1. Inverted papilloma is a benign epithelial tumor originating from the Schneiderian membrane of the nasal cavity and paranasal sinuses. 2. It most commonly affects males ages 30-50 and presents as a unilateral nasal mass, obstruction, and bleeding. 3. Treatment involves surgical resection, typically an endoscopic medial maxillectomy to remove the entire lateral nasal wall and clear the tumor attachment site.

1. Dr Mohammed Nishad N

2. Papilloma of the nose
Definition
Benign locally aggressive neoplasm originating from the
schneiderian membrane of nasal cavity
Male : female 3:1
Age group –30-50

3.  Most common site – lateral wall (70%)
ethmoid complex
septum

4. Papilloma are of three types
 Fungiform/ papillary/exophytic/everted papilloma
 Inverted papilloma
 Cylindrical papilloma

5. Inverted papilloma
 Schneiderian papillomas
 Ringertz tumour
 Transitional cell papilloma
 Polyp with inverting metaplasia
 Epithelial papilloma
 Soft papilloma
 Papillary fibroma
 Squamous papillary epithelioma

6. DEFINITION
 A Benign epithelial neoplasm arising from
Schneiderian membrane of nose and paranasal
sinuses.
 The mucosal lining of nose and paranasal sinuses is
known as Schneiderian membrane .
 Papillomas arising from this membrane is very unique
in that they are found to be growing inwardly and
hence the term inverted papilloma .

7.  Inverted papillomas behave like neoplasms, arising
from reserve / replacement cells located at the
basement membrane of the mucosa due to
UNKNOWN stimulus .
 The resulting thickening of the epithelium assumes an
inverting, fungiform or combination growth pattern

8.  Depending on the degree of metaplasia varying
amounts of respiratory / cylindrical cells may be seen
in Schneiderian papillomas .
 Rarely the papilloma may be composed entirely of
cylindrical cells, and hence the term cylindrical cell
papillomas is used to describe this subtype.

9. ANATOMIC CLASSIFICATION OF SCHNEIDERIAN
PAPILLOMA
 Inverted papilloma can be classified according to its
site of occurrence i.e. Lateral wall and septal
papillomas .
 Septal papillomas remain confined to the nasal
septum and may very rarely involve the roof and floor
of the nasal cavity. Carcinomatous transformation is
rare in septal papillomas & Vice versa in lateral wall
papillomas

10. INCIDENCE
 M > F, 20 to 70 yrs .
 Mean age is 50 yrs .
ETIOLOGY
HPV (with mutation of genes) 6,11,16,57b

11. GROSS APPREARANCE
 1. Papillary and exophytic.
 2. Inverted with inwardly invaginating epithelial
growth into underlying stroma.
 A combination of both patterns also can occur
The papillary form/fungiform papilloma tends to
commonly occur in the nasal septum, while the
inverted form often occurs in the lateral wall of the
nose and sinuses

13. MICROSCOPY
 Papillary form : epithelial proliferation over a thin core of
connective tissue. Inversion of epithelial masses is
usually not present .
In inverted papilloma of lateral wall –
 Proliferation of the covering epithelium & extensive
finger like inversion in to the underlying stroma of the
epithelium
 When they undergo malignant transformation the
stroma is found to be breached .
 The predominant cell type in these papillomas is
epidermoid in nature .

14. 

