Use of Diode Laser in Excising Bilateral Inverted Papilloma of Paranasal Sinuses

doi:10.4236/ijohns.2013.26059

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International Journal of Otolaryngology and Head & Neck Surgery, 2013, 2, 286-289

Published Online November 2013 (http://www.scirp.org/journal/ijohns)

http://dx.doi.org/10.4236/ijohns.2013.26059

Open Access IJOHNS

Use of Diode Laser in Excising Bilateral Inverted

Papilloma of Paranasal Sinuses

Saurabh Agarwal, Mohan Jagade, Avinash Borade, Anoop A, Rajesh Kar, Sunita Bage,

Shubhangi Kedar

Department of ENT, Grant Medical College & Sir J.J. Hospital, Mumbai, India

Email: [email protected]

Received June 7, 2013; revised July 8, 2013; accepted August 1, 2013

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

ABSTRACT

The inverted papilloma is an u ncommon unilateral benign unilateral tumor of the nose & p aranasal sinuses. Although a

benign pathology, it is associated with aggressive local destruction and recurrence after removal and malignancy. The

clinical picture presents non-specific signs and symptoms, such as unilateral nasal obstruction, anosmia and headache.

Treatment is essentially surgical. This report has the objective of presenting an uncommon bilateral nasal inverted

papilloma and the use of diode laser in surg ical excision & making a literature rev iew. The uniqueness in our case was

the use of diode laser in excision of inverted papilloma.

Keywords: Inverted Papilloma; Laser; Fess; Paranasal Sinuses

1. Introduction

WHO defines inverted papilloma as a benign epithelial

tumor composed of well differentiated columnar or cili-

ated respiratory epithelium having variable squamous

differentiation. The inverted papilloma (IP) is a rare and

benign nasosinusal tumor, bearing an incidence of 0.75

to 1.5 cases per 100,000/year. It comprises 0.5% to 4%

of all primary nasal tumors [1-3]. 91% to 99% of the

inverted papillomas are unilateral [4]. Inverted papillo-

mas originate from the lateral wall of the nasal cavity,

and they secondarily affect the maxillary, ethmoidal,

frontal and sphenoid sinuses.

The common symptoms are nasal obstruction, epis-

taxis and headache in some patients complaining of nasal

discharge, facial pain, chronic sinusitis, visual symptoms

and epiphora.

Surgery is the treatment of choice of which lateral

rhinotomy, medial maxillectomy, endoscopic endonasal

excision or combined approach is usually used. We

hereby report a rare case of bilateral inverted papilloma

which was excised with the help of a diode laser. The

uniqueness in our case was the use of the diode laser in

the excision which helped us to attain a bloodless field

during excision with minimal intra operative bleeding.

2. Case Report

A 40 years old, male patient presented with chief com-

plaints of blocking sensation through both nostrils for 4

years. It was associated with recurrent headache, recur-

rent attacks of cold & sneezing. Patient was operated

twice elsewhere at peripheral hospital but symptoms re-

curred again. He gave history of addiction to cigarette

smoking for 20 years. On anterior rhinoscopy examina-

tion, a reddish, nonglistening, polypoidal mass was seen

filling both nostrils. Maxillary & frontal sinu s tenderness

was present bilaterally. On diagnostic nasal endoscopy,

reddish polypoidal mass was seen around middle meatus

in both nostrils.

On CT Paranasal sinuses lobulated enhancing soft tis-

sue mass was seen involving right frontal & adjacent part

of right ethmoid, left frontal, left anterior ethmoid & bi-

lateral superior nasal cavities &right maxillary ostium

(Figure 1). Endoscopic guided biopsy from both nostrils

was suggestive of inverted papilloma. Patient was

planned for excision of papilloma under general anaes-

thesia (Figure 2). Right sided Lateral rhinotomy incision

was taken. Right medial maxillectomy was done & nasal

mass was excised with diode laser in toto (Figure 3).

Left sided mass was excised endoscopically.

S. AGARWAL ET AL. 287

Figure 1. Axial CT PNS showing mass in both nostrils.

Figure 2. Pre-op photograph showing nasal mass.

His postoperative period was uneventful and histopa-

thological examination was confirmatory of inverted

papilloma. Patient was followed up for 1 year with no

signs of disease recurrence.

3. Discussion

Inverted papilloma of th e nose and parana sal sinuses is a

rare tumor of the head and neck region. Inverted papil-

loma remains still poorly understood because of the high

recurrence rate and the association with carcinoma. The

mean age of the patients was between 52 and 59 years

with significantly higher incidence in males (male to

female ratio about 4:1 to 3:1) [5-7] with greater preva-

lence in Caucasians. Although benign, the inverted papil-

Figure 3. Inta-op photograph showing excision of mass with

diode laser.

loma is characterized by an aggressive growth, great in-

vasion potential [4,8,9], being multicentric (12%), high

recurrence rates [1-3] and malignization (2% to 53%).

