation. Intracranial extension or complications secondary to inverted papilloma are extremely rare. We report a case of inverted papilloma with a large frontal sinus mucocele eroding the frontal sinus, which presented with sudden neurological compromise. A literature review on intracranial extension of such tumours is also included.

Methods:

A Medline search of articles, using the terms ‘inverted papilloma’, ‘Ringertz tumour’, ‘intracranial extension’ and ‘complication’. Suitable references from the collected articles were also reviewed. Articles published in English were selected and reviewed.

Results:

A total of 10 cases was identified. Intracranial spread was more commonly seen in recurrent cases, especially if the recurrence involved the cribriform plate, fovea ethmoidalis or orbits. Cases with extradural disease seemed to have a better prognosis than those with intradural spread.

Conclusions:

Intracranial involvement of inverted papilloma is extremely rare, and is usually seen in recurrent cases. This case report highlights an unusual but serious case of inverted papilloma presenting with acute neurological deterioration secondary to a large frontal sinus mucocele eroding the frontal sinus. A literature review on intracranial extension of inverted papilloma indicated that common sites of intracranial spread include the cribriform plate, fovea ethmoidalis and orbits. The prognosis for patients with such tumours depends on the type of dural involvement, with intradural extension carrying a poorer prognosis.

Bilateral inverted papilloma: case report and literature review

The inverted papilloma is an uncommon unilateral nasosinusal benign tumor. The clinical picture presents nonspecific signs and symptoms, such as unilateral nasal obstruction, anosmia and headache. The diagnosis is established by anamnesis, physical exam, computed tomography and magnetic resonance imaging. Treatment is essentially surgical. This report has the objective of presenting an uncommon bilateral inverted nasal papilloma and making a literature review.

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

CONCLUSION

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

OBJECTIVES

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

PATIENTS AND METHODS

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

RESULTS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Clinical and pathological analysis of recurrent inverted papilloma

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Benign sinonasal neoplasms: a focus on inverting papilloma

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

Radiographic and Histologic Analysis of the Bone Underlying Inverted Papillomas

INTRODUCTION

Inverted papilloma (IP) is a benign but locally aggressive sinonasal tumor. Those localized to the maxillary sinus or medial maxillary wall have classically been removed through an external approach. In recent years, endoscopic removal has been advocated as an effective, minimally invasive approach. Successful endoscopic management is based on accurate intraoperative identification and complete resection of the tumor. The surgical management of the bone underlying the surface of an IP is less clearcut. Controversy exists as to whether the bony undersurface of an IP should be removed. In this article, histopathologic specimens and preoperative radiologic studies are prospectively examined to better understand the involvement of the bone underlying an inverted papilloma.

MATERIALS AND METHODS

A prospective study of patients with maxillary sinus IP treated with endoscopic or endoscopic-assisted resection over a 12-month period was conducted. Intraoperatively, the site of tumor attachment was identified, and a 1- to 2-cm wedge of bone with overlying tumor was removed en bloc and analyzed under light microscopy. Preoperative radiographic studies were analyzed with respect to bony changes in the area of the tumor pedicle.

RESULTS

On histopathologic analysis, the bony surface underlying the IP was irregular with multiple bony crevices in all nine cases. In two cases (22% of specimens), an isolated rest of normal-appearingsalivary gland and/or mucosal tissue was seen embedded in the underlying bone. Radiographic osteitic bony changes were seen at site of tumor attachment in 100% of cases.

CONCLUSION

The irregularity of the bony surface may hinder complete tumor removal because microscopic rests of mucosa can be hidden within the bony crevices. Intraoperative removal of the bony surface at the site of tumor attachment may ensure a more complete removal.

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.

Endoscopic and endoscope-assisted resections of inverted sinonasal papillomas

OBJECTIVE

To evaluate the success of endoscopic and endoscope-assisted resection of inverted sinonasal papillomas and to assess the indications for adjunctive external procedures.

STUDY DESIGN

Retrospective chart review.

RESULTS

Fifty patients were treated surgically during the 10-year study period and had greater than 1 year of follow-up care. These patients had a recurrence rate of 14% (7/50) with a mean follow-up of 31.1 months. Of these 7 patients with recurrences, 3 were treated primarily at this institution, and 4 had been treated prior to referral. Recurrence was 11% (3/27) for primary resections and 17% (4/23) for secondary resections. Average time to recurrence was 11.7 months. Of the patients, 38% (19/50) had adjunctive external procedures either during the initial resection or for the management of recurrent disease.

