Surgery offers the optimum modality of treatment for inverted papilloma although a considerable range of operative approaches have been described. The results are presented in a cohort of 37 cases treated by both endoscopic and combined endoscopic and external approaches with a recurrence rate of eight and 21 per cent respectively. This series is compared with those in the literature and demonstrates that it is extent of disease which primarily determines the choice of surgical approach, with previous treatment, individual patient factors and surgical expertise as secondary determinants

Lund, VJ

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UCL Discovery

Journal of Laryngology &amp; Otologyhttp://journals.cambridge.org/JLOAdditional services for Journal of Laryngology &amp; Otology:Email alerts: Click hereSubscriptions: Click hereCommercial reprints: Click hereTerms of use : Click hereOptimum management of inverted papillomaValerie LundJournal of Laryngology & Otology / Volume 114 / Issue 03 / March 2000, pp 194 ­ 197DOI: 10.1258/0022215001905319, Published online: 08 March 2006Link to this article: http://journals.cambridge.org/abstract_S0022215100000578How to cite this article:Valerie Lund (2000). Optimum management of inverted papilloma. Journal of Laryngology & Otology, 114, pp 194­197 doi:10.1258/0022215001905319Request Permissions : Click hereDownloaded from http://journals.cambridge.org/JLO, IP address: 144.82.107.169 on 17 Oct 2012The Journal of Laryngology and OtologyMarch 2000, Vol. 114, pp. 194–197Optimum management of inverted papillomaValerie J. Lund, M.S., F.R.C.S., F.R.C.S.(Ed.)AbstractSurgery offers the optimummodalityof treatmentfor inverted papillomaalthough a considerable range ofoperative approaches have been described. The results are presented in a cohort of 37 cases treated byboth endoscopic and combined endoscopic and external approaches with a recurrence rate of eight and 21per cent respectively. This series is compared with those in the literature and demonstrates that it is extentof disease which primarily determines the choice of surgical approach, with previous treatment,individualpatient factors and surgical expertise as secondary determinants.Key words: Papilloma, inverted; Surgical procedures, endoscopic; Paranasal sinusesIntroductionIn 1847 Kramer used the term ‘papillae’to describe acauli￿ower-like tumour of the mucous membrane.1In 1855 Ward2 reported a case of nasal papillomaalthough Billroth3 is usually credited with the ￿rstdescription of a true papillomaof the nasal cavity.In1938 Ringetz described the inverting nature of alesion of cylindrical or transitional cell type and formany years the lesion bore his eponym.4 Furtherconfusion was added by the term ‘Schneiderian’ afterVictor Conrad Schneider described an epithelialtumour deriving from ectoderm. The term ‘inverted’was coined by Lampertico et al. in 1963.5Not only are inverted papillomas one of thecommonest benign epithelial tumours of the nasalcavity but considerable interest has surrounded theirability to recur and undergo malignant transforma-tion. In the literature recurrence rates of betweenzero and 75 per cent are quoted6 although the term‘recurrence’ merely indicates residual disease in themajorityof cases and is directly related to the surgicalapproach and the ‘care’ with which the papilloma isremoved.The issue of malignant transformation has alsobeen exaggerated. Whilst a range of zero to 53 percent is found in the literature6 it is clear on reviewingthose papers claiming high rates of malignancy thatwell-differentiated squamous cell carcinoma waspresent ab initio in the majority of cases. In a studyof 123 cases conducted at the Institute of Laryngol-ogy and Otology the proven malignanttransformation rate was under two per cent.7However, notwithstanding these remarks, it