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Aims. The aim of this paper is to describe the surgical experience of 35 patients with Inverted Papilloma (IP) of paranasal sinuses and its recurrence rate after a year of follow-up.
Materials. A retrospective chart review was performed on patients presenting with IP of paranasal sinuses. Thirty-five patients comprised the focus of this study. For all patients was performed a pre-surgery TC, and for more 5 patients it was necessary to perform a Magnetic Resonance (MR) with gadolinium.
Results. Among 35 patients selected, 18 patients underwent to open surgery, 4 patients had a combined approach with endoscopy and open surgery, while 13 patients were managed only with an endoscopic approach, with a minimum of 1 year of follow-up. Our results highlighted that the global percentage of success 12 months after the treatment was 93% and it not vary according to the tipology of the approach used if a radical excision of the lesion is achieved. More in depth, among 35 cases, only 2 patients were found to have recurrences and were treated with coronal and endoscopic approach.
Conclusion. It is fundamental to underline that surgery must be carried on in a radical manner to treat these tend to recur. A complete removal of the lesion and bone peripheral border filing are essential to perform a correct and definitive treatment. Also, endoscopic approach can be taken into account when tumors are localized median to a sagittal plan crossing the orbit median wall and when they did not massively compromised paranasal sinus walls.
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Management and treatment of sinonasal inverted papilloma
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Department of Maxillo-Facial Surgery, Policlinico Umberto I, “Sapienza” University of Rome, Italy
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Management and treatment of sinonasal inverted papilloma
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                                                                                                      Review article



    Management and treatment of sinonasal inverted
    papilloma




                                                                                                       i
                                                                                                     al
                                                                                                  on
    Claudio Ungari, MD, PhD1                                  ment. Also, endoscopic approach can be taken in-
    Emiliano Riccardi, MD2                                    to account when tumors are localized median to a
    Gabriele Reale, MD, PhD2                                  sagittal plan crossing the orbit median wall and
    Alessandro Agrillo, MD, PhD1                              when they did not massively compromised
    Claudio Rinna, MD1                                        paranasal sinus walls.




                                                                                         zi
    Valeria Mitro, MD2
    Fabio Filiaci, MD2                                        Key words: inverted papilloma, papilloma diagno-
                                                              sis, papilloma surgery, sinus open surgery, sinus




                                                                           na
                                                              endoscopic surgery.
    1   Department of Oral and Maxillo-Facial Sciences,
        “Sapienza” University of Rome, Italy
    2   Department of Maxillo-Facial Surgery, Policlinico     Introduction




                                                                er
        Umberto I, “Sapienza” University of Rome, Italy
                                                              Inverted papilloma (IP) is a benign sinonasal epithelial
                                                              neoplasm, rising from the ectodermal schneiderian
    Corresponding author:                                     membrane. The correct etiology of IP is unknown, al-
    Emiliano Riccardi


                                                        t     though either chronic inflammation and human papillo-
                                                     In
    Department of Maxillo-Facial Surgery, Policlinico Um-
    berto I, “Sapienza” University of Rome
                                                              ma virus have been inconsistently associated (1, 2).
                                                              Sinonasal papillomas were first described by Ward and
    Via Valentino Banal, 31                                   Billroth in the 1850s, but it was Hyams (3) who classi-
    00177 Rome, Italy                                         fied IP, on the basis of its histological features (4). Al-
    E-mail: emiliano.riccardi@hotmail.it                      though IP is a tumor of benign entity, it often erodes ad-
                                               ni
                                                              jacent bone and it may potentially extend to the orbit or
                                                              to the intracranial cavity. Also, it is associated to a risk
    Summary                                                   of malignancy (5-7) ranging from 5 to 15% and it tends
                                    io

                                                              to recur. Because of its high recurrence (8, 9) rate and
    Aims. The aim of this paper is to describe the sur-       aggressive nature, the management of IP has changed
    gical experience of 35 patients with Inverted Pa-         from conservative intranasal piecemeal excision to a
    pilloma (IP) of paranasal sinuses and its recur-          more aggressive wide excision by lateral rhinotomy
                           iz



    rence rate after a year of follow-up.                     combined with a medial maxillectomy.
    Materials. A retrospective chart review was performed     IP involving the paranasal sinus is rare; an endonasal
    on patients presenting with IP of paranasal sinuses.      endoscopic approach is difficult to perform due to the
           Ed