CONCLUSIONS

Endoscopic and endoscope-assisted resections of inverted papilloma are effective techniques for managing inverted papilloma. The intraoperative findings, most importantly the site(s) of tumor attachment, dictate whether an endoscopic procedure is sufficient to complete resect the inverted papilloma or whether an adjunctive external procedure is required. Appropriate patient selection and an aggressive surgical approach are necessary for the management of these neoplasms.

Histological features and malignant transformation of inverted papilloma

Inverted papilloma (IP) is a primarily benign epithelial neoplasm with a propensity to transform to squamous cell carcinoma (SCC). Neither the etiology of IP nor the factors responsible for malignant transformation are fully known to date. A considerable number of histopathological grading systems have been suggested. It was the aim of this study to find histological parameters in IP that allow a prognosis concerning the occurrence of malignant transformation. In a group of 93 cases of IP, the patients' records, histological specimens and a questionnaire were evaluated. Thirteen patients had suffered a recurrence of a previously treated IP. SCC in the IP had been diagnosed in 12 of the cases. The histological specimen showed increased counts of mitosis and dyscariosis in the IP. All other histological parameters did not show a significant difference between the groups. History and symptoms proved to be nonspecific as well. Patients in the group with SCC were significantly older at the first diagnosis of IP than patients without carcinoma. This group also included a higher portion of male patients. Patients fulfilling the named histological criteria combined with male gender and higher age are a high-risk group in the necessary long-term follow-up.

Inverted papilloma: report of 89 cases

PURPOSE

In this study, the surgical management of an inverted papilloma of the nose and paranasal sinuses performed at our institution is reviewed.

METHODS

Eighty-nine patients diagnosed with an inverted papilloma and treated at the Ear, Nose, and Throat Department of Bologna University from January 1980 to January 2001 were retrospectively reviewed. Only 86 out of the 89 patients were retrospectively analyzed because 3 patients were treated for malignant tumors because of the association between inverted papilloma and invasive squamous cell carcinoma. Fifty patients were treated using traditional techniques such as lateral rhinotomy and midface degloving with medial maxillectomy (11 cases), a Caldwell-Luc procedure (21 cases), and transnasal ethmoidectomy or sphenoethmoidectomy (18 cases), whereas 36 patients were treated using an endonasal endoscopic approach for their primary tumor.

RESULTS

The traditionally treated patients had a mean follow-up of 8 years (6-19 years), whereas the endoscopically treated patients had a mean follow-up of 54 months (24-97 months). The overall recurrence rate was 15%. There were 12 recurrences (24%) in the traditionally treated patients: 1 out of 11 patients (9%) had a recurrence after a medial maxillectomy by means of a lateral rhinotomy/midface degloving, whereas 11 patients out of 39 (28%) had a recurrence after more conservative procedures such as the transantral approach and transnasal ethmoidectomy or sphenoethmoidectomy. On the other hand, 1 recurrence was observed in the endoscopically treated patients (3%).

CONCLUSIONS

Traditional techniques such as Caldwell-Luc and conservative transnasal ethmoidectomy or sphenoethmoidectomy are associated with a high rate of recurrence in the treatment of an inverted papilloma. On the other hand, the endoscopic endonasal approach is an effective treatment for an inverted papilloma in selected cases and, when performed by a skilled surgeon, can achieve a radical resection of the tumor because of excellent magnification and visualization, with results comparable to those of traditional techniques such as lateral rhinotomy with medial maxillectomy.

Long-term results of endonasal sinus surgery in sinonasal papillomas

OBJECTIVE

To assess the value of endonasal sinus surgery in the management of sinonasal papillomas.

STUDY DESIGN

Retrospective study including 43 patients operated on for sinonasal papilloma in a long-term follow-up.

METHODS

In 26 cases (60%) an endonasal approach, in eight cases (19%) an external approach, and in four cases (9%) a combined procedure was performed to remove these tumors. Five septal lesions (12%) were resected under direct vision. The original sections and charts of all patients were reviewed to assess clinical data. Follow-up information was available for 42 of our patients (98%) with a mean follow-up of 62 months.

