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Endoscopic Approach of the Inverted Papilloma - a continuos challenge for the ENT practitioner
Vlad Andrei Budu1*, Ioan Alexandru Bulescu2, Mihail Tusaliu2
1University of Medicine and Pharmacy, Romania
2University of Medicine and Pharmacy Carol Davila Bucharest, Romania
Submission: February 04, 2017; Published: February 07, 2017
*Corresponding author: Vlad Andrei Budu, University of Medicine and Pharmacy, Carol Davila, 14 Eroilor Blvd., Bucharest, Romania, Tel: +40788413218;Email: email@example.com
How to cite this article: V A Budu, Ioan A B, Mihail T. Endoscopic Approach of the Inverted Papilloma - a continuos challenge for the ENT practitioner. Glob J Oto 2017; 3(5): 555623. DOI: 10.19080/GJO.2017.03.555623
Inverted papilloma is a benign tumor arising from the epithelium of the nose and sinuses with a slow growing pattern and a confirmed viral etiology (Human Papilloma Virus) in more than 80% of patients. The main characteristics of inverted papilloma are represented by important distruction of surrounding structures, high risk of reccurence and malignant degeneration. In more than 180 cases of inverted papilloma which I approached endoscopically, I got the experience to emphasize on some tips and tricks regarding the diagnosis and surgical treatment of this sinonasal tumor.
Phisical and endoscopic exam of the nasal cavity reveals a raddish gray polipoid mass with friable apparence and bleeding history which usually causes unilateral nasal obstruction and epistaxis. CT-scan is considered to be the gold-standard investigation and provides complete data on the dimensions and extensions of the tumor, the involvment of the bony structures and the bony stalk or focal hyperostosis which correspond to the origin of the tumor (Figures 1 & 2).
Staging: In all our patients we used Krouse Staging System for inverted papilloma and that allowed us to decide the proper surgical technique for each case in particular. In our series the most frecquent situation was Krouse Stage III, and we could perform an accurate surgical procedure for complete removal of the tumor.
Endoscopic Sinus Surgery: Usually, while dealing with an inverted papilloma (stage I-III) we do not perform routinely a biopsy in before surgery, our surgical protocol is to harvest tumoral fragments for frozen sections. Endoscopic sinus surgery assures complete removal of the tumor and the adjacent mucosa, drilling of the underlying bone and mandatory the bony stalk (origin of the inverted papilloma) (Figures 3 & 4).
In Krouse Stages II and III medial maxillectomy is the gold standard for surgical approach, completed when necessary with ethmoidectomy (anterior or total), frontal recess and frontal sinus endoscopic approach and sphenoidotomy. It is not indicated an endoscopic approach for inverted papilloma situated in the lateral part of the frontal sinus.
Human Papilloma Virus: We performed a HPV-genotype
from every removed specimen in order to find the presence
of viral DNA at the tumor site. HPV is a virus with epithelial
tropism which determins premalignant or malignant lesions
in anogenital tract, but in nasosinusal region it is associated to
a high risk of reccurence and malignant transformation of the
The most frecquent question regarding inverted papilloma
is if we are dealing with reccurences of left overs. We had in our
series reapparence of the tumor after precise surgical tehnique
and also in early stages. There was no reason for reccurencein that particular cases so we are thinking more often as
microscopic fragments of tumor or mucosa with parts of viral-
DNA, which can not be seen during surgery, but exist and react
just like tumoral left-over. We also noticed in our series that
patients which already had a reccurence, have a greater risk for
another one. So reccurence can be explained by the presence
of intracellular viral-DNA, as a constant HPV infection in the
It was thought in the past that malignant transformation
of the inverted papilloma is due to the numerous surgical
procedures suffered by the patient. Nowadays we find and
confirm in lab (in situ DNA hybridization) in tumor fragments
or surrounding mucosa low risk subtypes (HPV6, HPV11) and
high risk subtypes (HPV16, HPV18) which are responsable for
malignant transformation of the inverted papilloma.
In this challenge with the inverted papilloma I faced
treatment begins when the tumor is on site and
in most of the cases surgical treatment is not enough
so we developed a protocol which consists in a multimodal
treatment: surgery, antiviral treatment (Interferon,
Cidofovir,etc), and antiangiogenetic factors (Bevacizumab)
we do not have yet no protocol to prevent malignant
degeneration of the inverted papilloma
Instead of conclusion I will launch some questions:
how can we manage HPV infection prophilaxis in
how can we predict which of our patient with HPV
infection in nasal mucosa will develop inverted papilloma?
which is the best therapeutic solution for a patient with
complete removal of an inverted papilloma with high risk HPV