Sinonasal Papillomas 

Updated: Apr 22, 2019
Author: Nader Sadeghi, MD, FRCSC; Chief Editor: Arlen D Meyers, MD, MBA 

Overview

History of the Procedure

In 1854, Ward first described schneiderian papillomas (SPs) of the nose (ie, sinonasal papilloma).[1] These benign lesions were named in honor of C. Victor Schneider who, in the 1600s, demonstrated that nasal mucosa produces catarrh and not cerebrospinal fluid (CSF) and identified its origin from the ectoderm. Kramer and Som classified SPs as true nasal neoplasms and described them as true papillomas, distinguishing them from inflammatory nasal polyps.[2] Ringertz was the first to identify the tendency of SPs to invert into the underlying connective tissue stroma, which differs from other types of papillomas.[3]

Problem

SPs represent a unique group of benign lesions that arise from the mucosal surfaces of the sinonasal tract. These neoplastic lesions are readily identified by their histopathologic characteristics. SPs, commonly called inverting papillomas, have many synonyms (eg, epithelial papilloma, transitional cell papilloma, squamous cell papilloma).

Unlike the rest of the upper respiratory tract mucosa, the sinonasal mucosa is ectodermal in origin, derived originally from the stomodeum (ie, primitive mouth) in the fourth week of gestation. Sinonasal mucosa is continuous with the mucosal lining of the nasopharynx, which is of endodermal origin but is of identical histology.

Lesions with similar histologic and biologic features infrequently arise outside the nasal cavity. These represent an ectopic migration of the schneiderian membrane during embryogenesis. Extrasinonasal sites where SPs may arise include the pharynx, the lacrimal sac, and the middle-ear space. Similar to SPs, these extranasal papillomas may recur after inadequate resection.

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Epidemiology

Frequency

SPs are relatively uncommon tumors of the nasal cavity, comprising 0.5-4% of all primary nasal tumors. Inverting papilloma accounts for approximately 70% of all SPs and has an incidence of 0.74-1.5 cases per 100,000 per year. Men are affected 4 times more often than women. White persons are most at risk, compared with persons of other races. Finally, although the age range for occurrence is 6-90 years, SPs are rare in children and young adults.

Etiology

The etiology of SPs remains unconfirmed. Proposed causes include allergies, chronic sinusitis, airborne pollutants, and viral infection.

Allergy as a cause has been largely discredited because patients with SPs often have histories negative for allergies. In addition, sinonasal papillomas are typically unilateral.

Paranasal sinusitis is a frequent finding in patients with SPs and is considered by many authors to occur as a result of a tumor obstructing the sinuses rather than an inciting event creating the tumor.

Extrinsic factors associated with air pollution and industrial carcinogens have been considered as possible causes of SPs; however, more studies are required to achieve statistical significance.[4]

Viruses have long been suspected to cause these neoplastic lesions because they have a well-known tendency to produce papillomas elsewhere in the body. Human papilloma virus (HPV) is an epitheliotropic virus that has been implicated in premalignant and malignant lesions of the anogenital tract. Similarly, both the low-risk subtypes (ie, HPV 11, HPV 6) and the high-risk subtypes (ie, HPV 16, HPV 18) have been identified in SPs. Kusiak and Hudson described the presence of intracytoplasmic and intranuclear inclusion bodies in SPs. In 1987, Respler et al, using an in situ hybridization technique, demonstrated HPV 11 in 2 of their patients.[5]

Weber et al confirmed these findings in a study of 21 patients using in situ DNA hybridization, and 16 patients were found to have HPV DNA.[6] In addition, all recurrent lesions in their series were positive for HPV DNA. They theorized that the presence of HPV might affect the biological behavior of SPs. On the other hand, some studies using the hybridization technique and polymerase chain reaction have shown that HPV 6 and HPV 11 are involved in most cases of fungiform SP but are only rarely involved in cases of cylindrical and inverted papillomas.