About 10% of the IP cases with cellular atypia are asso-

ciated with squamous cells carcinoma [3,10-13]. IP origi-

nate from the lateral wall of nasal cavity. The primary

involvement of the paranasal sinuses is extremely rare,

happening only to 5% of the cases [11-13].

Inverted papilloma has many synonyms such as

schneiderian pailloma, transitional cell papillloma, villi-

form papilloma, cylindrical cell papillloma. The first

description of this entity was by Ward who described the

macroscopic aspect of a papillomatous neoplasm [14]. It

was named schneiderian papilloma in honour of Sir. C.

Victor Schneider who in the 1600s identified nasal mu-

cosa origin from ectoderm [15]. Ringertz coined the term

inverted papilloma revealing the tendency to invert into

the underlying stroma [16].

The main theory on IP etiology proposes that Schnei-

der membrane, which forms the nasosinusal tract mucosa,

originates from the ectodermal invasion of the olfactory

placoid. This membrane would then suffer a number of

structural changes, causing a greater predisposition for

neoplastic differentiation [3,17].

The typical histopathological feature is inversion of

the multilayer epithelium into the underlyin g oedematous

stroma. Squamous cell epithelium is frequently found,

but there is also tran sitional cell epithelium, cylinder cell

epithelium, or combinations of these. The basement

membrane is typically intact. Stroma is well vascularized

and infiltrated with lymphocytes and plasma cells [18].

The commonest symptom of sinonasal inverted papil-

loma is progressive unilateral nasal obstruction. Other

Open Access IJOHNS

S. AGARWAL ET AL.

288

symptoms include blood mixed nasal discharge, head-

ache, facial pain, frequent clearing of throat, decreased or

loss of smell, epiphora or symptoms suggestive of sinusi-

tis. Inverted papilloma generally occurs unilateral, but

the bilateral involvement of the sinonasal tract has been

reported in less than 1% to 9% patients [19-21 ].

The diagnosis must start by a detailed examination,

investigating environmental exposure, noxious habits,

allergies and associated diseases, and by complete otorhi-

nolaryngological exam. Endoscopic evaluation and ra-

diological (CT and MRI) examinations are required for

tumor study and diagnosis. Biopsy together with histo-

pathology establishes the diagnosis. A unilateral mass

within the nasal cavity or paranasal sinuses with a sur-

face configuration that appears lobulated on CT is a new

sign that strongly suggests inverted papilloma as a pri-

mary diagnosis and also suggests inverted papilloma in

patients with tumor recurrence.

A columnar pattern is a reliable MRI indicator of IP

and reflects its histological architecture (positive predic-

tive value of 95.8%). The combination of this finding

with the absence of extended bone ero sion allows for the

confident discrimination of IPs from malignant tumours

[22].

Complete surgical removal is the first option for the

treatment of IP and is superior to radiation or chemo-

therapy [23,24]. Lateral rhinotomy has been regarded as

the traditional standard surgical approach to control IP

and to avoid recurrence [25]. It gives a good overview

and wide access to the surgical field and can also be per-

formed bilaterally [26]. Alternative techniques are the

midface degloving procedure & Denker’s approach. The

most recent developments in surgery are minimally inva-

sive transnasal endoscopic techniques [27,28]. In endo-

scopically accessible locations, recurrence rates for en-

doscopic vs. open surgery were similar [29]. However,

other studies reported higher recurrence rates of IP [30],

particularly in cases of peripheral extension, especially

into the maxillary sinus [31].

In our case lateral rhinotomy approach was used. The

diode laser was used for dissecting out the tumor from its

attachment along with the mucosa. Under direct vision,

the attachment was ablated with the laser in the cutting

and coagulation modes, and the tumor was then delivered.

The unique feature of our management was the use of the

diode laser. Inverted papillomas are notorious for exten-

sive bleeding, so a bloodless field was a great advantage.

The hemostatic property of the dode laser helped us to

achieve an almost bloodless field. This in turn helped us

visualize the exact site of tumor attachment. Laser was

essentially used in all three modes: contact, near-contact,

and noncontact to achieve cutting, vaporization and co-

agulation. The diode laser’s lesser depth of tissue pene-

tration and its capability to be used in contact, near con-

tact & non contact settings allows the laser to be safely

used near the lamina papyracea and skull base. So for

bilateral inverted papillomas limited to the nose and

paranasal sinuses, we believe our approach is a good

option in view of the low rates of intra operative blood

loss & minimal post operative morbidity.