isimportant that an inverted papilloma is removed inits entirety if only to ensure that patients are notsubjected to repeated surgical interventions over anumber of years.Material and methodsAll cases with inverted papilloma treated between1992 and 1998 were reviewed for surgical outcomeand recurrence. Pre-operative assessment includedendoscopic evaluation and computed tomography(CT) scanning in all cases (Figures 1 and 2) togetherFrom the Institute of Laryngology and Otology, University College London, London, UK.Accepted for publication: 1 December 1999.Fig. 1Coronal CT showing extensive recurrent inverted papillomafollowing several previous lateral rhinotomies intimatelyinvolving orbital periosteum requiring combined surgicalapproaches.194with review of previous histology where available.Magnetic resonance imaging (MRI) was performedin three cases to further elucidate the extent oftumour within the frontal sinus. No cases ofconcomitant squamous cell carcinoma wereincluded. Only cases with greater than one yearfollow-up were included. Follow-up consisted of aformal examination under anaesthesia between fourmonths and one year following the surgery in 30 outof 37 of the cases combined with endoscopicexamination at regular outpatient review and CTscanning in any case where recurrence was sus-pected.ResultsThirty-seven individuals with inverted papillomawere treated during this period. There were 26men and 11 women, their ages ranged from 25 to 81with a mean of 52 years. The follow-up ranged from1–7.5 years with a mean of 45 months. The surgicalapproach is shown in Table I. Thirteen were treatedby an exclusively endoscopic approach whilst 24, 14of whom had undergone previous surgery, weretreated by a combined endoscopic and an externalapproach. This previous surgery had included intrana-sal polypectomy(six on multiple occasions) and lateralrhinotomy (eight; one to three times). Recurrenceoccurred in one case (eight per cent) treated endo-scopicallyand in ￿ve cases (21 per cent) treated by thecombinedapproach. No case of malignanttransforma-tion was observed during the follow-up period.In all 13 cases treated by endoscopic surgery alonethe nasal cavity, anterior ethmoids and medialmaxilla were involved. In two cases the tumourextended into the sphenoid through the naturalostium and in three cases tumour extended into thefrontal nasal recess but without involvement of thesinus mucosa itself. In the two cases treated by acombined endoscopic and external fronto-ethmoi-dectomy, the frontal sinus mucosa was involved andin those cases treated by Caldwell-Luc, the maxillarysinus mucosa was extensively involved including thelateral wall and ￿oor. In those cases treated bylateralrhinotomy and mid-facial degloving there wasextensive disease involving both the maxilla and/orfrontal sinus, one case of which was bilateral.DiscussionThe optimum management of inverted papillomacommences with the early diagnosis of the condition.Six patients had undergone previous polypectomy, insome cases over a number of years prior to thediagnosis being made. It is clear that unless clinicianshave a low threshold of suspicion for the conditionFig. 2Coronal CT showing inverted papilloma limited to middlemeatus and ethmoids suitable for an endoscopic approach.Fig. 3Coronal CT showing inverted papilloma extending intofrontal sinus necessitating combined endoscopic and externalapproach.TABLE Isurgical approaches, previous surgery and recurrencerates in present series (1992–1998; n = 37)Approach nPrevioussurgery RecurrenceEndoscopic alone 13 – 1 (8%)Endoscopic.1 .external 24 14 5 (21%)1 External fronto-ethmoidectomy 21 Caldwell Luc 51 Lateral rhinotomy 91 Midfacial degloving 8optimum management of inverted papilloma 195and send material for histological examination, thediagnosis may go unsuspected. Inverted papillomamay