A Review of Inverted Papilloma at a Tertiary Centre: A Six-Year Experience

doi:10.4236/ijohns.2013.25034

Paper Menu >>

Journal Menu >>

International Journal of Otolaryngology and Head & Neck Surgery, 2013, 2, 156-159

http://dx.doi.org/10.4236/ijohns.2013.25034 Published Online September 2013 (http://www.scirp.org/journal/ijohns)

A Review of Inverted Papilloma at a Tertiary Centre:

A Six-Year Experience

Chiun Kian Chai1*, Ing Ping Tang2, Narayanan Prepageran1

1Department of Otorhinolaryngology, University of Malaya, Kuala Lumpur, Malaysia

2Department of Otorhinolaryngology, Faculty of Medicine, University Malaysia Sarawak, Kota Samarahan, Malaysia

Email: *[email protected]

Received December 16, 2012; revised January 12, 2013; accepted January 30, 2013

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Objectives: To ev aluate the clinical presentation and treatment outcome of all patients treated for inverted papilloma at

the University Malaya Medical Centre, Malaysia. Methods: A retrospective review of 22 patients with inverted papil-

loma, treated at our centre, from 1st Januar y 2005 to 31st August 2011. The demographic data, clinical features, r adio-

logical findings, surgical procedures, recurrent rate and malignant transformation were assessed. Result: The com-

monest presentation was a unilateral nasal blockage, comprising 77.3% cases. A total of 19 patients had undergone en-

doscopic surgery while three patients had open surgery performed. The mean duration of the follow-up period was 30.5

months. Seven (31.7%) patients were detected of tumour recurrence during the entire course of follow-up. However,

throughout the follow-up period, none had demonstrated malignant transformation. Conclusion: Endoscopic medial

maxillectomy is a well-accepted approach in treating inverted papilloma. Nevertheless, open surgery still plays an im-

portant role in extensive diseases and in cases of malignancy. Unilateral nasal obstruction is the most important symp-

tom. Repeated pre-operative biopsy or perhaps frozen section of intraoperative biopsies is necessary to avoid misdiag-

nosis. Krouse stage II disease showed the highest recurrent rate of 18.2%. Lifelong follow-up and emphasis on adher-

ence is mandatory for early detection of recurrence and malignant transformation.

Keywords: Inverted Papilloma; Medial Maxillectomy; Endoscopic Surgery

1. Introduction

Inverted papilloma is an important differential diagnosis

of unilateral nasal mass. It is a benign tumour which co m-

monly arises from the lateral nasal wall and rarely from

the mucosa of the paranasal sinuses [1]. Many terms ha ve

been used to describe inverted papilloma, such as Schnei-

derian papilloma, transitional cell papilloma, epithelial

papilloma, and squamous papillary epithelioma [2]. His-

topathologically, it is characterized by invagination of

the epithelial growth into the underlying stroma [3].

Inverted papilloma is locally destructive, with a high

tendency to recur and is associated with malignant trans-

formation [4]. Hence aggressive surgical approach is al-

ways advocated. Since the introduction of endoscopic

surgery, the trend of surgical approach has moved away

from the traditional techniques, e.g. lateral rhinotomy,

Denker procedure and Caldwell-Luc approach, to endo-

scopic approach. The role of endoscopic surgery in in-

verted papilloma is now well established and achieves

similar tumour recurrence rate comparing to open tech-

nique [3,5-7]. Nevertheless, open techniqu e still plays its

role in extensive diseases, significant anatomic distortion

due to previous surgery or in cases associated with ma-

lignancy [8,9] .

2. Materials and Methods

This is a retrospective study of all patients with inverted

papilloma treated in our centre from 1st January 2005 to

31st August 2011. The demographic data, clinical fea-

tures, surgical procedures and the outcome of these pa-

tients were collected from the medical record office and

statistically analysed. All the patients underwent rigid na-

soendoscopic examination, nasal mass biopsy and com-

puted tomography before operations. Krouse staging sys-

tem was used to grade the disease (Table 1). Post-opera-

tively, nasoendoscopic examination was carried out in

clinic setting to look for recurrence or residual disease.

The primary goal of this review is to evaluate the clinical

presentation, the management and the outcome of in-

*Corresponding author.

C. K. CHAI ET AL. 157

Table 1. Krouse staging.

Class Tumour Extent

I Tumour confined to nasal cavity

II Tumour limited to ethmoid sinus and medial and superior

portion of maxillary sinus

III Tumor involved t he lateral and inferior aspect of maxillary

sinus, or involveme nt of frontal or sphenoid si nus

IV Tumour outside nose and sinuses, and inclu de malignancy

verted papilloma at our cen tre.