A study by Stoddard et al detected evidence of HPV in the sinonasal inverted papillomas of all 19 patients in the report but determined that transcriptional activity of the virus was limited (occurring in less than 1% of SP cells in 11 patients). The investigators did not find HPV transcriptional activity to be associated with the progression, recurrence, or malignant transformation of SP.[7]

A study by Yang et al suggested that hypermethylation and abnormal expression of the genes MIR661, PLEC, and OPA3 may contribute to the malignant transformation of sinonasal inverted papillomas.[8]

Pathophysiology

Clinical behavior

Sinonasal SPs are almost always unilateral. The 3 main clinical characteristic attributes of the tumors are (1) the tendency to recur, (2) their destructive capacity to surrounding structures, and (3) their propensity to be associated with malignancy.

The recurrence rate of these neoplastic lesions is highly variable (0-78%), depending mainly on the type of surgical approach and the completeness of resection. Phillips et al found that the recurrence rate after lateral rhinotomy and medial maxillectomy is low compared with after transnasal excision with the Caldwell-Luc operation (35%) or non-endoscopic transnasal excision alone (58%), for which the recurrence rates are significantly higher.[9] The multicentric origin of SPs has also been proposed as another factor that leads to the high recurrence rate; however, this has been documented in only a few cases.

Squamous cell carcinoma is the most common malignant neoplasm associated with SPs. Other types of malignancy rarely associated with SPs are adenocarcinoma and small cell carcinoma. Of the 3 subtypes of SPs, fungiform papillomas have not been reported to have malignant potential. Conversely, inverted papillomas have been reported to develop into carcinoma in 5-10% of cases. Cylindrical papillomas appear to have a higher frequency (14-19%) of malignancy association. No correlation is evident between the number of recurrences or the interval between the recurrence and the development of malignancy.[10]

A study by Nudell et al of SPs that underwent malignant transformation found that 85% were inverted papillomas and also that 85% gave rise to squamous cell carcinomas, with the rest being mucoepidermoid or sinonasal undifferentiated carcinomas. In addition, the study, of 20 patients, found that nine patients presented with carcinoma that was synchronous with the SP.[11]

The combined lesions of squamous cell carcinoma and SP appear to form 3 histologic categories, and most patients have lesions in the first and second groups. In the first group, the SP and the squamous cell carcinoma occupy the same anatomic region, but no evidence suggests that the papilloma gives rise to the carcinoma. In the second group, the papilloma contains a focus of invasive carcinoma. In the third group, the invasive carcinoma develops after the papilloma is resected.

A study by Yan et al suggested that overall and disease-specific survival are better in patients in whom squamous cell carcinoma of the sinonasal cavity has developed from inverted papillomas than in those in whom it has arisen de novo. The study also indicated that in patients with early T-stage sinonasal squamous cell carcinoma, those whose tumors develop from inverted papillomas have better disease-free survival than do those with de novo tumors.[12]

Presentation

Unilateral nasal obstruction is considered the most common presenting symptom of patients with SP. Other symptoms may include epistaxis, nasal discharge, epiphora, and facial pain.

Physical examination usually reveals a unilateral polypoidal mass filling the nasal cavity and causing nasal obstruction. SPs have an irregular, friable appearance, and they often bleed when touched. They are reddish gray and may completely fill the nasal cavity, extending from the vestibule to the nasopharynx. The nasal septum is often bowed to the contralateral side. Proptosis and facial swelling sometimes develop secondary to expansion of the papillomatous lesion.

Contraindications

Endoscopic sinus surgery is contraindicated for tumors that arise from the lateral wall of the maxillary sinus and frontal sinus.

 

Workup

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.

CT scanning

Coronal and axial contrast-enhanced computed tomography (CT) scanning 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

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 MRI scans for inverted papillomas may be potentially distinctive in 80% of cases, according to Ojiri et al.[13, 14]

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.