RESULTS

Histologic examination revealed 34 cases of inverted papilloma (79%), five cases of exophytic papilloma (12%), and four cases of columnar cell papilloma (9%). Malignancy occurred in 4 of 43 patients (9%), and recurrences developed in 8 of 42 patients (19%). Two of these recurrences happened after endoscopic sinus surgery (two inverted papillomas), three after lateral rhinotomy (three inverted papillomas), one after a combined procedure (one inverted papilloma), and two after simple resection (two exophytic papilloma).

CONCLUSIONS

In keeping with our experience, the endonasal endoscopic approach, often in combination with a medial maxillectomy, is favored for the treatment of sinonasal papilloma because of a lower recurrence rate and a better cosmetic result. In some larger tumors and lesions in difficult locations, better visualization can be obtained by a combined external and endonasal approach.

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

OBJECTIVE

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

STUDY DESIGN AND SETTING

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

RESULTS

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

CONCLUSION

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

Endoscopic removal of sinonasal inverted papilloma including endoscopic medial maxillectomy

OBJECTIVES/HYPOTHESIS

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

STUDY DESIGN

A prospective study and an integrated literature review.

METHODS

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

RESULTS

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

CONCLUSIONS

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

Endoscopic Management of Inverted Papillomas of the Nose and Paranasal Sinuses

We performed endoscopic resection on six patients who had inverted papillomas of the nasal cavity. Disease was completely cleared in four patients after a single procedure, while two others—both of whom had bilateral disease—required repeat surgery. At follow-up, which ranged from 6 months to 5 years, all patients were disease-free. We believe that endoscopic surgery is ideally suited for the treatment of appropriately selected patients who have limited disease and who are likely to adhere conscientiously to a regular follow-up program.

Schneiderian papillomas and nonsalivary glandular neoplasms of the head and neck

Schneiderian papillomas and nonsalivary glandular neoplasms of the head and neck continue to be a source of confusion for both the clinician and pathologist. An update on these lesions is provided.

[Unilateral polyposis: evaluation of preoperative tests]

The aim of this paper is to study a group of patients with occupancy of a nasal fossal, apparently by polyps, and being the other side of the nose normal. Evaluating on the one hand the true incidence of unspecific polyposis and, of other diagnosis, and on the other hand to compare the preoperative radiological findings with those seen during surgery.

MATERIAL AND METHODS

A prospective study of 23 consecutive patients was carried out over a period of 30 months at the ENT Department of the Dr. Peset Hospital, in Valencia. A CT scan and preoperative biopsy was performed in all cases, the results of these being later compared with the surgical findings and the final histopathologic diagnosis.

RESULTS AND CONCLUSIONS

A discrepancy between the preoperative biopsy and final diagnosis was found in 26% of the patients. The incidence of polyposis was 52%, inverted papilloma 26%, malignant tumours 13% and other diagnosis 8.6%. There is a good correlation between preoperative CT scans and surgical findings in those cases of polyposis and inverted papilloma, but not in those of malignant tumours as CT scans often underestimated these lesions.

Inverted papilloma: a review of 53 cases

OBJECTIVE

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

STUDY DESIGN

Retrospective study.

SETTING

Tertiary health care center.

RESULTS

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

CONCLUSION

Aggressive initial management remains the therapeutic aim in this condition.

An evolution in the management of sinonasal inverting papilloma

OBJECTIVE

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

STUDY DESIGN

Retrospective.

METHODS

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

RESULTS

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

CONCLUSIONS

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

Aggressive endoscopic resection of inverted papilloma: an update

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Schneiderian papillomas and carcinomas: a review

The ectodermally derived Schneiderian mucosa gives rise to an extremely varied collection of benign and malignant neoplasms. Prototypical of these are the Schneiderian papillomas (inverted, fungiform, and cylindrical cell) and their malignant counterparts. Human papilloma virus (HPV) is currently the leading candidate as a cofactor in the pathogenesis of the papillomas. Carcinomas arise in association with the papillomas in about a 10% frequency. The carcinomas may be synchronous or metachronous. Recurrences of the papillomas are the bane of surgeons. The magnitude of the recurrences is directly proportional to the completeness of removal with the best results obtained by techniques that afford the best operative exposure. A comparison of results by different surgical procedures is presented. Histologic features sought to predict recurrences or malignant transformation have, by and large, not been helpful. Keratinization and hyperkeratosis in papillomas, however, are suggested to be sufficiently ominous as to warrant further study.

