[Downloaded free from http://www.azmj.eg.net on Sunday, March 22, 2020, IP: 36.68.239.
68]
Incidence of nasal inverted papilloma in unilateral nasal lesions
in Damietta Governorate
Wael F. Ismaeil, Mohamed H. Abd El Azim
Otorhinolaryngology Department, Faculty of
Medicine, Al Azhar University, New Damietta,
Egypt
Correspondence to Wael F. Ismaeil, MD,
Otorhinolaryngology Department, Faculty of
Medicine, Al Azhar University, New Damietta,
34517, Egypt. Tel: 01007026058; fax:
0473860840;
e-mail: dr_mallah@hotmail.com
Received 8 April 2018
Accepted 19 June 2018
Al-Azhar Assiut Medical Journal 2018,
16:33–37
Introduction
Unilateral sinonasal symptoms, nasal mass or polyp or
sinus opacity, are common presentations in the
otolaryngological department. The etiology is usually
an inflammatory condition that can be managed
conservatively with medical treatment, with few
patients requiring surgical intervention [1].
The presence of unilateral symptoms or pathology is
regarded with caution, as sinonasal neoplasms may also
present during their early stages with subtle symptoms
that mimic an inflammatory pathology [2].
Sinonasal inverted papilloma (IP) is a benign tumor
arising in the Schneiderian membrane, lining the
nasal cavity and paranasal sinuses. IP is clinically
important owing to its high rate of recurrence
(20–47%), locally aggressive nature, and association
malignancy (∼2–7%) [3].
According to the WHO, sinonasal papilloma is
classified into three different histopathological
© 2018 Al Azhar Assiut Medical Journal | Published by Wolters Kluwer - Medknow
Original article 33
Background
Unilateral nasal lesions are a characteristics group that need special attention from
ear, nose and throat surgeons. Inverted nasal papilloma is one of such lesions.
However, its incidence and pattern are not well-defined in Egypt.
Aim
To estimate the incidence of inverted nasal papilloma among patients with unilateral
nasal lesions.
Patients and methods
A prospective analysis of patients presented and treated owing to unilateral nasal
lesion was conducted in a 2-year duration. Patient demographics, clinical
presentation, and histopathological diagnoses were document.
Results
There were 117 (53 males and 64 female) patients with unilateral nasal lesions. The
mean age was 44.14 (±10.80) years. Nasal obstruction was reported in 50.4%,
nasal discharge in 17.1%, epistaxis in 12%, and facial pain in 5.1%. The lesion was
inflammatory in 79.5% and neoplastic in 20.5%. The most common inflammatory
lesion was chronic rhinosinusitis (44.4%), whereas the most common neoplastic
lesion was inverted papilloma in 10.3%, and squamous cell carcinoma in 4.3%.
However, males were significantly higher in neoplastic and inverted nasal
papilloma. Nasal obstruction was increased in inflammatory lesions, whereas
nasal discharge, facial pain, and epistaxis were increased in neoplastic group.
Conclusion
Inverted nasal papilloma was reported in 10.3%. It had male predilection and
usually presented in the fifth decade, and nasal discharge, epistaxis, and facial pain
were significantly associated with the disease.
Keywords:
chronic rhinosinusitis, inverted papilloma, mucocele, nasal polyp, unilateral nasal disease
Al-Azhar Assiut Med J 16:33–37
© 2018 Al-Azhar Assiut Medical Journal
1687-1693
groups: exophytic papilloma (fungiform, septal, and
squamous papilloma), inverted (inverting) papilloma,
and oncocytic papilloma (cylindrical cell and columnar
papilloma). IP is the most common among these
groups and generally appears as a large, polypoid
mass with a grayish color and an uneven
multinodular surface [4].
IPs are found mostly in the maxillary sinus, the
ethmoid sinus, and the lateral nasal wall. The
medical treatment has no or limited role in inverted
nasal papilloma. In addition, surgery type is not always
fixed, for example, open or endoscopic. However,
surgery type could be chosen according to tumor
size, location, invasion of surrounding tissues, or
surgeon expertise [5].
This is an open access journal, and articles are distributed under the terms
of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0
License, which allows others to remix, tweak, and build upon the work
non-commercially, as long as appropriate credit is given and the new
creations are licensed under the identical terms.
DOI: 10.4103/AZMJ.AZMJ_21_18
[Downloaded free from http://www.azmj.eg.net on Sunday, March 22, 2020, IP: 36.68.239.68]
34 Al-Azhar Assiut Medical Journal, Vol. 16 No. 1, January-March 2018
Aim
This study aimed to assess the incidence of IPs in the
nose and paranasal sinuses among patients with
unilateral nasal lesions in Damietta Governorate.
Patients and methods
A prospective study of all cases of unilateral nasal lesion
in the Department of Otorhinolaryngology (Al-Azhar
University Hospital, New Damietta) during the period
from January 2016 to January 2018 was carried out.
In our institution, all patients with unilateral sinonasal
symptoms were documented by detailed history taking
followed by complete ear, nose and throat examination,
Figure 1
Computed tomography scan, coronal cut, bone window, showing
unilateral mucosal thickening of the maxillary sinus (chronic sinusitis).
Figure 2
Computed tomography scan, axial cut (a) and coronal cut (b) showing maxillary sinus expansion (mucocele).
which included detailed nasal examination by anterior
and posterior rhinoscopy and diagnostic nasal
endoscopy. Patients with unilateral nasal mass/polyp
were further assessed radiologically by computed
tomography scan of paranasal sinuses (Figs 1–4).
Patients presenting with inflammatory conditions were
managed medically or surgically by endoscopic sinus
surgery. Neoplastic lesions were treated by endoscopic
biopsy followed by definitive management depending
on the histopathological diagnosis. The patients were
grouped according to their clinical and histopathological
diagnosis as inflammatory (sinusitis, antrochoanal polyp,
and mucocele) and neoplastic. For each patient, the
demographic data, presenting symptoms, and
radiological findings were documented.
Data analysis
Data were documented on an excel sheet. They were
coded and statistically analyzed by statistical package
for social science (version 22; IBM SPSS Inc., Chicago,
Illinois, USA). Numerical variables were presented as
arithmetic mean and SD, whereas categorical variables
were presented as relative frequency and percent
distribution. The Student (t) and the χ 2-tests were
used for comparison. The level of significance was P
value of less than 0.05.
Results
The present study included 117 participants who
presented with unilateral nasal lesion; 53 (45.3%)
were males and 64 (54.7%) were females. Patient
age ranged from 12 to 65 years, and the mean
(±SD) age was 44.05 (±11.04) years. Nasal
obstruction was reported in 20.5% of studied
participants, nasal discharge in 17.1%, epistaxis in
12%, facial pain in 5.1%, and eye symptoms in
[Downloaded free from http://www.azmj.eg.net on Sunday, March 22, 2020, IP: 36.68.239.68]