Diagnostic Procedures

See the list below:

  • 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.

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.

 

Treatment

Medical Therapy

Recognition of the propensity for recurrence and the association with malignancy has led to the evolution of treatment of sinonasal papillomas (SPs). The role of medical therapy is limited; it is used mainly as an adjunct to specific complications such as sinusitis.

Radiotherapy

Radiation therapy is generally not indicated in the treatment of benign papillomatous lesions. It is ineffective in the treatment of SPs, and it carries the presumed risk of malignant transformation in an otherwise benign lesion. However, radiation therapy can be used in the treatment of advanced and biologically aggressive SPs of the sinonasal tract or in those patients in whom the morbidity of the radical surgery would be intolerable. In cases in which SPs are associated with squamous cell carcinoma, radiation therapy appears to be an effective adjunctive procedure.[15, 16]

Surgical Therapy

Most clinicians agree that surgery is the treatment of choice for SPs. However, no consensus has been reached on the type or extent of surgical intervention.

The 3 goals of an adequate surgical procedure are to (1) allow exposure sufficient for complete resection of the tumor, (2) provide an unobstructed view for postoperative surveillance of the cavity, and (3) minimize cosmetic deformities and functional disabilities.

Early attempts to treat inverting papillomas with simple and conservative procedures frequently resulted in recurrence rates of 40-80%. Included among the conservative procedures were the intranasal approach (alone or combined with the Caldwell-Luc operation) and Denker rhinotomy. This high recurrence rate combined with the possibility of the multicentric origin of SPs led many surgeons to advocate aggressive early management with medial maxillectomy by using either lateral rhinotomy or midfacial degloving. A review of the surgical anatomy in the areas of recurrences show that the most common sites of recurrence are the lateral nasal wall in the middle meatus, the nasofrontal duct area, the supraorbital ethmoid cells, the region of the lacrimal fossa, and the infraorbital or prelacrimal recess of the maxillary sinus.

Many surgeons consider lateral rhinotomy with en bloc ethmoidectomy and medial maxillectomy the treatment of choice for SPs. This surgical procedure is associated with a recurrence rate lower than that of other conservative procedures. Michaux first described the lateral-rhinotomy approach in 1848, and popularized it in Moure in 1902. Wong and Heeneman refined the approach with 4 subtypes.[17]

Increasing numbers of authors have reported on endoscopic resection of SP. When appropriately performed, these procedures have success and recurrence rates similar to those of open medial maxillectomy. In many institutions, endoscopic or endoscopy-assisted resection, including transnasal endoscopic medial maxillectomy (TEMM), tailored to the extent of disease is becoming a common treatment. The authors recently reported on the anatomic basis for TEMM as an oncologic approach for sinonasal neoplasms.[18] A recent meta-analysis and another systematic literature review support endoscopic approach as a favorable treatment option compared with open approaches.[19, 20, 21, 22]

Moreover, a literature review by Peng et al indicated that for resection of sinonasal inverted papillomas, endoscopic operations have a lower recurrence rate than does open surgery. In patients who underwent an endoscopic approach, the overall recurrence rate was 12.80%, compared with 16.58% in those treated with an open approach and 12.60% in patients who underwent a combined approach. The risk ratio for recurrence, following adjustment for publication bias, was 0.66 for the endoscopic versus external approach, and 1.33 for the external versus combined approach.[23]

Intraoperative Details

Lateral rhinotomy approach

The lateral rhinotomy approach involves a curvilinear incision between the medial canthus and the dorsum of the nose. For this procedure, start the incision under the medial end of the eyebrow, extend the incision inferiorly between the medial canthus and the nasal dorsum and along the deep nasal-cheek groove adjacent to the ala of nose. Then, swing the incision up onto the floor of the nose. The incision includes the full thickness of skin down to the periosteum. A gentle W- or Z-plasty incision can be incorporated into the medial canthus region to help prevent postoperative webbing of the soft tissue.

