Authored by Tariq Tatwani*
Introduction
Sinonasal inverted papilloma (IP) also known as Schneiderian papilloma is one of the most intriguing pathology of nasal cavity and paranasal sinuses [1]. It is a benign epithelial neoplasm arising from the Schneiderian epithelium that lines the nose and paranasal sinuses [2]. Other names for this tumor include epithelial papilloma, Ringertz’s tumour, transitional cell papilloma, villiform cancer and Ewing’s papilloma [3]. It accounts for 70% of all sinonasal papillomas, remaining 30% are either exophyticpapillomas or columnar cell papillomas despite that it is not very common diseases (0.5-4% of all nasal and sinus tumours). However, IP attracts considerable interest because it is locally aggressive, has a high propensity to recur, and is significantly associated with malignant transformation-most frequently to squamous cell carcinoma in about 10-15% cases [4,5].
Nonetheless, there is growing evidence that human papilloma virus and environmental pollutants like cigarette smoke are convincingly implicated in pathogenesis of the tumour, its precise aetiology is still poorly understood [6,7]. Allergy, chronic longstanding inflammatory diseases and certain occupational factors are also reported as associated risk factors but their exact role in aetiology of IP is not delineated [8]. The most common site of origin of IP include lateral nasal wall and middle meatus followed by adjacent paranasal sinuses and other nearby anatomical structures like the orbit or base of skull [9]. Mostly the IP arises as a single, unilateral lesion and present with unilateral nasal obstruction [10]. However, it can rarely be multicentric and bilateral. Clinical presentation depends on the site of origin and laterality of the tumour [11]. Regarding the demographic distribution, IP is threefolds commoner in men as compared to women and peak incidence has been claimed in the 5th to 7th decade though the tumour has also been reported in children, adolescents and elderly [12].
Because of the tendency to recur, the ability to erode adjoining structures and the association with malignancy, in past decades most surgeons recommend medial maxillectomy via lateral rhinotomy for the treatment of IP, especially those for advance cases [13,14]. However, the lateral rhinotomy approach leaves permanent facial scars, which is one of the reasons why many surgeons consider it to be too invasive for the treatment of benign neoplasm. Besides the lateral rhinotomy approach, the mid facial degloving approach is a relatively uncomplicated alternative option for managing IP even when it has presented at an advance stage [15,16]. Furthermore, in the early 1990s, the endoscopic surgical approach was introduced for the treatment of inverted papilloma which shown comparable or even superior outcome than the conventional external approaches [17-19].
Today, it is established that IP need complete resection which may be done by either open traditional approaches or modern endoscopic resection techniques [20]. There are many reports supporting the feasibility of endoscopic resection with long-term follow-up [11,21,22]. Whether traditional approaches provide any advantage over modern endoscopic techniques is a subject of controversy and beyond the scope of this manuscript. The current study was performed to find the outcome of surgical management of inverted papillomas of the nose and paranasal sinuses in local Saudi patients.
Methods
It was a retrospective study conducted in the department of Ear Nose Throat (ENT) and Head and Neck Surgery (HNS), Prince Sultan Military Hospital/Medical City, Riyadh, Kingdom of Saudi Arabia. The patients who were histopathologically diagnosed to have an inverted type of sinonasal papilloma were retrospectively included in the study. All patients from any age group and gender were included in the study after obtaining informed consent, between January 1990 and March 2014. A total of 18 patients fulfilled the inclusion criteria. The clinical presentation (symptoms, signs), site, side of the lesion, duration of problem, assessment about destruction of adjacent structures, type of surgical approach performed, recurrence, association with smoking and cancer were recorded. All data was entered and analyzed with the help of SPSS version 17. Frequencies and percentages were given for qualitative/ discrete variables like gender, side and recurrence. Means were calculated for continuous/quantitative variables like age of patients and duration of symptoms. No statistical test of significance was applied as the nature of study was purely descriptive.
Results
The mean age of the patients enrolled in the study was 48.3 years. 15 patients (83.3%) were male while 3 (16.7%) were female (Figure 1). Male to female ratio was 5:1. Presenting males had a mean age of 46.5 years and that of females was 57.3 years. Maximum cases were reported form the age group between 21-40 years (Figure 2). The mean duration of symptoms was 2 years and 9 months ranging from 6 months to 10 years. Most common chief complaint with which the patients presented was nasal obstruction which involved 14 cases (77.8%), followed by rhinorrhea 8 (44.4%), postnasal drip 6 (33.3%), headache 5 (27.8%), epistaxis 2 (11.1%) and Hyposmia 2 (11.1%) (Figure 3).
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