Powered resection of an inverting papilloma.

A woman was referred for evaluation of recurrent left sinus infections associated with a persistent dull ache in the left cheek area. Computed tomography (CT) of the sinuses demonstrated left ostiomeatal complex obstruction and opacification of the left maxillary sinus (figure 1, A). Endoscopic nasal evaluation revealed an irregular, friable, polypoid mass that extended from the left middle meatus (figure 1, B). Endoscopic sinus surgery was performed with a microdebrider, and all the polypoid mass in the nose (figure 1, C) and maxillary sinus (figure 1, D) was removed. Pathology identified the tissue as an inverting papilloma. Follow-up examination 3 years postoperatively revealed no evidence of inverting papilloma on the left (figure 2). However, the patient was experiencing right-sided symptoms. Ethmoid opacification was seen, and she underwent functional endoscopic sinus surgery, which revealed inflammatory tissue in the right ethmoid. At follow-up 4 years after her initial resection, the patient had experienced no further problems.

[FIGURES 1-2 OMITTED]

Inverting papillomas of the nose and sinuses resemble benign polyps. Although they are benign, noninvasive tumors, their course can be fairly aggressive in view of the expansile nature of the polypoid disease. Inverting papillomas are associated with a significant rate of recurrence after initial excision and a long-term malignant transformation rate of 5 to 15%. (1)

Historically, surgical treatment has involved aggressive open procedures such as medial maxillectomy. (2) But the advent of endoscopic techniques for both meticulous removal of tissue and subsequent direct observation of the nose and sinuses has enabled surgeons to switch to a closed endoscopic procedure to remove inverting papillomas. (3) The use of powered dissection for the efficient and complete removal of polypoid tissue is well established. (4) A caveat in less invasive surgery is that the patient must be followed endoscopically over the long term. A high index of suspicion is also important at the time of surgery, especially in a patient with unilateral polypoid disease. Surgeons are well advised to make a complete microscopic diagnosis of all polypoid tissue.

Powered endoscopic resection is an effective technique for the removal of inverting papillomas from the middle meatus and maxillary sinus.

References

(1.) Yanagisawa E, Latorre R. Endoscopic view of multicentric noninverted intranasal papilloma. Ear Nose Throat J 1997:76:133-4.

(2.) Myers EN, Fernau JL, Johnson JT, et al. Management of inverted papilloma. Laryngoscope 1990;100:481-90.

(3.) Kennedy DW, Senior BA. Endoscopic sinus surgery. A review. Otolaryngol Clin North Am 1997;30:313-30.

(4.) Mirante JP Christmas DA, Yanagisawa E. Powered endoscopic nasal polypectomy. In: Yanagisawa E, Christmas DA, Mirante JP eds. Powered Instrumentation in Otolaryngology-Head and Neck Surgery. San Diego: Singular Publishing, 2001:17-26.

Dewey A. Christmas, MD; Joseph P. Mirante, MD; Eiji Yanagisawa, MD

From the Department of Otolaryngology, University of South Florida College of Medicine. Tampa, and the Halifax Medical Center, Daytona Beach, Fla. (Dr. Christmas and Dr. Mirante); and the Southern New England Ear, Nose, Throat, and Facial Plastic Surgery Group; the Section of Otolaryngology, Hospital of St. Raphael: and the Section of Otolaryngology, Yale University School of Medicine, New Haven, Conn. (Dr. Yanagisawa).