After the skin incision is made, elevate the periosteum to expose the medial orbital wall, the anterior maxillary wall up to the infraorbital foramen, and the pyriform aperture. The nasal bones can be retracted medially after medial and lateral osteotomies are performed. To achieve en bloc resection, perform osteotomies through the inferior and anterior aspects of the medial wall of the maxilla, through the medial wall of the orbit just inferior to the frontoethmoid suture line, and through the inferior orbital rim and orbital floor. By connecting these osteotomies, the specimen can be mobilized by using a heavy, curved Mayo scissors, which can be used separate the specimen from the posterior wall of the maxillary sinus.

For medial maxillectomy, include the region of the lacrimal fossa, the infraorbital rim, and the prelacrimal recess of the maxillary sinus. Divide the lateral nasal wall along the floor of the nose. Amputate the middle turbinate below its superior attachment, and remove the entire lateral wall intact after its detachment from the rest of the infraorbital rim.

To avoid epiphora, which is a common postoperative complication of this procedure, always incorporate dacryocystorhinostomy. Dacryocystorhinostomy can be accomplished by catheterization of the lacrimal duct by using an indwelling silicone tube (Guibor tube) or by incising the lacrimal sac vertically and sewing the edges to the adjacent tissues.

The medial canthus is usually displaced from its insertion and should be fixed to prevent unsightly telecanthus. If the tendon elevated is attached to the periosteum, it resumes its normal position after careful closure of the periosteum. Sometimes, the tendon is transected and should be tagged and approximated at the end of the procedure. Transnasal wiring is required if the lacrimal crest and adjacent bone are included in the resection.

Midfacial degloving approach

An alternative, versatile, and recommended approach is midfacial degloving for total excision of the SP. This approach consists of lifting the soft tissue from the mid portion of the face by means of a sublabial incision.

Four types of incisions are required in the midfacial degloving approach: (1) bilateral intercartilaginous incisions, (2) a complete septocolumellar transfixion incision, (3) bilateral sublabial incisions from the maxillary tuberosity to the tuberosity, and (4) bilateral pyriform aperture incisions extending to the vestibule. These incisions facilitate exposure of the pyriform aperture and the lateral nasal wall. En bloc resection of the lateral nasal wall is easy to perform, and it affords the possibility of extending the procedure to include the sphenoethmoidectomy and the medial orbital wall as dictated by the extent of the lesion.

Advantages of this approach include no external scarring, good visibility of the operative field, and simultaneous bilateral exposure. In addition, the recurrence rate of SP excised by using the midfacial degloving procedure is similar to those of lateral rhinotomy and medial maxillectomy. As with the lateral rhinotomy, the midfacial degloving approach can be combined with the craniofacial approach to treat lesions involving the base of the skull or anterior cranial fossa.

The primary limitation of the midfacial degloving approach is when surgery is required for more extensive tumors that invade the supraorbital ethmoid cells or the frontal sinus, which require a separate incision. Septal translocation through a sublabial incision is another approach that shares the same advantages of the midfacial degloving approach. It provides wide exposure with no external scarring.

Endoscopic medial maxillectomy

Stammberger reported the first purely endoscopic approach for treatment of SP, which was performed in 15 patients in 1981. Since then, numerous authors have reported their experience with endoscopic or endoscopy-assisted endonasal approaches. More than 500 reported cases have been treated with this technique. Most reported endoscopic resections have involved piecemeal resection of the inverting papilloma followed by piecemeal resection of the lateral nasal wall. Recent literature supports the concept of piecemeal resection or debulking of the intranasal component to then allow complete subperiosteal excision of all diseased mucosa around the origin. Different endoscopic surgical strategies can be used with reported success tailored to the extent of disease.

In tumors limited to the middle meatus, the anterior and posterior ethmoids, or the sphenoethmoidal recess, limited resection (less than endoscopic medial maxillectomy) may be performed. This resection includes anterior ethmoidectomy with clearance of frontal recess, posterior ethmoidectomy, large middle antrostomy, sphenoidotomy, and partial or complete middle turbinectomy. This procedure can be done en bloc.

