gms | German Medical Science

ESBS 2005: Skull Base Surgery: An Interdisciplinary Challenge
7th Congress of the European Skull Base Society held in association with
the 13th Congress of the German Society of Skull Base Surgery

18. - 21.05.2005, Fulda, Germany

Inverted Papillomas of the nasal cavity and the paranasal sinuses: clinical aspects, diagnosis and therapeutic results

Meeting Contribution

  • G. J. Ridder - Dept. of Otorhinolaryngology - Head and Neck Surgery, University of Freiburg, Freiburg, Germany
  • S. Behringer - Dept. of Otorhinolaryngology - Head and Neck Surgery, University of Freiburg, Freiburg, Germany
  • G. Kayser - Dept. of Pathology, University of Freiburg, Freiburg, Germany
  • C. C. Boedeker - Dept. of Otorhinolaryngology - Head and Neck Surgery, University of Freiburg, Freiburg, Germany

ESBS 2005: Skull Base Surgery: An Interdisciplinary Challenge. 7th Congress of the European Skull Base Society held in association with the 13th Congress of the German Society of Skull Base Surgery. Fulda, 18.-21.05.2005. Düsseldorf: German Medical Science GMS Publishing House; 2009. Doc05esbs20

DOI: 10.3205/05esbs20, URN: urn:nbn:de:0183-05esbs206

Published: January 27, 2009

© 2009 Ridder et al.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by-nc-nd/3.0/deed.en). You are free: to Share – to copy, distribute and transmit the work, provided the original author and source are credited.


Outline

Text

Introduction

Inverted Papilloma (IP) is a primary benign but locally aggressive epithelial sinonasal lesion. Etiology of IP is still unknown [15]. This tumour is also known as Schneiderian papilloma, because of the fact that nearly all cases of IP derive from the Schneiderian mucosa of the nasal cavity, which is of ectodermal origin and is embryologically different from the endodermally derived mucosa of the upper respiratory tract [1]. In the literature, some cases of multicentric manifestations of IP are described [10]. The multicentric origin of IP has been discussed as a possible tumour implantation at the time of the initial surgery, e.g. in the bronchial system [10]. It tends to occur above all in male patients in the 6th decade and is associated with tabacco usage, alcohol consumption and inflammatory conditions. In search of an etiology, the human papillomavirus seems to play a significant role in the development of this tumour [14]. IPs are characterised by locally destructive growth, the possibility of malignant transformation and local recurrence which may even occur after complete resection. The unilateral nasal obstruction represents the most frequent symptom. The primary site of origin is the lateral nasal wall, but it may also be localised in the ethmoid sinus and the maxillary sinus [4].

Although the tumour is rare, representing only 0.5% to 4% of all nasal tumours [12], it has been studied extensively for more than 150 years, since the first description of IP by Ward in 1854 [13]. But even today many aspects concerning its pathogenesis remain unknown. For that reason the different surgical approaches and the extension of surgical resection are still a matter of controversial discussion.

Material and Methods

In a retrospective study, we analysed 76 patients with sinonasal inverted papillomas, who had been operated at our department between 1990 and 2005. We determined the extension of the tumour according to the staging system by Krouse [8]. IPs with malignant tranformation were staged using the TNM-system (UICC). The grade of tumor differentiation was determined using the UICC grading system.

In our analysis, we directed our attention above all to the recurrence rate of IPs and its malignant transformation. The mean follow-up period was 23.4 months.

Dependent on the status of recurrence and on the location of the tumour, the surgical approach was either made microscopic or endoscopic. In cases of extensive tumour growth or extension to the skull base, the IP was resected by an external approach. In case of an IP localised in the anterior or lateral maxillary sinus, we preferred the Caldwell-Luc approach to remove the whole affected soft tissues [2], [3].

Results

There were 62 male and 14 female patients. The average age was 62 years. The main complaint was nasal obstruction, followed by rhinorrhea, epistaxis and headache (Table 1 [Tab. 1]).