3. Results

A total of 22 patients were analysed. These consisted of

16 males (72.7%) and six females (27.3%) with the age

ranging from 32 to 71 years old (mean age of 53.8 years

old). These 22 patients included 10 Chinese (45.5%),

seven Indians (31.8%), four Malays (18.2%) and one for-

eigner (4.5%).

The most frequent symptom encountered was nasal

blockage, which consisted of 21 (95.5%) patients. Out of

these 21 patients, 17 (77 .3%) patients p resented with un i-

lateral nasal blockage while four (18.2%) patients pre-

sented with bilateral nasal blockage. There were eight

(36.4%) patients presented with rhinorrhoea, six (27.3%)

with anosmia, four (18.2%) with ep istaxis and two (9.1%)

with facial pain (Table 2). The duration of symptoms

ranged from one week to 60 months with the mean dura-

tion of 14.6 months before these patients presented to our

otorhinolaryngology department. Among these 22 pa-

tients, five (22.7%) patients had previous nasal polypep-

tomy done 7 months to 30 years prior to their first pres-

entation at our clinic.

All the patients had nasoendoscopy performed in the

clinic setting. Thirteen (59.1%) patients had right-sided

nasal tumour while nine (40.9%) patients had tumour

over the left nasal cavity. Biopsy was taken in all these

patients, and the histopathological examination showed

inverted papilloma in 17 (77.3%) patients and nasal po-

lyp in five (22.7%) patients. In our study, tumour staging

was done not only b ased on the classical computer tomo-

graphy (CT) findings, but also intra-operative findings,

according to the Krouse classification. There were three

(13.6%) patients with Krouse stage I disease, eight (36 . 4 %)

patients with stage II disease, 10 (45.5%) with stage III

disease and one (4.5%) with stage IV disease (Table 3).

The mean waiting time for surgery was 3.1 months

with a range of less than one month to six months. A

total of 19 (86.4%) patients underwent endoscopic me-

dial maxillectomy while three (13.6%) patients had open

surgery. For the open surgery cases, one patient had

Caldwell Luc approach with endoscopic-assisted tumour

excision (Krouse stage III) while two other patients had

Table 2. Clinical presentations of inverted papilloma.

Symptoms No. of Patients (%)

Nasal Blockage 21 (95.5)

Unilateral 17 (77.3)

Bilateral 4 (18.2)

Rhinorrhoea 8 (36.4)

Anosmia 6 (27.3)

Epistaxis 4 (18.2)

Facial Pain 2 (9.1)

Table 3. Number of cases according to Krouse staging with

the site of involvement.

Involvement

Krouse

Stage Nose Maxillary

sinus Frontal

sinus Sphenoid &

Base of skullTotal

I 3 0 0 0 3

II 0 8 0 0 8

III 0 8 2 0 10

IV 0 0 0 1 1

lateral rhinotomy with medial maxillectomy (Krouse

stage II). The mean duration of surgery was 102.4 min-

utes for endoscopic surgery, compared to 165 minutes for

open surgery. Post-operatively, two (9.1%) patients from

endoscopic group complained of epiphora and one of

them suffered peri-orbital oedema with transient diplopia.

The eye symptoms resolved spontaneously after few days.

The mean duration of hospital stay was 4.6 days in en-

doscopic group.

The mean duration of the follow-up period was 30.5

months. A total of 11 (50.0%) patients had defaulted fol-

low-up after the mean duration of 15.7 months post-

operatively. Recurrence was detected in seven (31.7%)

patients and two (9.1%) of them had recurrence twice.

These include four (18.2%) patients with Krouse stage II

disease, two (9.0%) with Krouse stage III disease and

one (4.5%) with Krouse stage IV disease (Table 4). All

these patients had undergone endoscopic medial maxil-

lectomy. Maxillary sinus was found to be the commonest

site of recurrence, comprising 44.4% cases (Table 5).

The mean duration of recurrence was 21.4 months with a

range of six to 72 months. All recurrences were treated

with endoscopic tumour excision. Throughout the entire

course follow-up period, none of the patients demon-

strated malignant transformation.

4. Discussion

In our study, the mean age of patients was 53.8 years old,

with male to female ratio of 2.7:1. These were consistent

with most of the other studies conducted [2,4]. The most

common presentation in our study was unilateral nasal

C. K. CHAI ET AL.

158

Table 4. Recurrence according to Krouse stage.

No. of Patients (%)

Krouse Stage First Recurrence Second Recurrence

I 0 1

II 4 (18.2) 1 (4.5)

III 2 (9.0) 1 (4.5)

IV 1 (4.5) 0

Table 5. Number of cases according to the site of recur-

rence.

No. of Patients

Site of Recurrence First Recurrence Second Recurrence

Nose 2 1

Maxillary sinus

 Roof

 Lateral wall

 Anterior wall

Sphenoid 1 1

blockage (77.3%), followed by rhinorrhea (36.4%), an-

osmia (27.3%) and epistaxis (18.2%). In other words, uni-

lateral nasal blockage is the co mmonest symptom, which

demonstrates a similar highest percentage as compared to

64% to 81% described in other literatures [2,8].