    Thirty-five patients comprised the focus of this study.   nature of the anatomic border of the paranasal recess,
    For all patients was performed a pre-surgery TC, and      but, in the 1980s, it was introduced and it proved to
    for more 5 patients it was necessary to perform a         have favorably low recurrence rates (10, 11).
    Magnetic Resonance (MR) with gadolinium.                  Now, with the refinement of endoscopic techniques, a
    Results. Among 35 patients selected, 18 patients          resection of these challenging lesions may be amenable
    underwent to open surgery, 4 patients had a com-          to an endoscopic approach.
IC




    bined approach with endoscopy and open surgery,           Recent studies have demonstrated the efficacy of the
    while 13 patients were managed only with an endo-         endoscopic approach in management of this kind of
    scopic approach, with a minimum of 1 year of fol-         neoplasm (12-16), in a number of selected cases
    low-up. Our results highlighted that the global per-      where the tumor extension is limited.
C




    centage of success 12 months after the treatment          This report describes the surgical experience of 35
    was 93% and it not vary according to the tipology of      patients with IP of paranasal sinuses treated at the
    the approach used if a radical excision of the lesion     Department of Maxillo-Facial Surgery of the Policlini-
    is achieved. More in depth, among 35 cases, only 2        co Umberto I of Rome, and it recurrence rate after (at
                                                              least) a year of follow-up.
©




    patients were found to have recurrences and were
    treated with coronal and endoscopic approach.
    Conclusion. It is fundamental to underline that
    surgery must be carried on in a radical manner to         Materials and methods
    treat these tend to recur. A complete removal of
    the lesion and bone peripheral border filing are          Retrospective chart review was performed on pa-
    essential to perform a correct and definitive treat-      tients presenting with IP of paranasal sinuses from

    Annali di Stomatologia 2015; VI (3-4): 87-90                                                                       87
    C. Ungari et al.


    October 2003 to October 2011. Thirty-five patients           During pre-operative analysis all patients had a thor-
    with sinonasal papilloma were observed and treated.          ough head and neck evaluation to assess for regional
    Data points collected included age, extend of the tu-        disease. The face was evaluate to identify asymmetry
    mor, location(s), follow-up, surgery technique and           of distortion, and a complete cranial nerve examina-
    histopathological diagnosis. For all patients it was         tion was also necessary. Then, for all patients it was




                                                                                                           i
    performed a pre-surgery TC in the three projections          carried on a CT scan in the three projections with no




                                                                                                         al
    with no contrast and for 5 more patients it was nec-         contrast. CT scans can give more information about
    essary to perform a Magnetic Resonance Imaging               the extention of the neoplasm, its association with the
    (MRI) with gadolinium to better define the lesions.          skull base or orbit, its nature and the eventual recur-




                                                                                                      on
    Concerning the surgical approach, we started identi-         rence of bony alteration. Moreover, for 5 patients a
    fying localization and extension of the lesions; after-      Magnetic Resonance Imaging (MRI) with gadolinium
    wards, we performed 18 open surgeries, 13 endo-              was required to better discern between inflammation
    scopic approach and 4 combined approach (open                pouring and pathologic tissue among the breast itself.
    and endoscopic).                                             A subsequent magnetic RI can improve understand-




                                                                                            zi
    After surgery was performed, all patients were put be-       ing of a neoplasm by defining its limits and its post-
    fore a thorough follow-up, with periodical check-ups         obstructive effect on secondarily involved sinuses.
    at 1-4-8-12 months. Among 35 patients that were              Eleven patients of the study group underwent biopsy




                                                                             na
    treated, 33 resulted free of any symptoms within a           with referral to definitive histological examination con-
    year, while 2 recurrences were noted by radiographic         firmed the diagnosis of IP.
    surveillance and were promptly treated with coronal          Medical therapy is initiated preoperatively to reduce
    and endoscopic approach.                                     inflammation in all patients. This can help to minimize