Tumors that extend from the middle meatus into the maxillary sinus or that originate from the medial wall of the maxillary sinus should be treated with TEMM that includes resection of nasolacrimal duct to allow for complete removal of the medial maxilla. A recent anatomic study revealed that 65% of the volume of maxillary sinus falls bellow the attachment of inferior turbinate to the lateral nasal wall, and the nasolacrimal canal limits the visualization and access to lateral and anterior maxillary sinus wall.[18] This forms the basis for TEMM when the maxillary sinus is involved by the tumor.

Tumors that originate from or that involve the posterolateral, anterior, or inferior wall of the maxillary sinus may be managed with extended endoscopic medial maxillectomy to include these areas. Some authors have suggested the addition of a Caldwell-Luc procedure to the endoscopic approach in these circumstances.

The author's technique for TEMM involves en bloc resection of the entire lateral nasal wall and the tumor under endoscopic visualization as seen in the image below.

Sagittal illustration of transnasal endoscopic med 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).

After general endotracheal anesthesia is administered, perform topical intranasal decongestion with 2% oxymetazoline-soaked neurosurgical pledgets. Transorally infiltrate 1% lidocaine with 1:100,000 epinephrine into the sphenopalatine foramen. Inject the medication intranasally along the inferior meatal wall, into the turbinates, along the maxillary crest, up to the attachment of the middle turbinate, and into the tumor. Make the initial incision along the superior resection margin, which includes the ethmoids as seen in the image below. Apply bipolar cautery, then sever the attachment of the middle turbinate to the lateral nasal wall with endoscopic scissors.

Superior cut in transnasal endoscopic medial maxil 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).

By using a Freer elevator, perform the dissection along the roof of the ethmoids up to the sphenoid rostrum. Identify the ethmoid arteries, and cauterize them with bipolar cautery. Next, perform inferior resection, as seen in the image below, at the inferior meatus. Cut the mucosa with the electrocautery device at the junction of the lateral wall and the floor of the nose. Perform inferior meatotomy at the anterior end of the meatus. By using a straight osteotome, osteotomize the inferior meatus up to the posterior wall of the maxillary sinus.

Inferior incision in transnasal endoscopic medial 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 resection, as seen in the image below, includes a cut made inferiorly from the anterior attachment of the middle turbinate to include the uncinate process and the maxillary crest. The cut is continued anterior to the inferior turbinate head to connect to the inferior meatotomy cuts.

Anterior mucosal incision and osteotomy in transna 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).

After the soft tissue is elevated, perform anterior osteotomy along the maxillary crest into the maxillary sinus. Then, sever the nasolacrimal duct with endoscopic scissors and include the duct in the specimen. Mobilize the lateral wall medially with progressive dissection until it is pedicled on the sphenopalatine artery (as seen in the image below). Likewise, mobilize any tumor in the sinus.

Posterior cuts in transnasal endoscopic medial max 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).

Clip, cauterize, and cut the sphenopalatine artery. Cut the posterior attachment of the inferior turbinate, and remove the lateral wall along with the tumor. Remove the remaining mucosa of the ethmoids superiorly, and laterally if needed, for margin control, and remove the lining of the maxillary sinus if needed for margin control. If necessary, the lamina papyracea and adjacent medial wall of the orbit may be removed. By using 30° and 70° scopes, the entire lining of the superior and lateral wall of the maxillary sinus can be visualized, and the mucosa can be removed to clear potential multicentric disease. The anterior wall of the sphenoid sinus can easily be resected if needed.

Follow-up

Important in the management of sinonasal SPs is long-term follow-up. Many authors believe that most recurrences occur within the first 2 years of treatment. However, most recurrences are observed 5-10 years after treatment. Start follow-up care at regular intervals for at least 5 years after initial management. Nasal endoscopy is essential for follow-up and monitoring for disease recurrence.