Endoscopic treatment of inverted papilloma: safety and efficacy

PURPOSE

Inverted papillomas of the nose and paranasal sinuses are uncommon neoplasms, characterized by their tendency to recur and by their association with malignancy. Over the past 25 years, the standard surgical treatment of inverted papillomas has involved extranasal, en bloc resections because of high recurrence rates with less extensive surgery. The past decade has witnessed an increasing number of reports documenting the successful treatment of inverted papilloma with endoscopic approaches. This investigation examines the role of endoscopic procedures in treating inverted papilloma.

MATERIALS AND METHODS

The present article presents a thorough review of the literature relating to the history, pathology, diagnosis, and treatment of inverted papillomas of the nose and paranasal sinuses. It also provides a systematic review of the pertinent medical literature with pooled statistical analysis of data from 33 studies involving 1,426 patients.

RESULTS AND CONCLUSIONS

The findings suggest that many cases of inverted papilloma can be treated successfully with low recurrence rates and less morbidity through endoscopic surgery, with results comparable to extranasal procedures. Less aggressive approaches to the sinuses and nonendoscopic intranasal procedures, such as the Caldwell-Luc, have unacceptable rates of recurrence and should be abandoned. A staging system for inverted papilloma and a logical approach to treatment are presented.

Inverting papilloma of the sphenoid sinus: report of two cases

Two patients with sphenoid sinus inverting papilloma who were treated either by transcranial or sublabial trans-septal approach are reported. Inverting papillomas arising from the sphenoid sinus are exceedingly rare. The clinical and neuro-imaging features, as well as surgical treatment, for sphenoid sinus tumours are also briefly discussed.

Development of a staging system for inverted papilloma

OBJECTIVES

Inverted papillomas of the nose and sinuses are uncommon neoplasms. In the past decade there has been a trend toward the use of endoscopic surgical techniques in the management of these tumors, in contrast to the extensive open procedures recommended previously. This trend has not been without controversy, given the association of inverted papillomas with malignancy. It has been difficult to compare surgical approaches to these neoplasms, because of the absence of a uniformly applied staging system representing the extent of disease. It was the purpose of this study to develop such a system that could be easily applied in outcomes research.

STUDY DESIGN

This study involved an integrated literature review and a synthesis of findings from a number of studies.

METHODS

Previous and current clinical studies examining the treatment of inverted papilloma were reviewed. Findings were organized, and a staging system was framed based on this review.

RESULTS

A simple, easily applied staging system was developed based on the extent of tumor involvement noted on endoscopic examination of the nasal cavity and computed tomography (CT) scan evaluation.

CONCLUSIONS

Stage I disease is limited to the nasal cavity alone. Stage II disease is limited to the ethmoid sinuses and medial and superior portions of the maxillary sinuses. Stage III disease involves the lateral or inferior aspects of the maxillary sinuses or extension into the frontal or sphenoid sinuses. Stage IV disease involves tumor spread outside the confines of the nose and sinuses, as well as any malignancy.

Radiation therapy in inverted papillomas of the nasal cavity and paranasal sinuses

PURPOSE

Between December 1969 and September 1989, a total of 10 patients with advanced and/or recurrent inverted or cylindrical cell papillomas were treated with irradiation at the University of Florida in Gainesville.

MATERIALS AND METHODS

Nine of 10 patients had 1 or more recurrences before they received radiation therapy. Three patients were treated with irradiation alone, and 7 patients received surgery and irradiation (preoperatively in 1 patient and postoperatively in 6 patients). Eight patients had inverted papillomas (3 with concomitant squamous cell carcinoma), and 2 patients had cylindrical cell papillomas.

RESULTS

Local recurrence developed in 4 patients at 1.5, 6.5, 12, and 13 years after treatment. No evidence of recurrence was observed in 6 patients at 7, 8.5, 8.5, 9, 9, and 20.5 years after treatment. Four patients died of intercurrent disease. No patient developed a malignant transformation. Significant complications of treatment included, in 1 patient, an area of bone exposure in the orbit that necessitated debridement.

CONCLUSION

Surgery is the primary treatment of this entity. Radiation therapy should be considered in patients with incompletely resectable lesions, multiply recurrent tumors, and tumors associated with malignancy.

Inverted papilloma of the nasal cavity and paranasal sinuses: clinical data, surgical strategy and recurrence rates

BACKGROUND

In the last decade inverted papillomas of the nasal cavity and paranasal sinuses have been observed in increasing numbers, and treatment modalities have ranged from extensive open radical procedures to microinvasive endonasal surgical excision.

