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News -> January, 2004 News
Richard Orlandi, M.D.
Salt Lake City, UT
A 65-year-old man was referred for management of a sphenoid sinus mass. He had presented to another otolaryngologist with chronic symptoms of facial congestion and headache. A CT scan was performed and a sphenoid sinus mass was found. Endoscopic biopsy via a transethmoid approach demonstrated inverted papilloma with foci of carcinoma-in-situ. He was then referred to our institution for further management.
The patient had no visual symptoms and examination showed normal cranial nerve function. Endoscopic examination revealed a papillomatous lesion within the sphenoid sinuses extending into the posterior ethmoid sinuses and sphenoethmoidal recesses bilaterally. Review of the CT scan demonstrated obliteration of the intersinus septum and thinning of the lateral sphenoid sinus walls bilaterally (Figure). There was also extension into the posterior ethmoid cells. The MRI showed tumor filling the sphenoid sinuses.
After discussion of endoscopic and open approaches, the patient agreed to an endoscopic approach for resection of the mass. Image guidance was used given the proximity to the carotid arteries and optic nerves. The mass was approached with endoscopic total ethmoidectomies bilaterally. Tumor extended to the basal lamellae bilaterally and the middle and superior turbinates were resected to the skull base. Mucosa was elevated from the lamina papyracea bilaterally to obtain an anterior-lateral margin. The posterior portion of the perpendicular plate of the ethmoid and the keel of the vomer were removed with 1 cm. anterior-medial margins. The sphenoid face was then taken down to the level of the floor and all areas of tumor were removed with a 5 mm. margin inferiorly and superiorly. The tumor was peeled off the carotid artery and optic nerve bilaterally. The right carotid artery was dehiscent and the tumor was peeled off the adventitia without injuring the artery. Frozen sections were taken from the anterior, superior and inferior margins and showed no residual disease.
The patient had an unremarkable postoperative course. There were no visual or neurologic deficits. Final pathology revealed no malignancy. There were foci of severe dysplasia in the sphenoid and left middle turbinate specimens. All margins were free of tumor. The patient has been followed with endoscopic exams at quarterly intervals and has been free of disease for 18 months.
Discussion
Inverting papilloma is a benign, locally aggressive tumor of the sinonasal tract that requires complete removal, due to both its tendancy to recur and its association with squamous cell carcinoma. Long thought to be primarily due to human papilloma virus infection,1 early evidence suggests an inflammatory etiology as well.2-4 Endoscopic resection of inverted papilloma was first suggested over a decade ago5, 6 and, since that time, has been questioned by a number of experts.7 In contrast, numerous authors over the last decade have presented their series of successful resections of inverted papilloma.8, 9
The case presented above illustrates the utility and efficacy of an endoscopic resection. Alternatives to this approach include a lateral rhinotomy, midfacial degloving, transpalatal approach, or subcranial approach. Each of these open procedures would have introduced much more morbidity without a significant improvement in visualization of tumor margins or in the ability to resect them. The endoscope's magnification and illumination afforded the ability to better visualize tissue margins and was indispensable in delineating the tissue planes during removal of the tumor from the dehiscent carotid artery. This improved visualization is a significant advantage over resection using a headlight and surgical loupes.
Inverted papilloma of the sphenoid sinus is fortunately rare and its management presents challenges as far as the structures of the lateral sphenoid wall. Endoscopic resection affords the surgeon precise visualization of tumor and normal structures. Open approaches, with their attendant morbidity, add no advantage in this location. This case adds further support for endoscopic resection of inverted papilloma.
References
| 1. | Beck J.C., McClatchey K.D., Lesperance M.M., et al. Presence of human papillomavirus predicts recurrence of inverted papilloma. Otolaryngol Head Neck Surg 113:49-55, 1995. |
| 2. | Orlandi R.R. and Terrell J.E. Sinus inflammation associated with contralateral inverted papilloma. Am J Rhinol 16:91-95, 2002. |
| 3. | Michaels L. and Young M. Histogenesis of papillomas of the nose and paranasal sinuses. Arch Pathol Lab Med 119:821-6, 1995. |
| 4. | Deitmer T and Wiener C. Is there an occupational etiology of inverted papilloma of the nose and sinuses? Acta Otolaryngol 116:762-5, 1996. |
| 5. | Waitz G. and Wigand M. E. Results of endoscopic sinus surgery for the treatment of inverted papillomas. Laryngoscope 102:917-22, 1992. |
| 6. | Stankiewicz J. A. and Girgis S. J. Endoscopic surgical treatment of nasal and paranasal sinus inverted papilloma. Otolaryngol Head Neck Surg 109:988-95, 1993. |
| 7. | Bielamowicz S., Calcaterra T.C.,Watson D. Inverting papilloma of the head and neck: the UCLA update. Otolaryngol Head Neck Surg 109:71-6, 1993. |
| 8. | Tufano R. P., Thaler E. R., Lanza D. C., et al. Endoscopic management of sinonasal inverted papilloma. Am J Rhinol 13:423-6, 1999. |
| 9. | Han J.K., Smith T. L., Loehrl T., et al. An evolution in the management of sinonasal inverting papilloma. Laryngoscope 111:1395-1400, 2001. |
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