Original article: Inverted papilloma of the nasal cavity and paranasal sinuses: a study of 20 cases 1 Dr. Vijay Kumar Kalra, 2 Dr. Samar Pal Singh Yadav, 3 Dr. Swati 1Assistant Professor, 2 Senior Professor and Head, 3 Postgraduate Student Department of Otorhinolaryngology, Pt. B.D. Sharma PGIMS, Rohtak-124001, Haryana (India) Abstract Objective: To review the patients of inverted papilloma in an attempt to characterize the lesion and study the results of lateral rhinotomy with medial maxillectomy. Methods: Twenty patients of inverted papilloma who were treated by the lateral rhinotomy with medial maxillectomy were retrospectively analyzed at a tertiary care hospital. Results: The mean age at presentation was 48 years. There was preponderance in males as compared to females, male to female sex ratio was 3:1. The most commonly reported symptom was nasal obstruction followed by epistaxis, and nasal discharge. The most common radiographic finding was a unilateral nasal mass with opacification of the adjacent ethmoid and/or maxillary sinus. Lateral rhinotomy with medial maxillectomy was found to be associated with recurrence in 2 (10%) patients. Lifelong follow-up is urged. Conclusion: The experience with inverted papilloma at our institution has been reviewed with respect to clinical presentation and response to treatment. Treatment with lateral rhinotomy and medial maxillectomy is associated with low recurrence rate. Keywords: Inverted papilloma, nasal cavity, paranasal sinuses, lateral rhinotomy, medial maxillectomy. INTRODUCTION Inverted papilloma is a benign neoplasm of the respiratory mucosa that is best known for its invasiveness, tendency to recur, and association with malignancy. It is a relatively rare neoplasm, the incidence of inverted papilloma has been documented as approximately 0.6 cases per 100,000 people per year. 1 It comprises 0.5% to 4% of all primary nasal tumour. 2 In 1854, Ward first documented the occurrence of papilloma in the nasal cavity. 3 In 1935, Reingertz histologically described the nature of the tumour and noted its classic inverted nature in underlying connective tissue stroma. 4 Since then, many additional papers have been published on various aspects of these lesions. We studied the records of 20 patients with inverted papilloma of the sinonasal tract treated at our institution. The cases reviewed have been analyzed to characterize the lesion, and treatment results with lateral rhinotomy and medial maxillectomy. MATERIAL AND METHODS The present study was conducted in the Department of Otorhinolaryngology, Pt. B.D. Sharma PGIMS, Rohtak. The available records 143
of the patients were retrieved. The patient's age, sex, presenting symptoms and previous history of surgery was noted. Physical examination included the side, appearance, friability and site of attachment of the nasal and paranasal sinuses lesion. Radiological examination was performed with computed tomography. Surgical excision in all of the patients was carried out under general anaesthesia. Follow-up examination was performed with diagnostic nasal endoscopy to know the recurrence of tumour. RESULTS A total of 20 patients of inverted papilloma of the nose and paranasal sinuses were studied retrospectively. The age ranged from 17 to 80 years. The mean age at presentation was 48 years (Table 1). Out of 20 cases, 15 (75%) patients were males, while 5 (25%) were females. The most common symptom was nasal obstruction followed by epistaxis, and nasal discharge (Table 2). The duration of nasal symptoms varied from 1 month to 10 years. A total of 13(65%) of these patients had symptoms for 1 year or less. Six (30%) of the remaining patients had symptoms for more than 1 year to 5 years and 1 (5%) for over 5 years (Table 3). Eight (40%) of the lesions were right-sided and 12(60%) lesions were left-sided. Computed tomography was done for all of the patients in the study. In all cases, there was a unilateral nasal cavity mass. CT scan showed opacification of the ethmoid and/or maxillary sinuses in 16(80%) patients, sphenoid