                                                                   er
                                                                 eventual bleeding, to reduce tissue edema, and to
                                                                 enhance visualization. Among 35 patients selected,
    Results                                                      18 patients underwent to open surgery, 4 patients
                                                                 had a combined approach with endoscopy and open
    Thirty-five patients, 21 males and 14 females, com-


                                                            t    surgery, while 13 patients were managed only with an
    prised the focus of this study. Mean age of patients
    was 47 years. The minimal length of their follow-up
                                                         In      endoscopic approach.
                                                                 The histological diagnosis was always IP without any
    was 12 months and all patients had a control TC after        evidence of dysplasia.
    (at least) 8 months. Location of the tumor included          No intra or post-operative complications were en-
    the ethmoid-frontal sinus in 17 cases, the frontal-eth-      countered in this group of patient.
                                           ni
    moid-maxillary sinus in 13 cases and the frontal sinus       Our results highlighted that the global percentage of
    in 5 cases (Tab. 1); no case involved the sphenoid si-       success 12 months after the treatment was 93%. More
    nuses and the orbital cavity; skull base violation was       in depth, among 35 patients that underwent the treat-
                                 io

    not noted in any cases. Initial symptoms were unilat-        ment, after a follow up of 1 year only 2 recurrences were
    eral nasal obstruction (18), epistaxis (5), rhinorrhea       noted by radiographic surveillance and were promptly
    (3), facial pain (3), headaches (2), nasal mass (3)          treated with open surgery and endoscopic approach.
    and hyposmia (1) (Tab. 2).
                        iz



    Table 1. Localization site of attachment of IP. EFS: eth-    Discussion
            Ed




    moid frontal sinus; FEMS: frontal ethmoid maxillary sinus;
    FS: frontal.                                                 Sinonasal IP is a relatively rare entity that poses
                                                                 unique challenges given the difficulty tumor location.
    Site of Inverted Papilloma                 N. of cases       IP has an incidence of 0.74-1.5 cases for 100.000 in-
    EFS                                        17                habitants per year and accounts for approximately
    FEMS                                       13                70% of all sinonasal papillomas (17-19). It prevails in
    FS                                         4                 the fifth decades of life and males are four to five
IC




                                                                 times frequently affected than females.
    Total                                      35                From October 2003 to October 2011, 35 patients with
                                                                 sinonasal papilloma were observed and treated in our
    Table 2. Sympton of presentation of Inverted Papilloma       experience.
C




                                                                 IP treatment has involved from limited intranasal exci-
    Presenting symptom                    N. of cases            sions to complete and aggressive surgical resection,
                                                                 as IP demonstrates an intrinsically aggressive behav-
    Nasal obstruction                     18
                                                                 ior with a propensity for local invasion and potential
    Epistaxis                             5
©




                                                                 risk of malignant transformation. For a long time, ex-
    Rhinorrhea                            3
    Facial pain                           3                      ternal approaches have been the standard treatment,
    Headaches                             2                      providing the surgeon with good exposure and a
    Nasal mass                            3                      favourable tumor control rate.
    Hyposmia                              1                      The aggressive lateral rhinotomy and medial maxil-
                                                                 lectomy approach has been the gold standard treat-
    Total                                 35
                                                                 ment for many years.

    88                                                                             Annali di Stomatologia 2015; VI (3-4): 87-90
    Management and treatment of sinonasal inverted papilloma


    Another important procedure to treat the desease is            More in depth, among 35 cases, after a year of follow-
    the Midfacial degloving. It was first described by Cas-        up. 30 patients were totally free of symptoms, while 2
    son in 1974 in the management of extensive lesions             recurrences were noted by radiographic surveillance.
    of the sinonasal tract (20). Buchwald et al. (21) found        In the first recurrence, after about 17 months, the pa-
    that midfacial degloving was easily performed and re-          tient reported, at clinical control, again difficulty




                                                                                                                i
    vealed this method instead of or as a supplement to            breathing with the right nostril. A RM shown the recur-




