Inverted papilloma and Management

INVERTED PAPILLOMA & ITS MANAGEMENT

 

: Inverted papilloma is a benign lesion occurring in the nasal cavity and paranasal sinuses. Even though these tumors areclassified as benign they are known to cause local destruction, known to recur and also can undergo malignant transformation to squamous cell carcinoma. Inverted papilloma is a benign, locally aggressive neoplasm that arises in the nasal cavity and is associated with squamous cell carcinoma in approximately 5% of patients. Squamous cell carcinoma may be present with inverted papilloma at the initial diagnosis or it may occur metachronously after prior treatment. The condition has been given different terminologies like:-

 

1) Schneiderian papilloma.                                                

2) Inverted papilloma.

3) Benign papilloma of nose.

4) Cylindroma.

5) Malignant papilloma of nose

 

Definition: The mucosal lining of nose and paranasal sinuses is known as Schneiderian membrane in memory of Victor conrod Schnider who described its histology. Papillomas arising from this membrane are very unique in that they are found to be growing inwards and hence the term inverted papilloma. These papillomas are unique in their history, biology and location. Papillomas involving the vestibule is not included in this group because histologically, biologically and behaviour wise it is different.It should be borne in mind that the lining mucosa of nose and paranasal sinuses is unique Embryologically in the sense that it is derived from the ectoderm, in contrast to the lining epithelium of laryngobronchial tree which is derived from endoderm.

Incidence:
Inverted papilloma of nose is one of the commonest benign tumors involving the nose and paranasal sinuses.

Histology:

Inverted papillomas arise from reserve / replacement cells located at the basement membrane of the mucosa. The stimulus for this proliferation is largely unknown..Human papilloma virus have been implicated as an etiological agent.

 

Etiology:

Very little is known regarding the etiology of inverted papilloma. Studies have implicated Human papilloma virus as the probable etiology. Human papilloma virus DNA have been isolated from nasal papilloma cells. It should also be pointed out that HPV DNA have not been identified in all the papilloma cells.

Age group affected: Majority of these patients fall in the age group between 50– 70years.

Sex predisposition: It is three times more common in males than in females.

Anatomic classification:

Inverted papilloma can be classified according to its site of occurrence i.e. lateral wall and septal papillomas. They show differences in their behaviour patterns. The septal papillomas remain confined to the nasal septum and may very rarely involve the roof and floor of the nasal cavity.

Characteristic attributes of inverted papilloma:                                
1.Tendency to recur even after complete surgical                                 

     removal of mass

2.Its destructive capacity

3.Presence of associated nasal polypi

4.Malignant transformation

Symptoms: Include

Unilateral nasal obstruction

– This occurs when the mass is sufficiently large to cause airway obstruction.

Nasal discharge

– This is due to retained secretions in the nasal cavity and the excessive mucous secretions from mucoid glands present in the nasal mucosa.

Epistaxis

– Commonly unilateral and occurs unprovoked. Usually self limiting in nature.

Head ache

– Is caused due to blockage of the normal sinus drainage. If the head ache is intense and nocturnal then malignant transformation eroding the skull base should be suspected.

Sinusitis & swelling involving the nose

– This is usually due to the mass obstructing the sinus drainage. Swelling is seen in the alar region (flaring of the ala).

Anosmia

– This is very rare and is seen only in patients with bilateral mass lesions.

Hearing impairment

– Is caused when the mass expands into the naso pharynx to involve the eustachean tube. This can also cause tinnitus rarely.

Epiphora

– This is caused due to blockage of naso lacrimal duct at the inferior meatus

Numbness over cheek

– Due to involvement of infraorbital nerve

Altered speech

– Occurs when the mass involves the nasopharynx

Proptosis

– Is seen in patients in whom the lamina papyracea has been breached.

 

Management of Inverted papilloma.

There is only surgical treatment in the management of  inverted paapilloma basically endoscopic.

Types of endoscopic techniques in the management of inverted papilloma:

Three different types of endoscopic techniques are available to the surgeon for managing inverted papillomas. The decision on the technique is arrived at on detailed study of pre op images and intra op endoscopic findings.

Type I resection:

 If the naso lacrimal ductis involved or in order to provide better exposure, the duct can be sectioned just below the Krause valve

Type II resection:

This is also known as endoscopic medial maxillectomy procedure. It is indicated for inverted papillomas originating from ethmo nasal complex and secondarily involves maxillary sinus or when the lesion originates from the mucosal lining of the medial wall of maxillary sinus.

Type III resection:
This procedure is indicated in patients with inverted papilloma with involvement of mucosa of antero lateral and posterior walls of maxillary sinus. These patients require a rather wide exposure of maxillary sinus. This can be achieved by combining medial maxillectomy with resection of the medial portion of the anterior wall of maxillary sinus.

Medial maxillectomy is the radical surgery for the management of medial maxillectomy mostly in cases of malignant transformation of inverted papilloma. It maybe done by a endoscopic procedure of by an open operation with lateral rhinotomy incision.

 

Complications of medial maxillectomy:

1.Lid oedema

2.Asymmetry of palpebral fissures

3.Diplopia

4.Enophthalmos

5.Transient blindness due to retinal artery spasm

6.Orbital hemorrhage

7.CSF leaks.