4. Conclusion

Inverted papillomas are known for excessive bleeding

during tumour removal. The use of the diode laser in the

excision of inverted papillomas helps to achieve clear

intra operative field with no post operative blood transfu-

sion requirement.

REFERENCES

[1] D. P. Vrabec, “The Inverted Schneiderian Papilloma: 25-

Year Study,” Laryngoscope, Vol. 104, No. 5, 1994, pp.

582-608. http://dx.doi.org/10.1002/lary.5541040513

[2] T. T. Tsue, J. W. Bailet, D. W. Barlow and K. H.

Makielski, “Bilateral Sinusal Papilloma in Aplasic Maxi-

lar Sinuses,” American Journal of Otolaryngology, Vol.

l18, No. 4, 1997, pp. 263-268.

[3] M. C. Weissle r, W. W. Montgomery and S. K. Montgom-

ery, “Inverted Papiloma,” The Annals of Otolo gy, Rhinology,

and Laryngology, Vol. 95, 1986, pp. 215-221.

[4] K. Oikawa, Y. Furuta, N. Oridate, T. Nagahashi, A. Homma,

T. Ryu and S. Fukuda, “Preoperative Staging of Sinonasal

Inverted Papilloma by Magnetic Resonance Imaging,”

Laryngoscope, Vol. 133, No. 11, 2003, pp. 1983-1987.

[5] M. M. Lesperance and M. E. Ramon, “Squamous Cell

Carcinoma Arising in Inverted Papilloma,” Laryngoscope,

Vol. 105, No. 2, 1995, pp. 178-183.

http://dx.doi.org/10.1288/00005537-199502000-00013

[6] E. Raveh, R. Feinmesser, T. Shpitzer, E. Yaniv and K.

Segal, Israel Journal of Medical Sciences, Vol. 32, 1996,

p. 1162.

[7] D. P. Vrabec, “The Inverted Schneiderian Papilloma: A

25-Year Study,” Laryngoscope, Vol. 104, No. 5, 1994, pp.

502-605. http://dx.doi.org/10.1002/lary.5541040513

[8] L. Segal, E. Atar and C. Mor, “Inverted Papilloma of the

Nose and Paranasalsinuses,” Laryngoscope, Vol. 96, No.

4, 1996, pp. 394-398.

[9] J. A. Stankiewicz and S. J. Girs, “Endoscopic Surgical

Treatment of Nasal and Paranasal Sinus Inverted Papil-

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

109, No. 6, 1993, pp. 988-995.

[10] A. C. M. Alegre, A. H. C. Ramos, R. L. Voegels and F.

Romano, “Papiloma e Papilomainvertido,” In: C. A. Ca m-

pos and H. O. O. Costa, Eds., Tratado de Otorrinolarin-

gologia, Roca, São Paulo, 2003, pp. 126-132.

[11] J. H. Krouse, “Development of a Staging System for In-

verted Papilloma,” Laryngoscope, Vol. 110, No. 6, 2000,

pp. 965-968.

http://dx.doi.org/10.1097/00005537-200006000-00015

[12] D. P. Vrabec, “The Inverted Schneiderian Papilloma: A

Open Access IJOHNS

S. AGARWAL ET AL.

Open Access IJOHNS

289

Clinical and Pathological Study,” Laryngoscope, Vol. 85,

No. 1, 1975, pp. 186-221.

http://dx.doi.org/10.1288/00005537-197501000-00014

[13] E. N. Myers, J. L. Fernau and J. T. Johnson, “Manage-

ment of Inverted Papilloma,” Laryngoscope, Vol. 100, No.

5, 1990, pp. 481-490.

http://dx.doi.org/10.1288/00005537-199005000-00008

[14] R. Kramer and M. L. Som, “True Papilloma of the Nasal

Cavity,” Acta Oto-Laryngologica, Vol. 22, No. 1, 1935,

pp. 22-43.

http://dx.doi.org/10.1001/archotol.1935.00640030033003

[15] N. Ringertz, “Pathology of Malignant Tumors Arising in

Nasal and Paranasal Cavities and Maxilla,” Acta Oto-

Laryngologica, Vol. 27, 1938, pp. 31-42.

[16] R. A. Gaito, W. H. Gaylord and D. A. Hilding, “Ultra-

structure of a Human Nasal Papilloma,” Laryngoscope,

Vol. 75, No. 1, 1965, pp. 144-152.

http://dx.doi.org/10.1288/00005537-196501000-00016

[17] V. J. Hyams, “Papillomas of the Nasal Cavity and Para-

nasal Sinuses,” Annals of Otology, Rhinology and Laryn-

gology, Vol. 80, No. 2, 1971, pp. 192-206.

