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Inverted Papilloma is a benign neoplasm originating from the Schneiderian membrane of the nose and paranasal sinus cavities. It has varied clinical and histological features involving the lateral nasal wall, septum, ethmoids, maxillary and sphenoid sinuses and at times involves the skull base. Three interesting cases are reported below because of varied presentation of inverted papilloma.

Microlaryngoscopy and Endolaryngeal Surgery
Neck Masses – Evaluation
Carcinoma Ethmoid – Surgical Management

Since Inverted Papilloma is associated with chronic sinusitis, patients always had nasal and sinus surgery. Most authorities will consider this a true neoplasm because of its transformation into carcinoma as transitional cell, papilloma or squamous papillary epithelioma. Early clinical diagnosis and thorough evaluation by biochemical tests, high resolution coronal CT scanning and radical surgery is advocated. For its recurrence and malignant transformation few authorities advocate deep X–ray therapy following radical surgery. Sixteen cases were seen during 1980 to 1995 at KEM Hospital, Pune.

Inverted Papilloma Cases
Case No. 1
Mr. D. K. aged 68 had complaints of left nasal obstruction, headache, epiphora and bleeding from nostrils (epistaxis). He had nasal polypectomy and intranasal antrostomy done seven years ago. An ENT examination revealed a large greyish mass occupying the left nasal cavity pushing the septum to right side. A probe could not be passed around the nasal mass since it was coming from the lateral nasal wall. The nasal vault was tender and there was a evidence of nasolacrimal duct obstruction. Left maxilla was tender and mass did not bleed on touch. A provisional diagnosis of recurrence of nasal polyposis was made with the view of malignancy in mind.

The routine bio–chemical tests were within normal limits, X–ray paranasal sinuses revealed opacity and left maxillary sinuses with medial wall destruction. A CT scan also revealed a lesion of maxillary sinus with erosion of medial wall and a soft tissue mass in the left nasal cavity extending to the nasopharynx.

In view of the recurrence and erosion of the medial wall, the patient was subjected to lateral rhinotomy with medial maxillectomy procedure. The mass was removed with maxillary clearance. Histopathology confirmed the diagnosis of inverted papilloma with no evidence of malignancy. Post operative recovery was uneventful. The patient was reviewed in a follow up clinic and had no recurrence for the last one and a half year.

Case No. 2
Mrs. M. L. aged 48 had a bilateral nasal obstruction, mouth breathing and headache. She was non–diabetic, non–hypertensive and had nasal polypectomy two years ago. A routine clinical examination revealed bilateral polypoidal masses occupying both the nostrils. The color of the mass was grayish and firm in consistency and did not bleed on touch. Both maxillary sinuses were tender. Postnasal space did not show any soft tissue mass.

Clinical diagnosis of bilateral nasal polyposis was made (Recurrence) with associated Maxillary sinus and no extension to nasopharynx. Planned bilateral intanasal ethmoidectomies with bilateral intranasal antrostomy was carried out under GA after nasoendoscopic examination. Post operative recovery was uneventful. Histopathology of the biopsy revealed inverted papilloma. A review after 18 months was satisfactory without recurrence.

Case No. 3
Mr. A. K. aged 28 came to the ENT Clinic with the chief complaints of nasal obstruction, bleeding from left nostril, headache, and proptosis of left eye for over six months. A clinical diagnosis of the left nasal polyposis was made after a thorough clinical examination. A routine hemogram was performed and this including biochemical tests were within normal limits. A CT scan revealed a lesion involving the entire left ethmoid, nasal cavity, maxillary sinus, nasopharynx and anterior wall of sphenoid sinus.

A planned nasal polypectomy with ethmoidectomy and transantral maxillary clearance was done. The post operative period was uneventful. It was found that the patient’s left proptosis decreased and the histopathology report revealed inverted papilloma. Post–operative review after six months was quite satisfactory and without recurrence.


Discussion
Although most of the lesions arise from the lateral wall, middle meatus and ethmoid complex, they may sometimes arise from the septum and underlying perichondrium, the cartilage, lateral nasopharyngeal wall, maxillary sinus, sphenoid sinus and may involve the base skull. The distribution is: lateral wall 68%, ethmoid complex 57%, septum 28% intracranium 4%. The highest recurrence rate 70%.

The microscopic features that distinguishes a papilloma from an allergic polyp is the proliferation of the covering epithelium and extensive finger like inversions into the underlying stoma of the epithelium. The lesions are commonly seen in males more than females, and the ratio being 3:1. The age distribution is common between 30–50 years but lesions are also seen in the older age group of 60 plus.

The clinical appearance of the nasal mass resembles an allergic polyp looking like a gray and red nasal mass. Grading of inverted Papilloma shows:

Grade I Lesions involving nasal cavity only.
Grade II Lesions involving nasal cavity + Paranasal sinuses.
Grade III Lesions involving  nasal cavity + Paranasal sinuses + skull base (intra cranial extension).

Because of its varied presentation inverting papillomas can be difficult to distinguish from other nasal tumors and they tend to recur after limited operation and also tend to transform into carcinoma. Hence, it is impossible to predict which inverting papillomas will become malignant.

Management
A conservative surgical approach for septal and lateral wall tumors (intra–nasal surgery) is adopted. Tumors involving para nasal sinuses and ethmoids will need intranasal atronomies and Caldwell–lucs operation.

For recurrent masses a more radical surgery is advocated which includes – lateral rhinotomy along with medial maxillectomy with spheno–ethmoidal clearance (Enbloc Dissection). Because of its malignant transformation (3) in Ca (about 15%) some authorities recommended full radiotherapy courses (6000 rads) for six weeks (4).

Acknowledgement
I am thankful to the Chief Medical officer, Dr. Mrs. B. J. Coyaji for permitting me to publish this paper.

References Conference News
South Zone conference of AOI, was held in Madras on the 14,15, 16th of March 1997. The theme of the Conference was “Recent Advances in Otolaryngology”. Eminent international invitees attended the conference. The conference will also have a one day live surgical workshop, and feature prize winning papers by post–graduates.

Contributed by Dr. K. K. Desarda