Inverted Papilloma and Other Benign Sino-Nasal Tumors

1. Benign Sino-Nasal Tumors
Dr. Adhishesh Kaul
Moderator: Dr. Nagarathna H K
Associate Professor

2. Introduction

3. Types of Tumor
1. Epithelial Tumors
Inverted Papilloma
2. Vascular Tumors
Hemangioma ( Cavernous and Capillary)
3. Bony Tumors
Osteoma
Ossifying fibroma
4. Mesenchymatous Tumors
Glioma
Myxoma
Leiomyoma
Schwannoma

4. Inverted Papilloma

5. History and Basics
• Other Names
Ringertz tumor
Transitional cell papilloma
Schneiderian papilloma
• 2nd most common benign sinonasal tumor
• Type: Nasal epithelial benign tumor
• Discovered By: Ward : 1854
• Invasiveness discovered by: Ringertz : 1938
• Incidence: ~0.6/1lac population

6. • Characteristics:
1. Bone invasion and remodelling
2. Recurrence
3. ~10% incidence of SCC (synchronous > metachronous)
Time for transformation: Mean 52 months,
Range 6 – 180 months
• Features
Most common site: lateral nasal wall> maxillary sinus > ethmoids
Male: Female – 2-3:1
Age: 5th – 6th decade
Architecture: Endophytic
Molecular mutation: EGFR activations, TGFα

7. Clinical Presentation
• Unilateral nasal obstruction
• Watery rhinorrhea
• Epistaxis
• Epiphora/ Proptosis/ Diplopia/ Headache

8. Histopathology
• Epithelium is hyperplastic (5 -
30 cell layers in thickness)
• may be of squamous,
transitional or respiratory type
• Transmigrating neutrophils and
neutrophilic microabscesses
may be seen
• Stroma may have edema or
chronic inflammation
• Seromucinous gland in the
lamina propria is commonly
decreased or absent

9. Staging (Krouse staging)
T1: confined to nose without sinus extension
T2: Involves OMC/ medial maxillary sinus/ ethmoids
T3: Involving other areas of maxillary sinus/ sphenoid and/or frontal
sinus
T4: Extranasal/Extrasinus extension

10. Staging (Cannady Staging)

11. Diagnostic Workup
• Nasal Endoscopy
• CT/MRI
• Biopsy

12. Nasal Endoscopy
• Pale, polypoid lesion with a
papillary appearance
• Lesion protrudes from the
middle meatus

13. • Small red bumps (granular
mulberry appearance)
• Has undulations
• Firmer than polyp
• More vascular than polyp
• Not smooth like – polyp

14. Imaging Target
• AIM: extent and three-dimensional configuration of the lesion and to
disclose its relationship with surrounding structures
• Methods:
MRI with gadolinium enhancement
CT

15. CT Scan

17. MRI Scan

18. Etiology – Various Theories
• Viral Infection
• Inflammation
• Environmental exposure

19. Viral Infection : HPV
• 1st reported in 1980
• Correlation ranges from 0% - 100%
• Subtypes associated with IP: 6, 11, 16, 18
• Pathogenesis: HPV induces promoting agent in pathogenesis of
papilloma, which leads to gene alteration (p53) resulting in
development of IP

20. Chronic Inflammation
• IP is end stage of chronic inflammatory condition NOT A TRUE
NEOPLASM
• HPE shows more inflammatory cells in IP compared to other sino-
nasal papillomas

21. Environmental exposure
• Dietmer et al. 1996, case – control study
47 cases and 47 controls, found higher degree of occupational
exposure to smoke, dust, aerosol
• Sham et a. 2010, case – control study
50 cases and 150 controls found outdoor and industrial exposure
were associated with IP

22. Recurrence – Factors
1. Location of attachment
2. Completeness of resection in primary surgical resection
3. Increased chance of recurrence in revision cases: 18.1% vs 4.1%
complicated by scar tissue, absence of bony landmarks, residual
disease

23. Rate of recurrence on basis of site of tumor
location

24. Rate of recurrence on basis of Surgical
Technique
• Meta-analysis comparing contemporary endoscopic (1992–2004)
versus external approaches (1970–1995) demonstrated an improved
recurrence rate in the endoscopic group (12% vs. 20%, respectively).

