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Endoscopic 532-nm KTP laser excision of inverted papilloma of the nose and paranasal sinuses: a series of 9 patients.

Abstract

Over the past 2 decades, the surgical management of inverted papillomas has evolved from extensive radical excision to more conservative surgery. We conducted a study to evaluate the results of our endoscopic approach to tumor excision with the 532-nm potassium titanyl phosphate (KTP-532) laser. Our series included 9 patients with inverted papilloma of the nose and paranasal sinuses who were treated from January 1998 through December 2003 (72 mo). Only 1 patient (11.1%) experienced a recurrence. The recurrence was detected 12 months after initial treatment, and it was successfully managed via the same endoscopic approach; afterward, the patient was still tumor-free at 2.5 years of follow-up. The good results of this endoscopic approach for lesions limited to the nose and paranasal sinuses can be attributed to excellent visualization with the endoscope and to the bloodless dissection achieved with the KTP-532 laser. We emphasize the need for frequent and long-term follow-up of these patients; a thorough endoscopic examination at every visit is extremely important.

Introduction

Sinonasal papillomas were first described by Ward in 1854. (1) Although inverted papillomas represent only 0.5 to 4% of all primary nasal tumors, (2,3) they are the most common benign epithelial tumor of the nasal cavity. Their unique tendency to invert into underlying connective tissue stroma, which was first described by Ringertz in 1938, (4) led to the term inverted papilloma.

The characteristic clinical attributes of inverted papilloma are a tendency to recur, a capability to destroy surrounding structures, and an association with malignancy. The recurrence rates reported in different studies are highly variable (0 to 86%), depending mainly on the type of surgical approach that was used. (5,6)

Endoscopy is the most recent surgical approach. The introduction of endoscopes has enhanced our ability to diagnose and manage many nasal diseases, and most surgeons now advocate this more conservative approach for the treatment of inverted papillomas, keeping in mind its low associated recurrence rates. In a report of 160 cases, Lawson et al suggested that a conservative endoscopic removal of selected lesions is associated with recurrence rates that are comparable to those following more aggressive techniques. (7)

The 532-nm potassium titanyl phosphate (KTP-532) laser has been used for various ENT procedures at our institution (Tyrone County Hospital in Omagh, Northern Ireland) for more than 20 years. Its use in rhinology has improved the treatment of vascular lesions in the nose. Potassium titanyl phosphate is a solid crystal. When a 1,064-nm beam from a neodymium:yttriumaluminum-garnet (Nd:YAG) laser is passed through a KTP crystal, the wavelength of the light is halved to 532 nm, thus producing a KTP laser beam. This process is known as frequency doubling. (8) The KTP laser is in the visible range of the electromagnetic spectrum, and hence its use does not require an aiming beam, so problems with misalignment are precluded. This ensures a high degree of surgical accuracy in the nasal cavity, which is particularly important when working in critical areas such as the lamina papyracea, the roof of the sphenoid sinus, and near the thin lateral lamella of the cribriform plate. Moreover, the depth of tissue penetration of the KTP-532 laser (0.9 mm) is less than that of the Nd:YAG laser (4 mm), (9) which allows for its use near the orbit and skull base.

The development of modern surgical instruments has made it possible to pass a laser fiber through a channel along with a nasal endoscope. Alternately, a flexible quartz fiber can be passed through a handheld instrument. The quartz fiber tips are unsharpened and remain cool, which prevents accidental trauma and thermal burns, both to the patient and surgeon. A relatively bloodless field is particularly important when working in the vascular tissues of the nose. The wavelength of the KTP laser (532 nm) is selectively and highly absorbed in blood pigments such as hemoglobin, making it an excellent coagulator and resulting in minimal bleeding during nasal surgery.

In this article, we describe our study of 9 cases of inverted papilloma that were resected with the KTP-532 laser endoscopically.

Patients and methods

Our study population was made up of 9 patients--7 men and 2 women, aged 39 to 58 years (mean: 48.8)--with inverted papilloma of nose and paranasal sinuses. All patients were operated on and followed by the same surgeon (S.K.K.) from January 1998 through December 2003 (72 mo). Preoperative endoscopic examination (figure 1) and computed tomography (CT) (figure 2) were carried out in all cases.