occur in associationwith benignpolyposis whichmay mask the usual unilaterality of the condition.Although malignant transformation is a relativelyrare occurrence it is also important that all tissue iscarefully examined histopathologically, particularlyto avoid the confusion between well-differentiatedsquamous cell carcinoma and its benign counterpart.CT scanning remains the imaging modality ofchoice8,9 characteristically showing a lesion arisingwithin the middle meatus which dumb-bells into theadjacent sinuses, often associated with a heteroge-neous opaci￿cation and sclerosis in adjacent bone.However, the extent of disease may be exaggeratedby associated in￿ammation and/or retained secre-tions which can be clari￿ed by MRI.Surgery is the agreed primary therapeutic mod-alityof choice and a range of surgical approaches hasbeen described. It is clear that limited surgery suchas conventional polypectomy is not surprisinglyassociated with ‘recurrence’ rates of up to 75 percent.10 This has led to a greater reliance on moreconcerted attempts to completely remove the papil-loma via external approaches (Table II)accompanied by commensurately lower recurrencerates of between zero and 29 per cent. Since the1980s a number of authors have employed anendoscopic approach in appropriate cases, againreporting a similar range of recurrence zero to 27 percent (Table III). When all the cases in 20 seriesreported between 1977 and 1998 are aggregated, apatient cohort of 1 287 may be reviewed (Table IV)and demonstrate comparable recurrence results fromboth radical external and endoscopic approaches.This is largely a re￿ection of patient selection basedon extent of disease. In my own series, the majorityof recurrences occurred in the external group whichalso included those individuals with the moreextensive disease, many of whom had alreadyundergone radical and often multiple surgery.It is clear that when tumour invades the frontalsinus, lateral maxillary wall, naso-lacrimal region,orbit and/or skull base, the chances of inadequateexcision are considerably increased and it is thus theextent of disease which primarily determines theoptimum surgical approach. However, it may only bepossible at operation to absolutely determinewhether the papilloma has in￿ltrated the mucousmembrane or simply ‘dumb-belled’ into the sinuswith associated retention of secretion. In additionprevious treatment, individual patient factors andsurgical expertise must also be considered. Conse-quently there is no single right or wrong surgicalsolution but rather a range of procedures from whicha choice may be made in any individual case. Indeed,it may be necessary to warn the patient that the ￿nalchoice of procedure may be decided at the time ofsurgery and pre-operative discussion and consentshould re￿ect this.References1 Kramer (1847) Quoted in Kramer R, Som ML. Truepapillomas of the nasal cavity. Arch Otolaryngol1935;22:22–432 Ward N. Follicular tumour involving nasal bones, nasalprocesses of superior maxillary bone and septum of nose.Removal, death from pneumonia, autopsy. Lancet1855;ii:4603 Billroth T. Ueber dem Bau des Cchleimpolyp. BerlinReimer 18834 Ringetz N. Pathology of malignant tumours arising in thenasal and paranasal cavities and maxilla. Acta Otolaryngol1938;(suppl 27):31–425 Lampertico P, Russell WO, MacComb WS. Squamouspapilloma of upper respiratory epithelium. Acta Pathol1963;75:293–3026 Harrison DFN, Lund VJ. Papillomas of the nasal cavityand paranasal sinuses. In: Harrison DFN, Lund, VJ, eds.Tumours of the Upper Jaw. Edinburgh, London:ChurchillLivingstone, 1993;73–807 Woodson GE, RobbinsT, Michaels L. Inverted papilloma.Considerations in treatment. Arch Otolaryngol1985;111:806–118 Lund VJ, Lloyd G. Radiological changes associated withinverted papilloma of the nose and paranasal sinuses. Br JRadiol 1984;57:455–619 Woodruff