26. Other Risk Factors for Recurrence
• Tobacco usage
• Histological parameters
hyperkeratosis
hyperplasia
mitotic index
IHC markers

27. Treatment Goals
• Resection of tumor including tumor base
• Removal of bone/ burring the base
• NO NON-SURGICAL TREATMENT MODALITY
• Radiotherapy:
Incase of malignant transformation
Incompletely resectable tumors
Multiple recurrent tumors

28. Surgical Approaches
• Transnasal approach (without endoscopes)
• Open approach (Radical Surgery) – Try to get around the tumor
Medial Maxillectomy + Lateral Rhinotomy
+ Sublabial degloving
• Endoscopic

29. Open approaches Advantages
• Possibility of en-bloc resection
• Access areas with difficult endoscopic instrumentation
Anterior maxillary sinus
Region of Nasolacrimal duct
superior and lateral frontal sinus

30. Anterior Maxillary Sinus Residual tumor in lateral frontal sinus

32. Drawbacks of Open Approaches
• Cosmetic
• CSF Leak
• Orbital Injury
enophthalmos, ectropion, diplopia, orbital hemorrhage, rarely
blindness
• Lacrimal Injuries
epiphora, dacryocystitis,
• Mucocele
• Bleeding

33. Endoscopic approach advantages
• Improved precision for resection of involved areas
• Realization that site of attachment may be small and other structures
can be spared
• Greatly improved visualization to determine site of attachment before
resection is complete
• Improved follow up in office to detect and resect recurrences early

34. Contraindications for endoscopic approach
• massive involvement of the mucosa of the frontal sinus and/ or of a
supraorbital cell
• transorbital extension
• concomitant presence of a malignancy that involves critical areas
• presence of significant scarring and anatomic distortion from previous
surgery

35. Types of Endoscopic Approach
• Type 1: IP involving middle meatus, ethmoid, superior meatus,
sphenoid sinus, or a combination of these structures; even lesions
that protrude into the maxillary sinus without direct involvement of
the mucosa are amenable to this approach

36. • Type 2: which corresponds to an endoscopic medial maxillectomy, is
indicated for tumors that originate within the naso-ethmoid complex
and secondarily extend into the maxillary sinus or for primary
maxillary lesions that do not involve the anterior and lateral walls of
the sinus. The nasolacrimal duct can be included in the specimen to
increase the exposure of the anterior part of the maxillary sinus.

37. • Type 3: (endonasal denker / Sturman-Canfield operation)
entails removal of the medial portion of the anterior wall of the
maxillary sinus to enable access to all the antrum walls. It is therefore
recommended for inverted papillomas that extensively involve the
anterior compartment of the maxillary sinus

38. Endoscopic Medial Maxillectomy
Resection of the lateral wall, including the inferior turbinate and nasolacrimal duct (NLD)

44. Drawbacks of EMM
1. Empty nose syndrome
2. Decreased efficiency of nasal heating and humidification in CT-
based computational fluid dynamic
3. Impaired stimulation of trigeminal cold receptors, involved in
perception of nasal patency (eg, the TRPM8 receptor) in the
mucosa by mucosal cooling

45. Complications
• Bleeding
Most common: Greater Palatine artery
Management/ Prevention:
Locate and bipolarize
Low threshold for SPA ligation
Bipolarize posterior end of anterior IT remanent
• Epiphora
Management/ Prevention:
Do divide cleanly ,
Do not leave bone fragments around lacrimal duct
• Parasthesia
Palatal/ Teeth/ Infraorbital skin