[FIGURE 2 OMITTED]

All surgery was performed via an endoscopic intranasal approach, and each papilloma was resected with a KTP-532 laser set at 8 W of power in continuous mode with at least 80% calibration. General anesthesia was used in all cases; pledgets soakedwith a 4% cocaine solution were used to prepare the nose. The tumor was visualized under endoscopic vision, and a laser incision was made in the mucosa 5 mm anterior to the tumor. The mucosa was then lifted with a Freer elevator, and the elevation was gradually extended toward the tumor. Along with mucosa, the tumor was dissected from its attachment with the laser. Under direct vision, the attachment was ablated with the laser in the vaporization and coagulation modes, and the tumor was then delivered. In the patients with involvement of the ethmoids and sphenoid, complete endoscopic sphenoethmoidectomy was performed. The laser was essentially used in all three modes: contact, near-contact, and noncontact to achieve cutting, vaporization, and coagulation.

[FIGURE 1 OMITTED]

[FIGURE 3 OMITTED]

All gross tumor specimens were sent for histopathology (figure 3). Patients were followed regularly for a period of 2.5 to 7 years (mean: 4.9), and an endoscopic examination was performed at every visit. Patients were followed every week during the first month, then every month for the next 6 months, and finally every 4 months thereafter.

Results

The most common presenting symptom was unilateral nasal obstruction, which was seen in 7 patients (77.8%); the other 2 patients (22.2%) had bilateral nasal obstruction. Two patients had recurrent episodes of epistaxis. Other isolated symptoms included postnasal drip and swallowing discomfort (table).

The tumor was attached to the lateral nasal wall in 5 patients (55.6%), to the septum in 4 (44.4%), to the lamina papyracea in 4, to the middle turbinate in 1 (11.1%), and to the skull base in 1. Paranasal sinus involvement was present in 4 patients; 2 patients (22.2%) had ethmoid sinus involvement only, 1 had sphenoid sinus involvement only, and 1 had both ethmoid and sphenoid sinus involvement. The tumor extended to the posterior choana and postnasal space in 3 patients (33.3%). None of our patients had bilateral nasal involvement or orbital or intracranial extension. Also, no associated carcinoma was found in any patient (table).

Postoperatively, 2 patients required a Merocel nose pack. Each pack was removed the following day, and both patients were then discharged.

All nasal cavities healed in 4 to 6 weeks. Each follow-up endoscopic examination was thorough, and care was taken to inspect the sites where the tumor had been attached because recurrence is most common in these areas.

One patient (11.1%) experienced a recurrence. Although he was asymptomatic, endoscopy detected the recurrence in the posterior part of the septum 12 months postoperatively. The recurrent inverted papilloma was treated via the same endoscopic KTP-532 laser approach, and the patient remained disease-free at 2.5 years of follow-up.

Discussion

Proponents of aggressive open surgical procedures believe that the good exposure it provides during wide resection of inverted papillomas and their surrounding mucosa minimizes the risk of recurrence. For example, Myers et al found no recurrences among 13 patients whom they had treated with lateral rhinotomy with en bloc resection of the lateral nasal wall. (10) But on the other hand, Buchwald et al noted a high recurrence rate (50%) associated with the open approach. (11)

With advancements in diagnostic and endoscopic techniques, many surgeons are migrating away from the traditional open approaches. The tilt toward endoscopic approaches is also attributable to the fact that numerous studies comparing endoscopic approaches with open approaches have shown that recurrence rates are comparable:

* Lund reviewed 20 series totaling 1,287 cases of inverted papilloma published from 1977 through 1998 and reported recurrence rates of 58% after conservative intranasal removal, 14% after radical removal, and 18% after endoscopic removal. (12)

* In their analysis of 160 cases, Lawson et al reported recurrence rates of 18% among 112 patients who had been treated with lateral rhinotomy and 12% of 41 patients treated with conservative procedures, including endoscopic approaches. (7)

