Sinonasal Papillomas Workup

  • Author: Nader Sadeghi, MD, FRCSC; Chief Editor: Arlen D Meyers, MD, MBA   more...
 
Updated: Nov 28, 2011
 

Imaging Studies

  • Preoperative radiographic assessment of sinonasal papillomas (SPs) plays an important role in determining extension of the disease and involvement of adjacent structures; hence, choosing the appropriate approach is important.
  • Coronal and axial contrast-enhanced CT is considered the study of choice for assessing intranasal lesions.
    • As many as 75% of patients with SPs have evidence of various degrees of bone destruction. These may include thinning, remodeling, erosion, and (less commonly) sclerotic bony changes. The presence of bone destruction alone does not indicate dedifferentiation into malignancy from the SP. CT scanning is more precise than conventional radiography for identifying the areas of bony erosion.
    • With CT scanning, differentiating a papillomatous lesion from inspissated mucous, mucoperiosteal thickening, or polyps that result from the obstruction of a sinus drainage pathway is sometimes difficult.
  • MRI is an alternative study that is superior to CT scanning in distinguishing papillomas from inflammation and for providing better delineation of the lesions in contrast to surrounding soft tissue.
    • SPs have a heterogeneous appearance on MRI.
    • On T1-weighted images, sinonasal papillomas appear slightly hyperintense to muscle; however, on T2-weighted images, SPs have intermediate signal intensity.
    • A convoluted cerebriform pattern on T2 and enhanced T1-weighted MRIs for inverting papilloma may be potentially distinctive in 80% of cases, according to Ojiri et al.
    • Inflammatory polyps and inspissated material in the sinuses secondary to obstruction by the papilloma are hyperintense on T2-weighted images.
    • Because of the findings listed above, MRI can more accurately define the true extent of the lesion and can help in treatment planning.
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Diagnostic Procedures

  • Biopsy is the most important diagnostic tool when a sinonasal papilloma is suspected.
  • If intracranial pathology may be manifesting in the sinonasal cavity (ie, encephalocele, meningocele, meningoencephalocele), perform imaging studies before biopsy.
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Histologic Findings

SPs can be divided into 3 histologic subtypes: inverted, fungiform, and cylindrical (columnar). Inverted papillomas have an endophytic growth pattern found almost exclusively on the lateral nasal wall; these account for 47% of all cases of SPs. On the contrary, fungiform papillomas constitute approximately 50% of sinonasal SPs and have an exophytic type of growth. They are found mainly on the nasal septum. Cylindrical papillomas are the rarest type (3-5%) and are also called oncocytic SPs.

On gross examination, SPs originate from a narrow or broad-based stalk. Sinonasal papillomas have an irregular, friable appearance and bleed easily. On microscopy, the fungiform type is mainly composed of thick squamous epithelium and, less frequently, respiratory epithelium arranged in papillary fronds with exophytic type of growth. By comparison, the inverted type, which has an endophytic or inverted growth pattern, consists of thickened squamous epithelium admixed with mucocytes and intraepithelial mucous cysts. The cylindrical papilloma is composed of multilayered epithelium with an eosinophilic cytoplasm among which intraepithelial mucin cysts are identified.

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Contributor Information and Disclosures
Author

Nader Sadeghi, MD, FRCSC  Professor, Otolaryngology-Head and Neck Surgery, Director of Head and Neck Surgery, George Washington University School of Medicine and Health Sciences

Nader Sadeghi, MD, FRCSC is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society, American Thyroid Association, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Coauthor(s)

Khalid Al-Sebeih, MD, FRCSC, FACS  Associate Professor, Department of Surgery, Faculty of Medicine, Kuwait University

Khalid Al-Sebeih, MD, FRCSC, FACS is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, Canadian Academy of Facial Plastic and Reconstructive Surgery, Canadian Society of Otolaryngology-Head & Neck Surgery, Kuwait Medical Association, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Specialty Editor Board

Lanny Garth Close, MD  Chair, Professor, Department of Otolaryngology-Head and Neck Surgery, Columbia University College of Physicians and Surgeons

Lanny Garth Close, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Physicians, American Laryngological Association, American Society for Head and Neck Surgery, and New York Academy of Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Stephen G Batuello, MD  Consulting Staff, Colorado ENT Specialists

Stephen G Batuello, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Physician Executives, American Medical Association, and Colorado Medical Society

Disclosure: Nothing to disclose.

Christopher L Slack, MD  Private Practice in Otolaryngology and Facial Plastic Surgery, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders

Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA  Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society

Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation Unrestricted gift Unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo Consulting; Medvoy Ownership interest Management position; Cerescan Imaging Honoraria Consulting; GYRUS ACMI Honoraria Consulting

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Sagittal illustration of transnasal endoscopic medial maxillectomy (TEMM) shows the resected lateral nasal wall. Note the cavity of the maxillary sinus (M), resected ethmoid sinuses (E), nasolacrimal duct (NLD), sphenopalatine artery (SPA), and tumor (T).
Superior cut in transnasal endoscopic medial maxillectomy (TEMM) going through the anterior ethmoids (AE) along the ethmoid roof. Central circle shows the endoscopic view and the semitranslucent peripheral circle is the bird's-eye view to show the context. Image shows the middle turbinate (MT), nasolacrimal duct (NLD), Tumor (T), nasal septum (S), and inferior turbinate (IT).
Inferior incision in transnasal endoscopic medial maxillectomy (TEMM) through the mucosa and soft tissue to expose the bone for osteotomy. Broken line illustrates the position of the inferior osteotomy. Image shows the nasal floor (NF), septum (S), the anterior head of inferior turbinate (IT), nasolacrimal duct (NLD)), and tumor (T).
Anterior mucosal incision and osteotomy in transnasal endoscopic medial maxillectomy (TEMM) connecting the superior and the inferior cuts. Bony nasolacrimal duct is osteotomized to expose the duct (NLD). Image shows the nasal floor (NF), inferior turbinate (IT), septum (S), ethmoid sinuses (ES), and tumor (T).
Posterior cuts in transnasal endoscopic medial maxillectomy (TEMM). The nasolacrimal duct (NLD) is transected to allow medialization of the lateral nasal wall and to expose the maxillary sinus. Posterior cuts are completed in the maxillary sinus. The sphenopalatine artery is exposed. Semitranslucent bird's-eye view illustrates the ethmoid sinuses (ES) along with the lateral nasal wall that is medialized with the tumor (T). Image also shows the ethmoid roof (ER), nasal floor (NF), and sphenoid ostium (SO).
 
 
 
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