sinus in 2(10%) and frontal sinus also in 2(10%) patients. Lateral rhinotomy with medial maxillectomy was carried out in all of the patients. Per-operatively 15(75%) tumours involved the ethmoid and/or maxillary sinuses, 1(5%) involved the sphenoid sinus, and 1(5%) involved the frontal sinus. Diagnostic nasal endoscopy showed recurrence in 2(10%) patients. In our series, the most common postoperative complication observed was epiphora in 1(5%) patient. DISCUSSION Papillomas of the nose and paranasal sinuses include lesions lined with mature squamous epithelium and histologically diverse schneiderian papillomas. Papillomas lined with mature squamous epithelium usually develop in the vestibule of the nose, where they originate from skin. The schneiderian papillomas have many names, reflecting their different microscopic features. The major types are inverted papilloma, fungiform (everted) papilloma, and oncocytic schneiderian papilloma. Inverted papilloma is the most common of the subtypes, it arises in the lateral nasal wall and paranasal sinuses, about 10% to 15% of cases may develop malignant transformation. Fungiform (everted) papilloma arises in the nasal septum, it is not associated with carcinoma. Oncocytic scheneiderian papilloma is the type most prone to undergo malignant transformation. 5-7 The inverted papilloma is usually diagnosed in adult men, but occasionally they can also occur in children. 5 The mean age at presentation in our study was 48 years. Weissler et al reported that the mean age at presentation was 50 years. 8 There were 15 males and 5 females with a male:female ratio of 3:1. Literature reports a male to female predominance in the ratio of 2:1 to 3:1. 8,9 144
Hyams reported that the most common presenting features were nasal obstruction, epistaxis and pain. 10 In our study the most common presenting features were nasal obstruction, epistaxis, and nasal discharge. The most common anatomic sites of involvement in our study were lateral nasal wall and maxillary and/or ethmoid sinuses. Sphenoid and frontal sinuses were uncommonly involved. These findings are similar to those reported by Weissler et al. 8 Various procedures have been used for the treatment of inverted papilloma, with varying results. Initially, inverted papillomas were excised via a transnasal closed approach with headlight illumination, in fact, these early procedures mimicked polypectomies. 11,12 Although the intent of these procedures were curative, recurrence rate of 40 to 80% were unacceptably high. 13,14 This, in turn, led to the use of external approaches, such as Caldwell- Luc and external ethmoidectomy. High recurrence rates, in the range of 28% to 78%, were still the rule, 15 probably because of incomplete exposure of the tumour and failure to achieve en bloc excision. Several reports have described the use of endoscopic approaches to the treatment of inverted papilloma. Waitz and Wigand were among the first to publish their results comparing endoscopic resection of inverted papilloma to traditional open procedures; they noted similar recurrence rates of 17% versus 19%, respectively, in a series of 51 patients. 16 Although endoscopic surgery is appealing because of the avoidance of external incision, selection bias exists when comparing recurrence rates of inverted papilloma resected via open approaches versus endoscopically. 11 The inverted papilloma is a locally aggressive tumour that has a high rate of recurrence, associated malignancy, and tendency to multicentricity. These features have led many surgeons 17-19 to advocate the initial use of more aggressive surgical procedures. Lateral rhinotomy with medial maxillectomy has resulted in a recurrence rate of 6% 20 to 29%. 8 In our study, the recurrence was observed in 2 (10%) patients. The advantages of lateral rhinotomy with medial maxillectomy are the excellent exposure provided, the opportunity to extend the approach to adjacent areas of tumour extension (orbit, cranial vault, frontal and contralateral ethmoid sinus), and en bloc removal of inverted papilloma. Technical refinements have allowed this procedure to be performed with acceptable and minimal morbidity. 19 Conclusion The experience with inverted papilloma at our institution has been reviewed with respect to clinical presentation and response to treatment. In conformity with the literature present study clearly demonstrates the efficacy of lateral rhinotomy with medial maxillectomy. The procedure is associated with low recurrence rate and minimal morbidity. 145
