Several articles have showed the benefit of extranasal medial maxillectomy versus intranasal removal of inverted papilloma affecting either the ethmoid or maxillary sinuses, or both.1-6 Before the advent of the use of endoscopes for nasal and sinus diagnosis and surgery, there was no better way to control inverting papilloma, hence the need for extranasal medial maxillectomy. Treatment trials using a Caldwell-Luc operation and intranasal removal were not as successful as the extranasal medial maxillectomy.7'8 Extranasal medial maxillectomy recurrence rates were 9 to 42% versus 10 to 100% intranasally.2-10 Adding to the problem was information from Vrabec6 that a follow-up of at least 6 years was necessary to ensure local control. These data led to reflection on why extranasal surgery recurrences in some cases were as low as 10% and as high as 42% and on why intranasal surgery recurrences were as low as 10% and as high as 100%. The answers lie in the location of tumor, the surgeries done, and the control of disease. What one learns in reviewing these various studies is that optimal management of nasal and sinus inverting papilloma requires a number of considerations:

1. Inverting papilloma is not multicentric, as opposed to non-inverting papilloma, and will usually arise from one area (unifocal) and spreads sinus to sinus.6,7,11 This tumor can destroy bone, and it can be aggressive.

* Thanks are due to Ms. Susan Whelton for her assistance in manuscript preparation.

2. The most common site of inverting papilloma is the ethmoid sinus.6'7'11

3. Spread into the maxillary sinus is through the antrostomy and usually is limited to the medial wall.7'11 Spread can also occur through the fontanelle, with aggressive progression into the maxillary sinus.6

4. Disease spread or extension, or disease primarily occurring in the maxillary sinus away from the medial wall' in most cases cannot be cured by an intranasal surgery.1-3'6

5. Limited disease in the nose, turbinate, septum, or ethmoid sinus with a clean maxillary sinus on radiologic evaluation should be considered for intranasal removal.1,3,4-8

6. Contiguous sinuses to areas of tumor location require surgical evaluation to rule out spread of disease into those sinuses, with upper ethmoid tumor requiring frontal recess evaluation and biopsy,6,7,11 posterior ethmoid tumor requiring sphenoid sinus evaluation and possible biopsy,6,7,11 and anterior ethmoid tumor requiring evaluation and possible biopsy of maxillary sinus.6,7,11

7. The use of advanced radiographic studies such as computed tomography (CT) scanning with contrast and magnetic resonance imaging (MRI) with contrast can help identify tumor extent, allowing for better surgical planning.3,12,13 This is especially helpful in finding tumor extending into the frontal, sphenoid, or maxillary sinus as opposed to fluid or sinusitis secondary to ostia blockage.1

8. For the average practitioner, any inverting papilloma involving the ethmoid and maxillary sinus requires an extranasal ethmoidectomy and medial maxillectomy for optimum results.2,3,6

9. Endoscopy can offer excellent intranasal visualization, allowing for earlier diagnosis of inverting papilloma resulting in less extensive surgery in specific cases.1,4,5,14

10. Tumor limited to the nose and ethmoid sinus is amenable to precise endoscopic removal in experienced hands.1,3-5,8,14,15

11. Tumor limited to the ethmoid sinus or medial wall of the maxillary sinus, or both, is amenable to endoscopic eth-moidectomy and medial maxillectomy in experienced hands.14

12. Tumor extensively involving the maxillary sinus requires removal of all mucosa. This tumor requires an extranasal lateral rhinotomy or degloving approach to medial maxillectomy with possible Caldwell-Luc procedure.2,3,6,16 Performed by a surgeon experienced with endoscopy, the endoscopic medial maxillectomy can be used with the Caldwell-Luc.1,14

13. The use of computerized stereotaxic endoscopic technique improves tumor removal and control.17

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