WW, Vrabec DP. Inverted papilloma of thenasal vault and paranasal sinuses: spectrum of CT ￿ndings.Am J Rhinol 1994;162:419–2310 Calcaterra TC, Thompson JW, Paglia DE. Invertingpapillomas of the nose and paranasal sinuses. Laryngo-scope 1980;90:53–6011 Myers EN, Fernau JL, Johnson JT, Tabet JC, Barnes L.Management of inverted papilloma. Laryngoscope1990;100:481–9012 Dolgin SR, Zaveri VD, Casiano RR, Maniglia AJ.Different options for treatment of inverting papilloma ofthe nose and paranasal sinuses: a report of 41 cases.Laryngoscope 1992;102:231–6TABLE IIresults of radical external surgery in the literatureAuthor nF.U.(months)Recurrencerate (%)Myers et al.11 22 10.8 4Dolgin et al.12 42 >6 22–29Waitz and Wigand13 16 >12 18Vrabec14 101 9/12–25 yrs 2McCary et al.15 17 .1–100 25Lawson et al.16 112 >12 14Raveh et al.17 18 ? 22Yoskovitch et al.18 35 .1–18 yrs 0TABLE IIIresults of endoscopic sinussurgery for inverted papillomain the literatureAuthor nF.U.(months)Recurrencerate (%)Waitz and Wigand13 35 >12 17Stankiewicz and Girgis19 15 26 20McCary et al.15 7 5–19 0Buchwald et al.20 5 ? 0Kamel21 17 >24 0Raveh et al.17 9 >24 22Sham et al.22 22 >33 27TABLE IVoverall recurrence rates in published series between 1977and 19987,10–28 (n = 1287)Conservative (INP, INE, C/L) 240/413 58%Radical (LR, MFD) 110/764 14%Endoscopic 20/110 18%196 v. j. lund13 Waitz G, Wigand ME. Results of endoscopic sinus surgeryfor the treatment of inverted papillomas. Laryngoscope1992;102:917–2214 Vrabec DP. The inverted Schneiderian papilloma: a 25-year study. Laryngoscope 1994;104:582–60515 McCary WS, Gross CW, Reibel JF, Cantrell RW.Preliminary report: endoscopic versus external surgery inthe management of inverting papilloma. Laryngoscope1994;104:415–916 Lawson W, Ho BT, Shaari CM, Biller HF. Invertedpapilloma: a report of 112 cases. Laryngoscope1995;105:282–817 Raveh E, Feinmesser R, Shpitzer T, Yaniv E, Segal K.Inverted papilloma of the nose and paranasal sinuses: astudy of 56 cases and review of the literature. Isr J Med Sci1996;32:1163–718 Yoskovitch A, Braverman I, Nachtigal D, Frenkiel S,Rochon L, Black MJ. Sinonasal Schneiderian papilloma. JOtolaryngol 1998;27:122–619 Stankiewicz JA, Girgis SJ. Endoscopic surgical treatmentof nasal and paranasal sinus inverted papilloma. Otolar-yngol Head Neck Surg 1993;109:988–9520 Buchwald C, Franzmann M-B, Tos M. Sinonasal papillo-mas: a report of 82 cases in Copenhagen County,includinga longitudinalepidemiological and clinical study. Laryngo-scope 1995;105:72–921 Kamel RH. Transnasal endoscopicmedial maxillectomy ininverted papilloma. Laryngoscope 1995;105:847–5322 Sham CL, Woo JKS, van Hasselt CA. Endoscopicresection of inverted papilloma of the nose and paranasalsinuses. J Laryngol Otol 1998;112:758–6423 SuhKW, Facer GW, Devine KD,Weiland LH, Zujko RD.Inverting papilloma of the nose and paranasal sinuses.Laryngoscope 1977;87:35–4624 Kristensen S, Vorre P, Elbrønd O, Søgaard H. NasalSchneiderian papillomas: a study of 83 cases. ClinOtolaryngol 1985;10:125–3425 Segal K, Atar E, Mor C, Har-El G, Sidi J. Invertingpapillomaof the nose and paranasal sinuses. Laryngoscope1986;96:394–826 Weissler MC, Montgomery WW, Turner PA,MontgomerySK, Joseph MP. Inverted papilloma. Ann Otol RhinolLaryngol 1986;95:215–2127 Benninger MS, Lavertu P, Levine H, Tucker HM.Conservation surgery for inverted papillomas. Head Neck1991;13:442–528 Outzen KE, Grøntveld A, Jørgensen K, Clausen PP,Ladefoged C. Inverted papilloma: incidence and lateresults of surgical treatment. Rhinology 1996;34:114–8Address for correspondence:Professor V. J. Lund,Professor in Rhinology,Institute of Laryngology and Otology,University College London,330 Gray’s Inn Road,London WC1X 8DA.optimum management of inverted papilloma 197

Optimum management of inverted papilloma

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