Inverted papilloma (IP) is a benign tumor of the nasal cavity and paranasal sinuses that is unilateral in most cases. Bilateral IP, involving both sides of the nasal cavity and sinuses, is extremely rare. This paper describes a large IP that filled in both sides of the nasal cavity and sinuses, mimicking association with malignancy. The tumor was successfully treated by bilateral endoscopic medial maxillectomy (EMM). The patient is without evidence of the disease 24 months after surgery. If preoperative diagnosis does not confirm the association with malignancy in IP, endoscopic sinus surgery (ESS) should be selected, and ESS, including EMM, is a good first choice of the treatment for IP

Masashi Suzuki

Satoru Kodama

Toshiaki Kawano

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Case Reports in Otolaryngology
Volume 2012, Article ID 215847, 3 pages
doi:10.1155/2012/215847
Case Report
Bilateral Endoscopic Medial Maxillectomy for
Bilateral Inverted Papilloma
Satoru Kodama, Toshiaki Kawano, and Masashi Suzuki
Department of Otolaryngology, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hazama-Machi, Yufu, Oita 879-5593, Japan
Correspondence should be addressed to Satoru Kodama, satoruk@oita-u.ac.jp
Received 21 March 2012; Accepted 11 June 2012
Academic Editors: S. L. Goudy, V. A. Resto, and S. Ulualp
Copyright © 2012 Satoru Kodama et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.
Inverted papilloma (IP) is a benign tumor of the nasal cavity and paranasal sinuses that is unilateral in most cases. Bilateral IP,
involving both sides of the nasal cavity and sinuses, is extremely rare. This paper describes a large IP that filled in both sides of
the nasal cavity and sinuses, mimicking association with malignancy. The tumor was successfully treated by bilateral endoscopic
medial maxillectomy (EMM). The patient is without evidence of the disease 24 months after surgery. If preoperative diagnosis
does not confirm the association with malignancy in IP, endoscopic sinus surgery (ESS) should be selected, and ESS, including
EMM, is a good first choice of the treatment for IP.
1. Introduction
Inverted papilloma (IP) is a common benign tumor of the
nasal cavity and paranasal sinuses. IP is confined to one sides
of the nasal cavity in most cases, and bilateral IP is extremely
rare with only a few cases reported in the English literature
[1, 2]. Herein, we describe a large IP that involved both side
of the nasal cavity and extended into the orbita, mimicking
association with malignancy. The tumor was successfully
treated by bilateral endoscopic medial maxillectomy (EMM).
2. Case Presentation
A 55-year-old man presented with bilateral nasal tumor
that caused progressive bilateral nasal obstruction. He could
not breathe through the nose. Anterior rhinoscopy revealed
a pinkish mass that filled both nasal cavities (Figure 1).
The tumor could be also observed orally, in the pharynx.
Enhanced computed tomography (CT) showed a homoge-
neously enhancing mass that filled the bilateral nasal cavities
and maxillary, ethmoid, and sphenoid sinuses. The tumor
extended into the right orbita causing bone destruction. No
bone damage was observed at the skull base. Osteogenesis
was observed in the right ethmoid sinus (Figure 2). The
frontal sinuses were poorly pneumatized. The base of the
tumor was considered to be at the right ethmoid sinus.
Biopsy revealed IP; however, association with malignancy
could not be ruled out because of local aggressiveness. No
neurological or visual defects were observed. Endoscopic
sinus surgery (ESS) was then performed under general
anesthesia. The anterior portion of the tumor, protruding
from the nose, was cut using the harmonic scalpel (HS).
The tumor was removed piece by piece with the HS to
avoid bleeding. Intraoperative frozen section examinations
were repeated suspecting a malignancy; however, the results
showed all IP without malignancy. Since the tumor was
widely spread in the maxillary sinus in both sides, the medial
maxillary wall was incised, and EMM was performed in both
sides. Enlarged resection of the lateral wall allowed complete
removal of the tumor in the sinuses. The left nasolacrimal
duct was preserved; however, the right lacrimal sac and duct
were cut and removed due to the tumor involvement. The
base of the tumor was identified at the roof of the right
ethmoid sinus with a neogenerated bone and was removed
along with surrounding mucosa.The bone of the skull base
was preserved. The tumor in the orbita was also removed
completely, and the periosteum of orbita was left intact.
Intraoperatively, a septal perforation due to septal invasion
of the IP was observed, and the tumor on the right side