Complications

Complications can occur after surgical resection of sinonasal papillomas (SPs). The most serious complications are related to the orbit. Blepharitis, diplopia, and intermittent dacryocystitis have been reported after lateral rhinotomy and medial maxillectomy. Ectropion can result secondary to scarring with a downward pull of the lower lid. CSF leak can develop if the base of the skull is violated during surgery.

Late complications include prolonged crusting, infection, nasocutaneous fistula, vestibular stenosis, and nasal-valve collapse.

The most common complication after the midfacial degloving procedure is vestibular stenosis. Oroantral fistula, intermittent paresthesia, and prolonged crusting can also occur.

Endoscopic resection poses the same risk of any endoscopic sinus surgery. Potential complications include CSF leak, orbital complications (orbital or periorbital hematoma, diplopia, injury to the optic nerve, injury to the extraocular muscle, epiphora) prolonged crusting, bleeding, infection, and synechia.

Future and Controversies

The advent of nasal endoscopy, with strong illumination, superior resolution, and angled visualization, together with advances in CT scanning and MRI, have led to precise identification, good localization, and successful resection of intranasal lesions (including SPs) by using an endoscopic approach.

Many reports in the literature support successful treatment of SPs with endoscopic sinus surgery. Preoperative CT scanning and MRI allow for an accurate assessment of the extent of the lesion and, hence, allow for improved selection of the lesions appropriate for endoscopic resection. MRI can help in clearly distinguishing a tumor from opacification secondary to obstructive sinusitis. Endoscopic resection may include total sphenoethmoidectomy, wide meatotomy, resection of the middle turbinectomy, and visualization of the frontal sinus. Some have advocated sampling of the margins. All specimens should be sent for histopathologic examination to ensure complete removal of papillomatous lesions.

Authors of a new study advocate the use of a microdebrider with endoscopic sinus surgery to resect SPs. The various tissues resected and suctioned through the microdebrider must be collected in a separate container and sent for histopathologic study to rule out malignancy. The different tissue entities resected by using the microdebrider do not lose their important morphologic features.

Investigators continue to endorse the endoscopic approach as a feasible and effective approach for the treatment of sinonasal papilloma. The technique is increasing refined and tailored to the extent of the disease, and systematic and well-defined steps to reproducibly perform endoscopic medial maxillectomy are defined. Authors with long-term experience with the open approaches are also performing endoscopic approaches with comparable or improved success.

The advantages of the endoscopic transnasal approach over traditional medial maxillectomy are the lack of an external scar and its related potential for cosmetic deformity; shortened hospitalization; decreased blood loss; and ability to directly visualize the precise extent of the tumor, which increases the likelihood of complete resection. Furthermore, the reported recurrence rate of SPs after endoscopic resection (approximately 17%) is comparable with that of the standard technique of lateral rhinotomy and medial maxillectomy.

The endoscopic approach had already been successful in papillomatous lesions confined to the lateral nasal wall or minimally extending into adjacent paranasal sinuses. Reports also suggest its effectiveness in more advanced disease. Involvement of the maxillary sinus is no longer considered a contraindication to endoscopic or endoscopy-assisted surgery. Some authors have suggested the addition of the Caldwell-Luc procedure to the endoscopic approach when the anterior or posterolateral maxillary sinus is involved. The presence of carcinoma in the endoscopically resected specimen likely indicates a need for more aggressive treatment, depending on the size and location of the carcinomatous foci. For tumors that arise from the frontal sinus, endoscopic sinus surgery is similarly contraindicated.

Detailed preoperative assessment of the extent of the lesion with CT and/or MRI helps in selecting and individualizing the approach for each patient. In addition, the skill and experience of the surgeon with regard to a particular procedure are important factors in selecting the right approach for each patient.

For additional information, see Human Papillomavirus.