The lower recurrence rates following endoscopic procedures have been attributed to precise identification and good localization of the tumor, which helps the surgeon accomplish a complete resection. The use of advanced endoscopes has not only helped surgeons, but it has also helped patients by giving them an option of scarless surgery with no cosmetic deformity and shorter hospitalizations. Also, newer endoscopes with strong illumination, superior resolution, and angled visualization not only help in identification of the exact anatomy, but they preserve the basic physiology of nasal airflow, as well. (13) This is why Waitz and Wigand considered even patients with large lesions (e.g., those affecting the nasofrontal duct, posterior ethmoid sinus, or sphenoid sinus) to be acceptable candidates for an endoscopic approach. (14)

We took advantage of all the benefits of the endoscopic approach to treat our patients. But the unique feature of our management was the use of the KTP-532 laser. Inverted papillomas are notorious for extensive bleeding, so a bloodless field would be a great advantage. The hemostatic property of the KTP-532 laser helped us achieve an almost bloodless field. This in turn helped us visualize the exact site of tumor attachment; such visualization is difficult when bleeding is extensive.

In order to ensure a wide resection, we made an incision 5 mm anterior to the tumor attachment. Then we elevated the mucosa and tumor and ablated the attachment with the laser in vaporization and coagulation modes. Endoscopic visualization after gross tumor removal provides a good magnified view of sites that are otherwise inaccessible, so any residual tumor or even mucosal involvement can be removed or ablated. The wide-field resection of tumor ensures removal of mucosa where the disease might not be clinically apparent. The KTP-532 laser's lesser depth of tissue penetration (compared with that of the Nd:YAG laser) and its capability to be used in contact, near contact, and noncontact settings allows the laser to be safely used near the lamina papyracea and skull base.

In our series, the healing time of the cavity was 4 to 6 weeks, which is a little longer than that associated with conventional endoscopic surgery. Based on our detailed regular endoscopic follow-up observations, we believe that this was because the laser approach caused more edema than does conventional surgery. Gerlinger et al noted a similar pattern of healing in their study. (15) In our series, the edema resolved completely without any treatment. Postoperatively, none of our patients complained of gross nasal obstruction, epistaxis, infection, swallowing discomfort, or excessive pain.

Regarding the 1 patient in our study who experienced a recurrence, his primary tumor had been attached to the right side of the septum, the nasal floor, and the right lateral wall. Following excision of the primary, he remained disease free for 12 months. At that point, the follow-up examination detected a suspicious area in the posterior part of the right side of the septum. From this suspicious area we took a biopsy, which confirmed the recurrence. We treated the recurrence with the same endoscopic laser procedure, and the patient remained disease-flee throughout the remainder of the study. The magnified view offered by endoscopy is an excellent aid to early identification of any suspicious areas during postoperative follow-up. Indeed, frequent and long-term follow-up examinations are an important aspect of our management strategy. Frequent follow-up allows us the opportunity to identify any recurrence at a very early stage, and long-term follow-up is important because recurrences have been found many years after the primary surgery. So for inverted papillomas limited to the nose and paranasal sinuses, we believe our approach is a good option in view of the low rates of recurrence and the minimal postoperative morbidity.

References

(1.) Ward N. A mirror of the practice of medicine and surgery in the hospitals of London. London Hosp Lancet 1854;2:480-2.

(2.) Lampertico P, Russell WO, MacComb WS. Squamous papilloma of upper respiratory epithelium. Arch Pathol 1963;75:293-302.

(3.) Skolnik EM, Loewy A, Friedman JE. Inverted papilloma of the nasal cavity. Arch Otolaryngol 1966;84 (1):61-7.

(4.) Ringertz N. Pathology of malignant tumors arising in the nasal and paranasal cavities and maxilla. Acta Otolaryngol 1938;27 (Suppl):31-42.

(5.) Lawson W, Ho BT, Shaari CM, Biller HF. Inverted papilloma: A report of 112 cases. Laryngoscope 1995;105(3 Pt 1):282-8.