Table 1 Distribution of patients with inverted papilloma by age Age years Number of patients (%) 11-20 2(10%) 21-30 1(5%) 31-40 3(15%) 41-50 5(25%) 51-60 6(30%) 61-70 2(10%) 71-80 1(5%) Total cases 20(100%) Table 2 Symptoms of patients with inverted papilloma Symptoms Number of patients (%) Nasal obstruction 15(75%) Epistaxis 7(35%) Nasal discharge 6(30%) Headache 5(25%) Nasal mass 4(20%) Pain over cheek 1(5%) Orbital pain 1(5%) Table 3 Duration of symptoms Duration (years) Number of patients (%) < 0.5 7(35%) > 0.5-1 6(30%) > 1-5 6(30%) >5 1(5%) Total 20(100%) 146
Table 4 Peroperative anatomic sites of inverted papilloma of the sinonasal tract Site Number of patients (%) Nasal cavity 20(100%) Ethmoid and/or maxillary sinuses 15(75%) Frontal sinuses 1(5%) Sphenoid sinuses 1(5%) REFERENCES 1. Buchwald C, Nielsen LH, Nielsen PL. Inverted papilloma: A follow-up study including primarily unacknowledged cases. Am J Otolaryngol 1989;10:273-81. 2. Vrabec DP. The inverted Schneiderian papilloma: A 25-year study. Laryngoscope 1994;104:582-605. 3. Ward N. A mirror of the practice of medicine and surgery in the hospitals of London. London Hospital Lancet 1854;2:87-99. 4. Ringertz N. Pathology of malignant tumors arising in the nasal and paranasal cavities and maxilla. Acta Otolaryngol 1938;27:31-42. 5. Respiratory tract. 10 th ed. In: Rosai J, editor. Rosai and Ackerman's Surgical pathology. Philadelphia; Mosby Elsevier; 2011.p.291-436. 6. Mills SE. Nose, paranasal sinuses, and nasopharynx. 6 th ed. In: Mills SE, Greenson JE, Hornick JL, Longacre TA, Reuter VE, editors. Sternberg's Diagnostic Surgical Pathology. Philadelphia: Wolter Kluwer; 2015.p.947-993. 7. Williams MD, El-Nagger AK. Head and neck. 2 nd ed. In: Gattuso P, Reddy VB, David O, Spitz DJ, Haber MH, editors. Differential diagnosis in surgical pathology. Philadelphia: Saunders Elsevier; 2012.p.121-215. 8. Weissler MC, Montgomery WW, Turner PA. Inverted papilloma. Ann Otol Rhinol Laryngol 1986;95:215-21. 9. Lawson W, Biller HF, Jacobson A. The role of conservative surgery in the management of inverted papilloma. Laryngoscope 1983;93:148-55. 10. Hyams VJ. Papillomas of the nasal cavity and paranasal sinuses: A clinopathological study of 315 cases. Ann Otol Rhinol Laryngol 1971;80:192-206. 11. Melroy CT, Senior BA. Benign sinonasal neoplasms: A focus on inverting papilloma. Otolaryngol Clin North Am 2006;39:601-17. 12. Wormald PJ, Ooi E, Van Hasselt CA. Endoscopic removal of sinonasal inverted papilloma including endoscopic medial maxillectomy.laryngoscope 2003;113:867-73. 13. Han JK, Smith TL, Loehrl TA. An evolution in the management of sinonasal inverting papilloma. Laryngoscope 2001;111:1395-400. 14. McCary WS, Gross CW, Reibel JF. Preliminary report: Endoscopic versus external surgery in the management of inverting papilloma. Laryngoscope 1994;104:415-9. 15. Osguthorpe JD, Weisman RA. "Medial maxillectomy" for lateral nasal wall neoplasms. Arch Otolaryngol Head Neck Surg 1991;117:751-6. 147
16. Waitz G, Wigand ME. Results of endoscopic sinus surgery for the treatment of inverted papillomas. Laryngoscope 1992;102:917-22. 17. Myers EN, Schramm VL, Barnes EL. Management of inverted papilloma of the nose and paranasal sinuses. Laryngoscope 1981;91:2071-84. 18. Segal K, Atar E, Mor C. Inverting papilloma of the nose and paranasal sinuses. Laryngoscope 1986;96:394-8. 19. Weisman R. Lateral rhinotomy and medial maxillectomy. Otolaryngol Clin North Am 1995;28:1145-56. 20. Calcaterra EC, Thompson JW, Paglia DE. Inverting papillomas of the nose and paranasal sinuses. Laryngoscope 1980;90:53-60. 148