[18] C. de Flippis, G. Marioni, A. Tregnaghi, F. Marino, E.

Gario and A. Staffieri, “Primary Inverted Papilloma of the

Middle Ear and Mastoid,” Otology & Neurotology, Vol.

23, No. 4, 2002, pp. 555-559.

http://dx.doi.org/10.1097/00129492-200207000-00027

[19] P. P. Philips, Ro Gustafson and G. W. Facer, “The Cen-

tral Behaviour of Inverted Papilloma of the Nose and

Paranasal Sinuses: Report of 112 Cases & Review of the

Literature,” Laryngoscope, Vol. 100, 1990, pp. 463-469.

[20] J. Yiotaki, A. Hantzakos, D. Kandiloros and E. Ferekidis,

“A Rare Location of Bilateral Inverted Papilloma of the

Nose and Paranasal Sinuses,” Rhinology, Vol. 40, No. 4,

2002, pp. 220-222.

[21] V. Visvanathan, H. Wallace and P. Chumas, “An Unusual

Presentation of Inverted Papilloma Case Report & Lit-

erature Review,” Journal of Laryngology and Otology,

Vol. 124, No. 1, 2010, pp. 1-4.

http://dx.doi.org/10.1017/S0022215109990703

[22] R. Maroldi, D. Farina, L. Palvaini, D. Lombardi, D. To-

menzoli and D. Nicolai, Magnetic Resonance, Vol. 18,

No. 5, 2004, pp. 305-310.

[23] U. Ganzer, K. Donath and R. Schmelzle, “Geschwulste

der Inneren Nase, der Nasennebenhohlen, des Ober- und

Unterkiefers,” In: H. H. Naumann, J. Helms, C. Herber-

hold and E. Kastenbauer, Eds., Oto-Rhino-Laryngologie

in Klinik und Praxis, Vol. 2, Thieme, Stuttgart, New York,

1992, pp. 312-359.

[24] V. J. Lund, “Optimum Management of Inverted Papil-

loma,” Journal of Laryngology & Otology, Vol. 114, No.

11, 2000, pp. 194-197.

[25] E. N. Myers, V. L. Schramm and E. L. Barnes, “Man-

agement of Inverted Papilloma of the Nose and Paranasal

Sinuses,” Laryngoscope, Vol. 91, No. 12, 1981, pp. 2071-

2084.

http://dx.doi.org/10.1288/00005537-198112000-00009

[26] S. A. Hosal and J. L. Freeman, “Bilateral Lateral Rhi-

notomy for Resection of Bilateral Inverted Papilloma,”

Otolaryngology—Head and Neck Surgery, Vol. 114, No.

1, 1996, pp. 103-105.

http://dx.doi.org/10.1016/S0194-5998(96)70292-9

[27] M. Winter, R. A. Rauer, U. Gode, G. Waitz and M. E.

Wigand, “Invertierte Papillome der Nase und ihrer Ne-

benhohlen. Langzeitergebnisse Nach Endoskopischer En-

donasaler Resektion,” HNO, Vol. 48, No. 8, 2000, pp.

568-572. http://dx.doi.org/10.1007/s001060050618

[28] P. J. Wormald, E. Ooi, C. A. van Hasselt and S. Nair,

“Endoscopic Removal of Sinonasal Inverted Papilloma

Including Endoscopic Medialmaxillectomy,” Laryngo-

scope, Vol. 113, No. 5, 2003, pp. 867-873.

http://dx.doi.org/10.1097/00005537-200305000-00017

[29] T. Klimek, E. Atai, M. Schubert and H. Glanz, “Inverted

Papilloma of the Nasal Cavity and Paranasal Sinuses:

Clinical Data, Surgicalstrategy and Recurrence Rates,” Acta

Oto-Laryngologica, Vol. 120, No. 2, 2000, pp. 267-272.

http://dx.doi.org/10.1080/000164800750001071

[30] P. P. Phillips, R. O. Gustafson and G. W. Facer, “The

Clinical Behavior of Inverting Papilloma of the Nose and

Paranasal Sinuses: Report of 112 Cases and Review of

the Literature,” Laryngoscope, Vol. 100, No. 5, 1990, pp.

463-469.

http://dx.doi.org/10.1288/00005537-199005000-00004

[31] C. Zumegen, J. P. Thomas and O. Michel, “Erfahrungen

mit der Endonasalen Endoskopischen Operation des In-

vertierten Papilloms der Nase und Nasenebenhohlen,”

Laryngorhinootologie, Vol. 79, No. 4, 2000, pp. 221-225.

http://dx.doi.org/10.1055/s-2000-8991