15.  Intercellular bridges can be clearly demonstrated.
 Microscopic mucous cysts can also be identified in
both these types.
 It shows complex ,arborescent exoendophytic growth
pattern with primary ,secondary & tertiary
ramifications in to underlying stroma
 Keratinisation is very minimal. Excessive
keratinisation is very rare, and should prompt the
pathologist to other diagnosis like malignant
transformation

17. Clinical features
 Unilateral nasal mass .
 Commonly fleshy in nature .
 Sometimes it may occur behind a sentinel nasal polyp
 It commonly involves the nasal cavity, erodes the
medial wall of maxilla and may present inside the
maxillary sinus

18. Symptoms:
 Unilateral nasal obstruction .
 Nasal bleeding .
 Nasal discharge .
 Hyposmia/anosmia
 Proptosis , diplopia ,if lamina papyracea is breached
Reddish ,firm , solitary,friable and granular mulberry
/knobby type

19. KROUSE STAGING SYSTEM
 (1) Tumour confined to nasal cavity with no evidence
of malignancy.
 (2) Tumour involving the ostiomeatal complex,
ethmoid sinuses, and/or medial portion of maxillary
sinus ,with no evidence of malignancy .
 (3) Tumour involving the lateral, inferior, superior,
anterior, or posterior walls of maxillary sinus, the
sphenoid sinus, and/or the frontal sinus with or
without involvement of the nasal cavity.
 (4) All malignant tumours and those tumours with
extra nasal and extra sinus extension.

20. Schwals staging
 T1 –Confined to nasal cavity
 T2 &T3– Progressive involvement of PNS
 T4– Tumour extended in to orbit or intra cranial cavity

21. Skolnick et al
 T1 – Tumour confined to one anatomical site with in
the nose
 T2 – Tumour involves two sites with in the nose
 T3– Involvement of sinuses
 T4—Extension outside the nose and sinuses

22. Can get transformed to
 Transitional cell carcinoma
 Squamous cell carcinoma
Inverted papilloma can coexist with squamous cell
carcinoma in 27% (synchronous)

23. Endoscopic view

24. Differential diagnosis
 Antrochoanal polyp
 AFRS
 Esthesionueroblastoma
 Malignancy

25. Investigation
 Biopsy –For definite diagnosis
 CT Scan with contrast –hyper dense areas and
calcification (linear). Bony destruction & Erosion of
the lateral wall
 MRI .. Intracranial & extra cranial extension .
Enhancing mass with heterogeneous conveluted
cerebriform appearance -- characteristic

27. TREATMENT
 Medial maxillectomy – TOC
Approches by 1)endoscopic
2) lateral rhinotomy
3) sublabial midfacial degloving

28. Treatment
 Choice –surgery with marginal clearance
Endoscopic medial maxillectomy
Recurrance ..Lateral rhinotomy (moure”s incision) &
Medial maxillectomy+ with spheno ethmoidal
clearance (en-bloc dissection) depending on extent of
tumour

29. Endoscopic medial maxillectomy
Indications
 Inverted Papilloma (Schneiderian Papilloma)
 Benign sinonasal neoplasms arising from the lateral
nasal wall or maxillary sinus
Highlights:
 Sinonasal landmarks are identified, including the
maxillary sinus ostium, middle & inferior turbinates,
and ethmoid roof
 Attachment of the tumor (stalk) is identified and
transected
 Bulk of the tumor is excised

30.  Bone at the base of the tumor (stalk attachment site) is
drilled and/or resected in order to clear microscopic
disease
 The entire lateral nasal wall, including the inferior
turbinate, is resected
 At the completion of surgery the maxillary sinus and
nose should be a common cavity, enhancing
postoperative surveillance for tumor recurrence

31.  Keep in mind:
 If the nasolacrimal duct is transected during surgery, a
lacrimal stent is placed to decrease the likelihood of
postoperative epiphora. This stent is removed one
week after surgery.
 Postoperative nasal saline irrigations are helpful to
clear crusts which commonly form after this surgery

35.  Sub cranial approach Lateral rhinotomy is generally
reserved if exenteration of the orbit is needed
simultaneously
 BEST Endoscopic Resection
 Caldwell-Luc or the “limited open approach” was
initially used but has fallen out of favour , given the
poor visualization and higher rates of recurrence
associated with this technique

40. Bone removed & tumor exposed

41. Tumour removed & inicision closed

42. Midfacial degloving approach

43. Thank you