Clinically it is difficult to differentiate between in-

verted papilloma and inflammatory polyp since they

share similar symptoms and signs. Nevertheless, detec-

tion of the unilateral nasal mass should raise the index of

suspicion for inverted papilloma [2]. In such circum-

stances, pre-operative biopsy plays an important role in

confirming the diagnosis. In our study, however, five

(22.7%) patients had initial pre-operative biopsies show-

ing inflammatory polyps instead of inverted papilloma.

These patients had functional endoscopic sinus surgery

(FESS) performed, which included uncinectomy, widen-

ing of maxillary antrum, anterior and posterior ethmoi-

dectomy. The diagnosis of inverted papilloma was later

established from the histopathological specimens sent

from these surgeries, proposing the need of endoscopic

medial mexillectomy later for these patients. Therefore,

in cases highly suspicious of inverted pap illoma, perhaps

it is worthwhile to repeat another pre-operative biop sy, or

take biopsies intra-operatively and send for frozen sec-

tion to avoid misdiagnosis.

Nowadays, tumour staging is mostly performed with

the combination of CT and MRI findings based on

Krouse classification. In Malaysia, MRI of paranasal si-

nuses are not routinely performed due to its expensive

cost and lack in facilities. CT, on the other hand, may

manifest some artifacts, increasing its difficulty in dif-

ferentiating tumours from inflamed mucosa, polyps or

retained fluid in the paranasal cavity [6,10]. Hence, our

study modified Krouse classification by integrating intra-

operative findings to the CT findings.

In recent years, the trend of surgery had moved from

open surgery to endoscopic approach [2,11]. This phe-

nomenon was demonstrated in our study as well, with 19

patients underwent endoscopic surgery and three patients

had open surgery performed. Out of the three, two lateral

rhinotomy cases were performed in year 2005, and one

was converted to Caldwell Luc surgery from initial en-

doscopic approach when the tumour involvement at the

anterior maxillary wall was found intra-operatively. In

view of the high recurrent rate of inverted papilloma and

its association with malignancy, aggressive excision is

always advocated [3 ,5]. In our centre, patients diagnosed

with inverted papilloma would be offered for medial

maxillectomy. Surgical margin is ex tended up to lacrimal

bone anteriorly, sparing the nasolacrimal duct; posteri-

orly, up to the posterior maxillary wall; superiorly, till

the base of the skull and; inferiorly, until reaching the

floor of the nose. Inferior turbinate is removed while

middle turbinate is preserved.

The recurrent rate of inverted papilloma in our study

was 31.7% or seven out of 22 patients. This figure was

slightly higher in comparison with 0% to 27% reported in

others literatures [2-4]. According to the recurrent rate

among our patients in correlation with the Krouse staging,

the highest recurrent rate of 18.2% was demonstrated in

Krouse stage II disease, followed by Krouse stage III

disease (9.1%), and Krouse stage IV disease(4.5%). The

second recurrent rate among these recurrent cases, on the

other hand, was slightly lower in our stud y, consisting of

28.6%.

All the recurrent cases in our study occurred in the en-

doscopic surgery group. Among these patients, two had

tumour involvement at frontal sinus, which made endo-

scopic approach technically difficult for tumour clear-

ance, as endoscopic surgery is possible only if the tu-

mour is confined to the frontal recess or the medial part

of frontal sinus.

The advantages of the endoscopic approach is not only

limited to the cosmetic aspect, it had also shortened the

duration of operation as well as hospital stay [7,12]. The

mean operative duration was 102.4 minutes for each en-

doscopic procedure. The period of hospital stay was 4.3

days for endoscopic cases in our study, including the day

before the operation and the day of operation. In other

words, the period of post-operative hospital stay could be

just about two days.

The tumour recurrence happened as early as six

months or as long as 72 months with the mean time of

21.4 months. Unfortunately, 11 (50.0%) patients had de-

faulted follow-up after a mean period of 15.7 months

after surgeries. Thus, the follow-up period is definitely

C. K. CHAI ET AL.

159

inadequate to detect tumour recurrence in this context.

Malignancy is another main concern, which makes long-

term follow-up necessary, with the risk of malignant

transformation ranging from 5% to 21% as well as the

mean duration of 52 months to develop carcinoma, re-

ported in many other literatures [3,7,13]. Currently there

are no universal guidelines for follow-up regime after

surgery. Nevertheless, some authors had suggested for

quarterly follow-up in the first two years, six monthly in

the subsequent two years and yearly thereafter [3]. In

other words, long-term follow up is mandatory and ad-

herence to follow-up should always be emphasized to all

patients [10].