penetrated in to the left side through the perforation at
2 Case Reports in Otolaryngology
Figure 1: Preoperative view of the nose. The huge tumor filled in
the bilateral nasal cavity. The tumor spread from the right to the
left.
the posterior part of the nasal septum. Thus, the tumor
was an advanced unilateral tumor that has eroded into the
other side by erosion of the septum. In the progressive
dissection, the tumor was completely removed in both sides,
and the surgical margin was free of disease. The operating
time was 5 hours, and intraoperative blood loss was 300 mL.
Permanent histopathologic examination revealed IP without
malignancy. The postoperative course was uneventful, and
no recurrence was observed at the 2-year follow-up exami-
nation.
3. Discussion
IP is a benign tumor of the nasal cavity and paranasal sinuses.
The management of sinonasal IP is often complicated due
to its local aggressiveness, high recurrence rate, and asso-
ciation with malignancy. The accepted treatment of choice
is complete wide local resection. Several external surgical
procedures, such as lateral rhinotomy, medial maxillectomy,
and the midfacial degloving approach, have been performed
for extended IPs [1, 3]. ESS is now widely accepted and
commonly performed in cases requiring nasal or paranasal
sinus surgery. ESS provides superior magnification, illu-
mination, and angled visualization, thereby allowing the
surgeon to isolate the base of the tumor and accurately
define the extent of disease. The assessment of endoscopic
resectability depends on preoperative endoscopic findings
and imaging. The skill of the surgeon is also an important
factor when selecting a surgical technique. Surgeons with
extensive training and experience in ESS would likely be
more comfortable in utilizing endoscopic techniques as the
extent of the disease increases. Recently, EMM has been
validated as an effective treatment for IP [3, 4]. Removing
the medial wall of the maxillary sinus by using an endoscopic
approach results in a recurrence rate comparable to that of
traditional open medial maxillectomy. In the present case,
although the tumor was an advanced unilateral tumor that
has eroded into the other side by erosion of the septum
(a)
(b)
Figure 2: Enhanced computed tomography (CT) image (a, b). A
homogeneously enhancing mass that filled the bilateral nasal cavi-
ties and the maxillary and ethmoid sinuses. Bone destruction of the
right orbita was observed. Osteogenesis was observed in the right
ethmoid sinus.
and filled in bilateral maxillary sinus, EMM was effective
for the complete removal of IP with a good visualization
and a wide working space. The advantages of EMM are
lack of facial or gingival incision, lack of external scar, no
loss of bony nasal or anterior maxillary support, low risk
of infraorbital nerve paresthesia, shorter hospital stay, less
postoperative pain and facial swelling, less blood loss and
crusting, and low morbidity [5]. Bilateral IP is extremely
rare; to our knowledge, the case reported here is the first
that included resection by bilateral EMM that was completed
without complications.
In conclusion, ESS could be successfully used to achieve
the complete removal of a large tumor such as an IP that
affects bilateral nasal cavities and sinuses. If preoperative
diagnosis does not confirm the association with malignancy,
ESS should be selected for IP. ESS, including EMM, is a good
first choice of the treatment for IP.
Case Reports in Otolaryngology 3
References
[1] S. A. Hosal and J. L. Freeman, “Bilateral lateral rhinotomy for
resection of bilateral inverted papilloma,” Otolaryngology Head
and Neck Surgery, vol. 114, no. 1, pp. 103–105, 1996.
[2] J. Yiotakis, A. Hantzakos, D. Kandiloros, and E. Ferekidis, “A
rare location of bilateral inverted papilloma of the nose and
paranasal sinuses,” Rhinology, vol. 40, no. 4, pp. 220–222, 2002.
[3] J. H. Krouse, “Endoscopic treatment of inverted papilloma:
safety and efficacy,” American Journal of Otolaryngology, vol. 22,
no. 2, pp. 87–99, 2001.
[4] P. J. Wormald, E. Ooi, C. A. Van Hasselt, and S. Nair, “Endo-
scopic removal of sinonasal inverted papilloma including
endoscopic medial maxillectomy,” Laryngoscope, vol. 113, no.
5, pp. 867–873, 2003.
[5] J. M. Busquets and P. H. Hwang, “Endoscopic resection of
sinonasal inverted papilloma: a meta-analysis,” Otolaryngology
Head and Neck Surgery, vol. 134, no. 3, pp. 476–482, 2006.
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Case Report Bilateral Endoscopic Medial Maxillectomy for Bilateral Inverted Papilloma

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Case Report Bilateral Endoscopic Medial Maxillectomy for Bilateral Inverted Papilloma

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