OBJECTIVE

To establish criteria for selecting patients for open osteoplastic or endonasal surgery according to clearly defined pathological and clinical data.

MATERIAL AND METHOD

In a retrospective study, clinical data of 55 patients treated surgically in the University ENT Clinic Giessen from 1991 to 1998 were analysed. In 33 patients (60%) endonasal excision of the papillomas was carried out and in 22 (40%) osteoplastic lateral rhinotomy or maxillotomy were performed. All histological specimens were revised. Patients were followed up and endoscopically examined until 31 March 1999.

RESULTS

In 22 patients, tumours involving the frontal sinus, maxillary sinus, parts of the frontal skull base and anterior ethmoid, and the orbit were operated on using open osteoplastic procedures, with 4 (18%) recurrences observed. Tumours excised endonasally showed the same recurrence rate: 6 out of 33 (18%). These tumours were smaller in size and localized in the nasal cavity, the middle and posterior parts of the ethmoid involving the sphenoid, and the medio-posterior wall of the maxillary sinus. The functional outcome was excellent for all patients; two patients developed a mucocele. Cancerization was observed in three cases.

CONCLUSIONS

In select cases the endonasal microsurgical approach to inverted papillomas has the same good results concerning function and tumour control as osteoplastic open rhinotomy. This method should still be preferred in tumours localized in the frontal sinus, anterior ethmoid. anterior. caudal and lateral parts of the maxillary sinus and beyond the sinuses.

Endoscopic management of sinonasal inverted papilloma

Since 1992, 42 patients at the University of Pennsylvania have been treated for inverted papilloma (IP). Thirty-three patients were managed endoscopically with or without a Caldwell Luc approach (CLA) and retrospectively analyzed. The CLA, which involves a gingivobuccal incision for access to the maxillary sinus, is distinguished from a formal Caldwell Luc procedure. These 33 patients with histologically confirmed IP were without evidence of malignancy. They also did not have evidence of intracranial, orbital, or frontal sinus IP. Seventeen of 33 patients (17/33) were without prior treatment (primary). Sixteen of 33 (16/33) presented from an outside institution with recurrent IP (secondary). The recurrence rate using this method to treat primary IP was 6% (1/17), and for secondary IP was 25% (4/16). Scheduled postoperative endoscopic surveillance permitted early detection of recurrence and continued endoscopic control of IP. All 33 patients were endoscopically free of disease at the end of the study. These preliminary data are encouraging for the use of intranasal endoscopy with and without CLA as a means of managing and controlling IP in selected cases.

The role of midfacial degloving in modern rhinological practice

The midfacial degloving approach has been available for twenty five years and is slowly increasing in popularity in the management of extensive benign lesions of the sinonasal region, for selected malignancy in this area and to afford access to the nasopharynx and infra-temporal fossa. The advantages, applications and low complication rate are presented in a cohort of 86 patients, ranging from three to 79 years of age with a mean follow-up of 5.5 years. Seventy-seven per cent of the group had benign pathology of which juvenile angiofibroma was the commonest (40 cases). The 20 cases of malignant disease were a heterogeneous group histopathologically including adenoid cystic carcinoma (four cases), malignant schwannoma (two cases), rhabdomyosarcoma (two cases) and squamous cell carcinoma (two cases). Five underwent bilateral radical maxillectomies combined with orbital clearance in one patient. Complications include oro-antral fistula (three cases) and epiphora (three cases) all of which were successfully treated.

The endoscopic management of sinonasal inverted papillomas

Sinonasal inverted papillomas are well known for high recurrence rates after surgery and the risk of malignant change. Recurrent disease occurs because of inadequate excision as a result of poor exposure and visualization. For these reasons, aggressive surgery has been advocated-classically a lateral rhinotomy and en bloc medial maxillectomy. Endoscopic techniques have provided excellent visualization and a less invasive approach to these tumours. We describe 18 patients with inverted papillomas treated endoscopically at the Singapore General Hospital since 1993. The presentation, sites of involvement and diagnostic imaging are presented. All the patients had a minimum follow-up of 18 months with a mean of 32.8 months. One case of recurrence at the frontal recess is reported. Endoscopic management is appropriate for the diagnosis, follow-up and treatment of circumscribed primary and recurrent inverted papillomas.