Sinonasal Papillomas Treatment & Management

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. ^{[16, 17]}

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. ^[18]

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. ^[19] A recent meta-analysis and another systematic literature review support endoscopic approach as a favorable treatment option compared with open approaches. ^{[20, 21, 22, 23]}

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. ^{[24, 25]}

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. ^[19] 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 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).

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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 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).

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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 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).

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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 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).

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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 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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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.

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 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.

A retrospective study by Rozendorn et al indicated that in patients with SPs who undergo revision surgery, those who have concomitant mucosal inflammation have a significantly lower rate of 5-year recurrence-free survival than do those without inflammation (80.6% vs 100%, respectively). However, in study patients undergoing primary surgery, there was no statistically significant difference in recurrence rate between those with mucosal inflammation and those without (15.4% vs 7.5% respectively). ^[26]

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.

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 (HPV).