For most surgeons, the treatment of inverting papilloma affecting the ethmoid and maxillary sinuses is not controversial. The treatment is ethmoidectomy with medial maxillectomy. The extranasal approach is the safest and surest way to accomplish total tumor removal. For a handful of skilled surgeons, the eth-moidectomy and medial maxillectomy can be accomplished endoscopically. Both approaches should be guided by frozen-section biopsy.

Tumor can hide laterally, anteriorly, or posteriorly in the maxillary sinus and may be missed even with extranasal medial maxillectomy, leading to recurrence. These areas need to be visualized with direct vision via a Caldwell-Luc operation or with angled telescopes at the end of surgery to ensure that all tumor has been removed. Endoscopic observation used during and after surgery can often identify precisely where inverting papilloma originated, ensuring complete removal. Endoscopic follow-up can identify recurrent disease that may be amenable to an endoscopic salvage if medial maxillectomy has already been performed. Tumor uncontrolled with proper extensive surgery can be followed, biop-sied, debulked, and debrided using endoscopic techniques. Inverting papilloma that does not involve the maxillary sinus is amenable to endoscopic removal. Any ethmoidectomy must be accompanied by mucous membrane removal to bone or even lamina papyracea removal. State-of-the-art imaging using CT and MRI scanning can identify tumor extension into contiguous sinuses, aiding in surgical planning. Computerized stereotactic surgery can precisely identify all pockets of disease as well as orbit, skull base, optic nerve, and carotid artery, assisting with tumor removal in hazardous anatomic sites. Radiation therapy should be reserved for inverted papilloma with frank carcinoma, carcinoma in situ that cannot be removed, and diffuse uncontrolled inverting papilloma.


Stankiewicz—CHAPTER 5

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2. Lawson W, Ho BT, Shaari CM, Biller HF. Inverted papilloma: a report of 112 cases. Laryngoscope 1995;105:282-288

3. Bielamowicz S, Calcaterra TC, Watson D. Inverted papilloma of the head and neck: UCLA update. Otolaryngol Head Neck Surg 1993;109:71-76

4. Waitz G, Wigand M. Results of endoscopic sinus surgery for the treatment of inverted papilloma. Laryngoscope 1992;102:917-922

5. Kamel RH. Conservative endoscopic surgery in inverted papilloma. (OtolaryngolHead Neck Surg 1992;118:649-653

6. Vrabec DP. The inverted Schneiderian papilloma: a 25-year study. Laryngoscope 1994;104:582-605

7. Buchwald C, Franzmann MB, Tos M. Sinonasal papillomas: a report of 82 cases in Copenhagen county. Laryngoscope. 1995;105:72-79

8. Ravel E, Feinmesser R, Shpitzer T, Yaniv E, Segal K. Inverted papilloma of the nose and paranasal sinuses: a study of 56 cases and review of the literature. Israel J Med Sci 1996;32: 1163-1167

9. Siegel R, Atar E, Mor C. Inverted papilloma of the nose and paranasal sinuses. Laryngoscope 1986;96:358-394

10. Suh K, Facer G, Device K. Inverted papilloma of the nose and paranasal sinuses. Laryngoscope 1977;87:35-46

11. Hyams V. Papillomas of the nasal cavity and paranasal sinuses: a clinicopathological study of 315 cases. Ann RhinolLaryngol 1971;80:192-206

12. Woodson J, Robbins K, Michael L. Inverted papilloma. Arch Otolaryngol 1985;111:806-811

13. Woodruff WW, Vrabec DP. Inverted papilloma of the nasal vault and paranasal sinuses: a spectrum of CT findings. AJR 1994;161:419-423

14. Kamel RH. Transnasal endoscopic medial maxillectomy in inverted papilloma. Laryngoscope 1995;105:847-853

15. Ouzen KE, Grontveld A, Jorgensen K, Clausen PP, Lode-forged C. Inverted papilloma: in advanced and late results of surgical treatment. Rhinology 1996;34:114-118

16. Krause DH. Lateral rhinotomy approach to inverted papilloma. Am J Rhinol 1995;9:77-80

17. Petruzzelli G, Origitano TC, Stankiewicz, JA, McSherry D, Anderson DE. Frameless stereotactic localization in cranial base surgery. Skull Base Surgery 2000;10:125-129

18. Guedea F, Mendenhall WM, Parsons J. The role of radiation therapy in inverted papilloma of a nasal cavity and paranasal sinuses. Int J Radiat Oncol 1991;20:777-780

The inverting Schneiderian papilloma has been recorded in the medical literature for more than a century and remains a topic of controversy.1 It is generally accepted that inverting papilloma is a benign tumor of the sinonasal tract mucosa that is locally aggressive and has significant malignant potential. It is an uncommon lesion in which proliferated epithelial reserve cells invert into the underlying stroma rather than growing outwardly from the surface.2 Inverting papilloma is derived from sinonasal (Schneiderian) mucosa, formed from the invaginating ectoderm of the olfactory plates at the end of the fourth week of embryonic life.1 The neoplastic epithelium may be of a respiratory, transitional, or squamous type. Inverting papillomas most often arise from the lateral nasal wall in the area of the middle turbinate and may extend into the maxillary and ethmoid sinuses. In most cases, this slow-growing tumor is unilateral.3

Inverting papillomas are unique, characterized by their capacity to destroy bone by pressure erosion.4 They are also associated with squamous cell carcinoma and have a tendency to recur if incompletely excised. Lesperance and Esclamado5 retrospectively found squamous cell carcinoma with inverting papillomas in 27% of cases in their study.

Questions that remain unanswered regarding inverting papilloma include its etiology, malignant potential, and appropriate management.

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