46. Modifications of EMM
• Partial medial maxillectomy
• Inferior turbinate preservation
• NLD preservation
• Pre-Lacrimal Approach

47. Prelacrimal Approach
(Endoscopic Modified Medial Maxillectomy)
• Access similar to that of EMM along with anterior maxillary sinus
visualization
• Preservation of nasal morphology

50. Surgical Queries
How to decide what resection to do? Physical examination
Imaging
What approach to use? Tumor base access
Surgeon preference

51. Challenges – Frontal Sinus IP
• Incidence: 1 – 16%
• Approach:
• Recurrence: 22.4% (Walgama et al 2012)
Approach Location of IP
Modified Lothrop Inferomedial
Osteoplastic Flap Lateral, superior wall

53. Lothrop Procedure
• Traditional Procedure: first described in 1914, uses a combined
external and transnasal approach to resect the median frontal
sinus floor, superior nasal septum, and intersinus septum to
drain the frontal sinus.
• Modified Lothrop: Also known as draf III
Remove entire sinus floor, including AS septum

55. Osteoplastic Flap

56. Challenges – Sphenoid Sinus IP
• Attachment over Optic Nerve, Carotid Artery - 4.76times greater risk
of recurrence
• Intracranial Extension
• Orbital involvement

57. Invasion
• Intracranial: 17 patients studied by Wright, with 49.2 years of mean
age, 60% had recurrent disease, with commonest side of invasion
from frontal sinus and cribriform plate
• Orbital: 10 patients studied by Elner, with mean age 62 years, 100%
with malignant transformation, 80% orbital exenteration, 30%
intracranial extension

58. Prognostic Markers
• Increased risk of recurrence if involvement of sphenoid sinus,
frontal sinus or maxillary sinus walls other than medial or
extrasinus extension
• Major cause of recurrence is incomplete resection
• Risk of malignant transformation is ~9% in inverted papilloma
(range: 5 - 15%)

59. • Endoscopic rate of recurrence ~ 12%
• Open procedure rate of recurrence ~18%
• Involvement of maxillary sinus floor and lateral recess required
additional sublabial approach

60. Endoscopic Surveillance for Early Detection
• On posterior part of medial
orbital wall

61. Indications for EMM
• Impaired Mucociliary function
CF/ Wegeners disease/ Prior Caldwell-Luc with impaired mucocilary
clearance
• Postoperative obstruction of normal ostium
Osseo neogenesis in normal ostium from surgery/ prior orbital
decompression of normal ostium
• Access in difficult airways
Odontogenic infection/ Foreign bodies/ AC polyp with attachment in
anterior or lateral wall
• Destroyed medial wall
extensive mucocele with destruction of medial wall/ allergic fungal
sinusitis

62. Osteoma

63. • Benign, slow growing, osteoblastic lesion
• Incidence: 1% of population undergoing radiographs,
3% of population undergoing CT for Sinus symptoms
• Age: 2nd to 5th decade of life
• Male preponderance
• Site: Frontal > Ethmoid > Maxillary sinus > Sphenoids

64. • Gross appearance:
hard, white, multilobulated mass,
• Types:
Ivory: lobulated, made of compact dense bone, and contains a
minimal amount of fibrous tissue without evidence of haversian ducts.
Mature : spongy, mature bone with bony trabeculae divided by a
conspicuous amount of fibrous tissue; the lesion contains fibroblasts in
different stages of maturation and a great number of collagen fibers, and the
connective tissue may often contain distended thin-walled vessels.
Mixed

65. • Theories for development
Embryogenic Theory: osteoma develops at the junction between
the embryonic cartilaginous ethmoid and the membranous frontal
bone
Traumatic Theory: development of osteoma with a previous
trauma
Infective Theory: local inflammation may alter adjacent bone
metabolism by activating osteogenesis