The primary site of origin of IP was the nasal cavity, the ethmoid sinus and the maxillary sinus (Table 1 [Tab. 1]). Forty-two patients (55.3%) showed tumour growth to the skull base. Bilateral lesions were present in 9 patients (11.8%).

32 patients underwent resection using external approaches such as the Caldwell-Luc procedure or the lateral rhinotomy with medial maxillectomy, and 23 patients were treated by endonasal operative approaches. In 21 cases, an endonasal approach was combined with an external approach. The decision regarding the surgical approach was made depending on the exact location and extension of every single tumour. Whenever it was doubtful that the IP could be completely resected via an endonasal approach we used an extranasal approach.

The major intraoperative complication was the leakage of cerebrospinal fluid due to tumour associated arrosion of the skull base (n=4).

The total recurrence rate was 35% (n=27). Fifteen of those patients presented to our department with a recurrence after initial resection of an IP at other institutions. The recurrence rate for patients initially operated in Freiburg was 13.1%. The average duration until development of a recurrence of the tumour was 12.6 months. Nearly all patients had just one recurrence. Only one patient each developed 2, respectively 3 recurrence tumours.

Malignant transformation or associated malignancy was found in 8 patients or 10.5%. In 4 of those cases it concern a primary manifestation of the tumour and in the other 4 cases the malignancy was found in a recurrence of the IP. The histopathological examination revealed a poorly differentiated carcinoma in 5, a moderately differentiated carcinoma in 3 and a highly differentiated carcinoma within an IP in 1 case. According to the TNM-classification, we evaluated the IP with squamous cell carcionoma 3 times to the stage T1 N0 M0, one time to the stage T2 N0 M0, and 3 malignant transformations to the stage T4a N0 M0. In addition, epithelial dysplasia was found in 7 cases. In cases of histologically proven malignant transformation, we performed much more radical surgery procedures to be sure having resected the tumour in toto.

Discussion

The age and gender distribution of our patients reflects the data of the existing literature very well [4], [9]. The most frequent presenting complaint was nasal obstruction, being reported in 97% of the patients. The primary site of origin was the nasal cavity, the ethmoid sinus and the maxillary sinus.

The recurrence rate for patients initially operated in our department was 13.1%. In addition, there were 15 patients presenting to our department with a recurrence after initial resection of an IP at other institutions. In the literature, we found percentages for malignant transformation of the IP to be approximately 12% [7], [11]. In 8 cases, the histopathologic examination revealed a malignant transformation and an epithelial dysplasia in 7 cases. In those cases, patients were treated with more radical procedures like the lateral rhinotomy with medial maxillectomy.

Whenever possible we tried to operate our patients via an endonasal approach, but whenever it was doubtful that the IP could be completely resected endonasally we used an extranasal approach. Our patients were operated endonasally in 32 cases and in 23 cases, we used an external operative approach. These procedures were combined in 21 cases. We observed the highest recurrence rate after endonasal operations (25%).

The leakage of cerebrospinal fluid due to tumour associated arrosion of the anterior skull base was the major intraoperative complication (n=4). Therefore, complete preoperative radiological assessment of tumour extent is essential [5].

The optimal treatment of IP of the nose and paranasal sinuses is a challenge for the otorhinolaryngologist because of its still unknown etiology, its locally destructive growth, its tendency to recur and its propensity to be associated with malignancy. Occasionally, the otorhinolaryngologist is faced by leakage of cerebrospinal fluid because of tumour arrosion of the anterior skull base.

In conclusion we may say that with respect to the high rate of recurrence complete tumour resection at the site of attachment and preserving healthy tissue, represents the key to successful treatment of patients with these neoplasms. Especially in recurrent inverted papillomas a thorough planning of the operative procedure and the intraoperative use of navigation control are most useful and lead to good results with regard to function and control in this insidious tumour entity. To optimize the therapeutical management, it is of great importance, not only to find out the correct surgical strategy, but also to investigate the real etiology of this pernicious tumourous lesion.


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