5. Conclusion

Endoscopic medial maxillectomy is a well-accepted ap-

proach in treating inverted papilloma. Nevertheless, open

surgery still plays an important role in extensiv e diseases

and in cases of malignancy. Unilateral nasal obstruction

is the most important symptom. Repeated pre-operative

biopsy or perhaps a frozen section of intraoperative biop-

sies is necessary to avoid misdiagnosis. Krouse stage II

disease showed the highest recurrent rate of 18.2%. Life-

long follow-up and emphasis on adherence is mandatory

for early detection of recurrence and malignant transfor-

mation.

REFERENCES

[1] E. Pasquini, V. Sciarretta, G. Farneti, G. C. Modugno and

A. R. Ceroni, “Inverted Papilloma: Report of 89 Cases,”

American Journal of Otolaryngology, Vol. 25, No. 3,

2004, pp. 178-185. doi:10.1016/j.amjoto.2004.01.004

[2] M. A. Thorp, M. F. Oyarzabal-Amiqo, J. H. du Plessis

and S. L. Sellars, “Inverted Papilloma: A Review of 53

Cases,” Laryngoscope, Vol. 111, No. 8, 2001, pp. 1401-

1405. doi:10.1097/00005537-200108000-00016

[3] S. G. Wolfe, R. J. Schlosser, W. E. Bolger, D. C. Lanza

and D. W. Kennedy, “Endoscopic and Endoscope-As-

sisted Resections of Inverted Sinonasal Papillomas,”

Otolaryngology—Head and Neck Surgery, Vol. 131, No.

3, 2004, pp. 174-179. doi:10.1016/j.otohns.2004.05.011

[4] H. Katori and M. Tsukuda, “Staging of Surgical Ap-

proach of Sinonasal Inverted Papilloma,” Auris Nasus

Larynx, Vol. 32, No. 3, 2005, pp. 257-263.

doi:10.1016/j.anl.2005.03.015

[5] R. J. Schlosser, J. C. Mason and C. W. Gross, “Aggres-

sive Endoscopic Resection of Inverted Papilloma: An Up-

date,” Otolaryngology—Head and Neck Surgery, Vol.

125, No. 1, 2001, pp. 49-53.

doi:10.1067/mhn.2001.116789

[6] T. J. Lee, S. F. Huang, L. A. Lee and C. C. Huang, “En-

doscopic Surgery for Recurrent Inverted Papilloma,” La-

ryngoscope, Vol. 114, No. 1, 2004, pp. 106-112.

doi:10.1097/00005537-200401000-00019

[7] J. M. Busquets and P. H. Hwang, “Endoscopic Resection

of Sinonasal Inveted Papilloma: A Meta-Analysis,” Oto-

laryngology—Head and Neck Surgery, Vol. 134, No. 3,

2006, pp. 476-482. doi:10.1016/j.otohns.2005.11.038

[8] W. Lawson and Z. M. Patel, “The Evolution of Manage-

ment for Inverted Papilloma: An Analysis of 200 Cases,”

Otolaryngology—Head and Neck Surgery, Vol. 140, No.

3, 2009, pp. 330-335. doi:10.1016/j.otohns.2008.11.010

[9] W. M. Mendenhall, R. W. Hinerman, R. S. Malyapa, J. W.

Werning, R. J. Amdur, D. B. Villaret and N. P. Men-

denhall, “Inverted Papilloma of Nasal Cavity and Para-

nasal Sinuses,” American Journal of Clinical Oncology,

Vol. 30, No. 5, 2007, pp. 560-563.

doi:10.1097/COC.0b013e318064c711

[10] G. Eggers, J. Muhling and S. Hassfeld, “Inverted Papil-

loma of Paranasal Sinuses,” Journal of Cranio-Maxillo-

facial Surgery, Vol. 35, No. 1, 2007, pp. 21-29.

doi:10.1016/j.jcms.2006.10.003

[11] F. Carta, B. Verillaud and P. Herman, “Role of Endo-

scopic Approach in the Management of Inverted Papil-

loma,” Current Opinion in Otolaryngology & Head and

Neck Surgery, Vol. 19, No. 1, 2011, pp. 21-24.

doi:10.1097/MOO.0b013e3283425213

[12] P. Peng and G. Har-El, “Management of Inverted Papil-

lomas of the Nose and Paranasal Sinuses,” American

Journal of Otolaryngology, Vol. 27, No. 4, 2006, pp. 233-

237. doi:10.1016/j.amjoto.2005.11.005

[13] C. von Buchwald and P. J. Bradley, “Risk of Malignancy

in Inverted Papilloma of the Nose and Paranasal Sin u s es,”

Current Opinion in Otolaryngology & Head and Neck

Surgery, Vol. 15, No. 2, 2007, pp. 95-98.

doi:10.1097/MOO.0b013e3280803d9b