66. • Imaging: CT Scan: Shows features of cortical bone, tapering to ground
glass appearance in periphery
• Management:
1. Wait and watch in case asymptomatic
2. Excision: in case producing symptoms because of
Obstruction of sinus clearance
Compression on orbital structures/ optic nerve
encroaching anterior skull base causing CSF leak,
pneumocele, etc

67. Lobular Capillary Hemangioma

68. • Rapidly growing lesion characterized by proliferation of capillaries
arranged in lobules, separated by loose connective tissue stroma,
infiltrated by inflammatory cells.
• Age: 10 years – 72 years
• No gender predisposition
• Etiology: Trauma, hormonal influences, viral oncogenes, microscopic
arteriovenous malformations, angiogenic growth factors

69. • DNE: red to purple mass, <1cm, associated with epistaxis
• CT: unilateral mass with soft tissue density
• MRI: T2: Hyperintensity
T1: Hypointensity
CE: vivid enhancement
• Definitive diagnosis: Histological examination
• Management: Endoscopic radical resection

70. Fibrous Dysplasia

71. • It is a genetical developmental anomaly of the bone-forming
mesenchyme with a defect in osteoblastic differentiation and
maturation, leading to replacement of normal bony tissue by fibrous
tissue of variable cellularity and immature woven bone.
• Fibrous dysplasia, lacks capsule and has presence of more immature
bone without osteoblastic activity.
• Psammomatoid ossifying fibroma, is a variant, with numerous small
ossicles in stroma, resembling psammoma bodies.

72. • Types:
Monostotic
Polyostotic
Disseminated
• Presentation:
Pain and pressure symptoms
Compress optic nerve/ orbit

73. • CT Scan: associated with degree of mineralization of the tissue
Early – High density of fiberous tissue,
Lesion: Radiolucent to lytic appearance
Late – Ground glass to sclerotic appearance
• MRI: T1 – Hypointense
T2 – Variable
CE - non homogeneous enhancement

74. • Management: Resection to relieve symptoms
Resection: Partial vs Radical
• Medical Management: Bisphosphonates – inhibit osteoclastic activity

75. Ossifying Fibroma

76. • Occurrence: 3rd and 4th decade of life
• Race: more common in black women
Psammomatoid variant affects young men more commonly with
aggressive local behavior
• Presents as SOL in nasal cavity on endoscopy
• CT: well defined, multiloculated lesion, bordered by peripheral
eggshell-like dense rim
• MRI: T2: Hyperintense
T1: central part : intermediately intense to hyperintense
outer shell : hypointense

77. • Management: Radical resection i/v/o high rate of relapse, with local
destruction and invasion of adjacent structures

78. Schwannoma

79. • Neurogenic tumor arising from schwann cells of sheath of myelinated
nerves
• Age: 6 years to 78 years
• No sex predisposition
• Origin: V2 and V3,
Sympathetic fibers of carotid plexus
Parasympathetic fibers of pterygopalatine ganglion

80. • Well delineated, unencapsulated
globular, firm to rubbery, yellow
– tan mass
• polypoid mass filling the left
nasal cavity with network of
capillaries on the surface of the
lesion, suggesting a diagnosis of
hypervascularized tumor.

81. • HPE: cellular Antoni A areas with
Verocay bodies and hypocellular
myxoid Antoni B areas
• IHC: S 100 protein

82. • Imaging
CT: Non diagnostic
MRI: shows histologic features
of lesion
lesions with a prevalent Antoni
A component have an
intermediate signal on both T1-
and T2-weighted
predominant Antoni B pattern,
which is related to a loose
myxoid stroma, hyperintensity
is observed on T2-weighted
images
• Management:
Radical surgery

83. References
• Scott Brown Ed 6-8
• Jatin P Shah
• Cummings
• Mohan Bansal
• Hazarika
• AIIMS ENT
• Global ENT Outreach
• Sydney ENT Clinic: Prof Richard Harvey
• Seattle science foundation
• Pathology outlines