                                                                                                              al
    traditional lateral rhinotomy.                                 rence of the disease at the frontal-ethmoid-maxillary si-
    Shohet and Duncavage (22) described 2 patients with            nus. The patient consequently underwent an endoscop-
    frontal sinus IP who were treated successfully with            ic biopsy that shown IP so another surgery was per-




                                                                                                           on
    osteoplastic flap.                                             formed through coronal and endoscopic approach and
    With the advent of minimally invasive endoscopic ap-           she is now free of symptoms from 11 months.
    proaches, many Authors have shown a growing trend              In the second recurrence the disease reappeared
    toward endoscopic technique (23-27).                           11 months after surgery was carried on with epis-
                                                                   taxis. Taken a new maxilla-facial CT, the reappear-




                                                                                                 zi
    It is fundamental to underline that surgery must be
    carried on in a radiacal manner to treat these neo-            ance of disease was shown at the frontal-ethmoid-
    plasms that tend to recur, in 8% of cases in malignant         maxillary sinus. A combined approach with endo-
                                                                   scopic and frontal osteoplastic surgery was then




                                                                                 na
    forms (28).
    Patients comprised in this analysis were treated either        performed and now the patients is free of symptoms
    with open surgery (18 patients), and with endoscopic           from 14 months.
    approach (13 patients), and with combined approach (4
    patients), depending on the location of the lesion. We




                                                                     er
    tried, where possible, to start with an endoscopic ap-         Conclusions
    proach, to eventually turn it afterwards in open surgery,
    as happened for 4 cases where lesions had already              Often, open procedures like osteoplastic flap are es-
    massively invaded the paranasal sinus walls.                   sential for a complete excision of IP, depending on



                                                            t
    Of 18 patients treated with frontal osteoplastic, presurgery   the extend and location of the lesion.
    TC shown a massive tumor invasion of the paranasal
                                                         In        It should be noted that imaging studies are often im-
    sinuses, involving, in 13 cases, even the back bony            perfect and intraoperatively the extent of disease may
    walls of the sinuses.                                          exceed what is predicted. Therefore, in most IP cases
    In 13 cases treated with endoscopic approach, le-              of paranasal sinuses the patient should be prepared
    sions were always localized at the median spot of              and should agree on an osteoplastic flap approach, to
                                               ni
    sagittal plan crossing the orbit medial wall, as report-       have a complete tumor removal. The ideal approach
    ed in international literature as well, and they did not       is frequently determined intraoperatively, based on
    massively compromised the paranasal sinus walls.               the IP attachment sites.
                                    io


    Choosing the right approach is always an uncomfort-            On the basis of clinical and radiological results
    able decision and depends on several variables as le-          shown in this report and in accordance with the Inter-
    sions localization and size and patients compliance.           national literature we noted that endoscopic ap-
                           iz



    Compared to open surgery, endoscopic excision is               proach can be taken into account when tumors are
    associated with several advantages, like superior vi-          localized median to a sagittal plan crossing the orbit
    sualization, preservation of normal sinonasal physio-          median wall and if they did not massively compro-
          Ed




    logic function and achievement of mucociliary clear-           mised paranasal sinus walls.
    ance patterns, absence of external scars, minimal              Because of its tendency to recur and to harbor carci-
    morbidity and low recurrence rates. Perhaps, there             noma IP is an aggressive invasive lesion.
    are two major disadvantages for the successful ac-             A complete removal of the lesion and bone peripheri-
    complishment of endoscopic approach: the need of               cal border filing are essential to perform a correct and
    considerable familiarity with the endoscopic tech-             definitive treatment.
IC




    nique and its inability to adequately provide access to        Careful preoperative planning coupled with meticu-
    the anterior and lateral walls of the maxillary sinus.         lous surgical technique are absolute requisites for
    Open surgery is preferable as it grants better surgical        successful management of these difficult tumors.
    view, better control of bleedings, stronger confidence
C




    in removing the neoplasm.
    Disadvantages might be found in longer hospitaliza-            References
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          Ed
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C
©




    90                                                                                        Annali di Stomatologia 2015; VI (3-4): 87-90
