Endoscopic management of inverted papillomas of the nose and paranasal sinuses. (Original Article).

Abstract

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 S 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.

Introduction

Inverted papillomas are one of the most common benign epithelial tumors of the nasal cavity. They generate considerable interest because they can recur and undergo malignant transformation. Reported recurrence rates vary widely, ranging from 0 to 78%. (12) Because of the possibility of recurrence, many authors recommend radical surgery to extirpate these lesions. The traditional extemal approach has been a medial maxillectomy via a lateral rhinotomy or midfacial degloving. (24) Of late, however, endoscopic resection has been given increasing consideration because it obviates the inherent complications of the external approach. (5-7) In this article, we report our experience with endoscopic endonasal sinus surgery in the treatment of six patients with inverted papillomas.

Patients and methods

Since August 1995, we have used endoscopic excision to treat six patients--five men and one woman, aged 30 to 65 years (mean: 49)--with inverted papillomas of the nose and paranasal sinuses. All six patients were assessed preoperatively by endoscopic examination and computed tomography (CT) (figure). One patient (patient 5) had undergone a previous nasal polypectomy at another institution.

Each resection was performed with the patient under general anesthesia. To reduce intraoperative bleeding, a solution of 1:100,000 adrenaline in saline was injected into the lesion, middle turbinate, inferior turbinate, and nasal septum prior to surgery. As each tumor was removed, simultaneous cauterization was applied to control bleeding. Adequate margins of mucosa at all involved sites were also removed. All gross tumors and mucosal specimens were sent for histopathologic analysis. All patients were followed up with regular endoscopic evaluation. Patients who developed recurrences underwent repeat surgery.

Results

During surgery, the middle turbinate and the anterior ethmoid sinuses were found to be involved in all six patients (table). The posterior ethmoid sinus was involved in four patients, the sphenoid sinus in three patients, and the frontal recess in two. Tumor prolapse into the maxillary antrum was noted in three patients.

Disease was bilateral in two patients and unilateral in four. Both patients with bilateral disease (patients 1 and 3) had initially been misdiagnosed with nasal polyps, and they underwent primary functional endoscopic sinus surgery. The diagnosis of inverted papilloma was made following postoperative histopathologic analysis. When both patients experienced recurrences, they were treated with disease-oriented endoscopic surgery. Patient 1 was free of disease 5 years following a single repeat surgery. Patient 3, meanwhile, required three repeat surgeries, and he was free of disease at the 1-year follow-up. The four patients with unilateral disease showed no evidence of recurrence during follow-up that ranged from 6 months to 3 years.

Discussion

The search for an ideal surgical approach to removing inverted papillomas has been fairly controversial, with proponents of radical surgery vying with those who support endoscopic endonasal procedures. The external approaches include medial maxillectomy, frontoethmoidectomy, and Caldwell-Luc surgeries. Recurrence rates following these procedures have been reported to range from 4 to 35%. (2,8-10) The short-term complications of these approaches include epiphora, dacryocystitis, diplopia, transient blepharitis, lid edema, and cerebrospinal fluid leak. Late complications include persistent crusting, pain, nasocutaneous fistula, frontal sinus mucocele, vestibular stenosis, unacceptable scarring, and nasal collapse.

To circumvent these complications, nonendoscopic intranasal procedures were proposed. However, these procedures were associated with unacceptable rates of recurrence--as high as 75%. (11) As a result, nonendoscopic intranasal approaches did not gain widespread acceptance.

The subsequent use of endoscopes in nasal surgery, however, did become increasingly popular during the 1990s. Endoscopy obviated problems that hindered the use of nonendoscopic procedures, such as poor illumination and difficulty in accessing lesions, and made it possible to achieve greater clearance of inverted papillomas. Greater clearance resulted in a commensurate reduction in recurrence rates to between 17 and 27%--rates that are comparable to those seen following radical procedures. (4,12)

Another advantage of endoscopy is that it can be used during follow-up to detect any recurrences early. However, this type of follow-up requires a serious commitment on the part of the patient, so only those patients who are capable of returning for regular follow-up visits should be considered for endoscopic surgery. On follow-up endoscopy, any suspicious area should be sampled under local anesthesia and sent for histopathologic analysis. CT should be obtained if the biopsy confirms a recurrence in order to assess its site and extent. The patient can then be scheduled for either a repeat endoscopic procedure or external surgery, depending on the extent of the tumor.