(6.) Krouse JH. Endoscopic treatment of inverted papilloma: Safety and efficacy. Am J Otolaryngol 2001;22(2):87-99.

(7.) Lawson W, Kaufman MR, Biller HF. Treatment outcomes in the management of inverted papilloma: An analysis of 160 cases. Laryngoscope 2003;113(9):1548-56.

(8.) Kaluskar SK, Sachdeva S. Complications in Endoscopic Sinus Surgery. Diagnosis, Prevention and Management. London: Lippincott Williams & Wilkins; 2002:125-6.

(9.) Reinisch L. Laser physics and tissue interactions. Otolaryngol Clin North Am 1996;29(6):893-914.

(10.) Myers EN, Schramm VL Jr., Barnes EL Jr. Management of inverted papilloma of the nose and paranasal sinuses. Laryngoscope 1981;91(12):2071-84.

(11.) Buchwald C, Nielsen LH, Nielsen PL, et al. Inverted papilloma: A follow-up study including primarily unacknowledged cases. Am J Otolaryngol 1989;10(4):273-81.

(12.) Lund VJ. Optimum management of inverted papilloma, l Laryngol Otol 2000;114(3): 194-7.

(13.) Lueg EA, Irish JC, Roth Y, et al. An objective analysis of the impact of lateral rhinotomy and medial maxillectomy on nasal airway function. Laryngoscope 1998;108(9):1320-4.

(14.) Waltz G, Wigand ME. Results of endoscopic sinus surgery for the treatment of inverted papillomas. Laryngoscope 1992;102(8):917-22.

(15.) Gerlinger I, Lujber L, Jarai T, Pytel J. KTP-532 laser-assisted endoscopic nasal sinus surgery. Clin Otolaryngol Allied Sci 2003;28 (2):67-71.

S.K. Kaluskar, MS, FRCS; Rahul Mehta, MS, MRCS; Turlough B. Farnan, MRCS; S.I. Basha, MS, FRCS

From the Department of ENT and Head & Neck Surgery, Tyrone County Hospital, Omagh, Northern Ireland.

Corresponding author: Dr. Rahul Mehta, 8 Millmount Lane, Dundonald, Belfast BT161WN, Northern Ireland, UK. Phone: 44-289-048-2740; fax: 44-283-839-2934; e-mail: drrahulmehtauk@yahoo.co.uk
Table. Summary of demographic and clinical data

      Age/
Pt.   sex           Presentation

1     54/M   Right nasal obstruction
             and epistaxis

2     48/M   Bilateral nasal obstruction
             and postnasal drip

3     44/F   Left nasal obstruction

4     58/M   Right nasal obstruction
             and swallowing discomfort

5     46/F   Right nasal obstruction

6     45/M   Right nasal obstruction

7     39/M   Left nasal obstruction

8     50/M   Bilateral nasal obstruction
             and postnasal drip

9     55/M   Left nasal obstruction
             and epistaxis

                Site of tumor                          Disease-free
Pt.              attachment               Recurrence      years

1     Right middle turbinate                  No            7

2     Right side of the septum, nasal        Yes            2.5
      floor, and right lateral wall

3     Left lateral wall, left sphenoid        No            5
      sinus, left wall of the posterior
      choana, and right skull base

4     Right side of the septum,               No            4
      posterior choana, and
      right lamina papyracea

5     Right lateral wall, right ethmoid       No            6
      sinus, and right lamina papyracea

6     Nasal floor, right side of the          No            3
      septum, and right lamina
      papyracea

7     Posterior septum and left               No            4.5
      lateral wall

8     Right ethmoid sinus, right lamina       No            6
      papyracea, and posterior choana

9     Left lateral wall, anterior and         No            6
      posterior ethmoid sinuses,
      and left sphenoid sinus
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Article Details
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Title Annotation:ORIGINAL ARTICLE
Author:Kaluskar, S.K.; Mehta, Rahul; Farnan, Turlough B.; Basha, S.I.
Publication:Ear, Nose and Throat Journal
Article Type:Clinical report
Geographic Code:4EUUK
Date:Apr 1, 2009
Words:2635
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