4.4 Inverted Papillomas
Key Features
An inverted papilloma is a soft tissue neoplasm often arising from the lateral nasal wall.
It is benign but can be locally aggressive.
Malignant degeneration can occur.
An inverted papilloma is considered a benign neoplasm. However, reports suggest that as many as 10 to 20% of cases can contain, or degenerate to, in situ or invasive squamous cell carcinoma. Thus, complete surgical removal is the treatment of choice.
Epidemiology
Males are affected three times more frequently than females. The tumor is more common in older adults.
Clinical
Signs
The patient presents with a polypoid unilateral intranasal mass. Any patient presenting with a unilateral nasal mass should raise suspicion for neoplasm. Allergic fungal sinusitis may present unilaterally as well.
Symptoms
The patient has a unilateral nasal obstruction, with or without sinusitis. Rhinorrhea and/or epistaxis may occur. Histologically, an inverted papilloma consists of in-folded epithelium that may be squamous, transitional, or respiratory.
Differential Diagnosis
The differential diagnosis includes an inverted papilloma, fungiform papilloma (often arises from anterior nasal septum), cylindrical papilloma (often arises from lateral wall; rare tumor), minor salivary gland benign or malignant tumors, lacrimal sac tumors, olfactory neuroblastoma, carcinoma such as squamous cell carcinoma or sinonasal undifferentiated carcinoma, mucosal melanoma, chondrosarcoma, angiofibroma, inflammatory nasal polyp, allergic fungal rhinosinusitis. Other tumors include schwannomas, hamartomas, giant cell granulomas, neurofibromas, and chondromyxoid fibromas.
Evaluation
History
A standard history is taken.
Physical Exam
A full head and neck exam is done, with attention paid to the cranial nerves. Nasal endoscopy with a rigid 0° or 30° endoscope will be useful to assess the intranasal extent and location of soft tissue mass. After imaging excludes possible encephalocele, a biopsy may be obtained in the office or operating room.
Imaging
Computed tomography (CT) provides bony detail and is reviewed with attention to erosive changes at the orbit and skull base. Magnetic resonance imaging (MRI) is helpful in assessing soft tissue tumor extent and can distinguish between inspissated secretion and tumor. CT will often overestimate tumor extent. Images should be reviewed in axial, coronal, and sagittal planes.
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