With respect to the two patients in our series who were originally misdiagnosed with nasal polyps (patients 1 and 3), other authors have reported similar cases. (12,13) Therefore, we consider it mandatory to obtain histopathologic analysis of all tissue samples that are obtained during routine endoscopic surgery for nasal polyposis. Patient 1 remained disease-free 5 years following a single repeat surgery for a recurrence, and patient 3 was disease-free 1 year after three repeat surgeries for recurrences. The recurrences in both of these patients arose in the maxillary antrum (inferomedial angle) and in the frontal recess area; it is probable that these sites not been completely cleared of disease during previous surgeries. In patient 3, some tumor was left near the cribriform plate on repeat surgery.

It has been argued that comparing recurrence rates following endoscopic surgery with those following external approaches is not a valid exercise because patients who are selected for endoscopic surgery usually have limited disease. (14) Indeed, basing the selection of surgical procedure on the extent of tumor is an area of controversy. Kamel suggested that endoscopic surgery is appropriate for removing lesions that do not involve the maxillary sinus and that transnasal medial maxillectomy is appropriate for those who do. (7) Stankiewicz and Girgis recommended that the endoscopic approach be used for disease that is limited to the ethmoid or sphenoid sinuses, the lateral nasal wall, and the medial wall of the maxillary sinus. (6) Both the maxillary antrum and the frontal sinus are relatively inaccessible by endoscopic surgery, so the gross involvement of either would be an indication for an external approach. Two of our patients had involvement of the frontal recess area (patients 1 and 6) that were successful ly cleared. In patient 6, CT findings led us to suspect that the frontal sinus was involved, and therefore we obtained preoperative consent to use an external approach if necessary. However, during endoscopic surgery, the frontal sinus was found to contain only collected secretions, and it was essentially tumor-free.

The surgical approach to removing inverted papillomas of the nose and paranasal sinuses must be flexible and tailored to the individual patient. The type of surgery depends on the extent of the tumor, the number of previous surgeries, the patient's commitment to follow-up, and the surgeon's experience. Endoscopic endonasal surgery is an excellent procedure for treating patients who have limited disease that involves the lateral nasal wall, the anterior and posterior ethmoid sinuses, the sphenoid sinuses, and the medial maxillary wall. Patients whose disease extends beyond these sites should be considered for an external approach, with or without adjunctive endoscopic surgery.

In conclusion, our experience indicates that endoscopic endonasal surgery to remove inverted papillomas is a simple and effective means of achieving good tumor control in appropriately selected patients who are motivated to comply with regular postoperative follow-up.

Table

Patient characteristics

     Age/  Affected  Tumor site *   Tumor site *     No. repeat
Pt.  sex     side       on CT         intraop        surgeries

1.   38/M   Both     NC, INF, MS,  NC, INF, MT, MS,      1
                     AE, PE, SP    FR, AE, PE, SF
2.   45/M   Left     NC, INF, MS,  NC, INF, MT, AE,      0
                     AE,PE,SP      PE, SP
3.   30/M   Both     NC, INF, MS,  NC, INF, MT, MS,      3
                     AE, PE, SF    AE, PE, SP
4.   65/M   Right    NC, INF, AE,  NC, INE, MT, AE       0
                     PE, SP
5.   55/M   Right    NC, INF, MT,  NC, INF, MT, MS       0
                     MS, AE, PE    AE, PE
6.   61/F   Right    INF, FS, AE,  INF, MT, FR, AE       0
                     PE

     Age/  Disease-free
Pt.  sex   period postop

1.   38/M      5 yr

2.   45/M      3 yr

3.   30/M      1 yr

4.   65/M      8 mo

5.   55/M      6 mo

6.   61/F      6 mo


* NC = nasal cavity

INF = infundibulum

MS = maxillar sinus

AE = anterior ethmoid sinus

PE = posterior ethmoid sinus

SP = sphenoid sinus

MT = middle turbinate

FS = frontal sinus

FR = frontal recess.

References

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(14.) Bielamowicz S, Calcaterra TC, Watson D. Inverting papilloma of the head and neck: The UCLA update. Otolaryngol Head Neck Surg 1993:109:71-6.

From the Department of Otorhinolaryngology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India.

Reprint requests: Paramita Baruah, MS, Otorhinolaryngology, DIBIT Istituto Scientifico San Raffaele, 3A1 Lab 3, Via Olgettina 58, 20132 Milan, Italy. Phone: [phone]; fax: [phone]; e-mail: [e-mail]