Incidence of nasal IP in unilateral nasal lesions in Damietta Governorate Ismaeil and Abd El-Azim 35

Figure 3 Table 1 Distribution of the collected data in the studied

populations
Variables Statistics
Sex (male : female) [n (%)] 53 (45.3) : 64 (54.7)
Age 44.04±11.04 (12–65)
Symptoms [n (%)]
Nasal obstruction 24 (20.5)
Nasal discharge 20 (17.1)
Facial pain 6 (5.1)
Epistaxis 14 (12.0)
Eye symptoms 4 (3.4)
Lesion [n (%)]
Inflammatory 93 (79.5)
Neoplastic 24 (20.5)

Table 2 Types of pathological lesion in the studied

populations
Computed tomography scan, coronal cut, bone window showing left Pathology n Total (%) Pathology (%)
antrochoanal polyp.
Inflammatory
Chronic rhinosinusitis 56 47.8 60.2
Figure 4 Antrochoanal polyp 23 19.7 24.7
Fungal sinusitis 11 9.0 11.8
Mucocele 3 2.6 12.5
Neoplastic
Inverted papilloma 12 10.3 50.0
SCC 5 4.3 20.8
Adenocarcinoma 4 3.4 16.7
NHL 3 2.6 12.5
NHL, non Hodgkin’s lymphoma; SSC, squamous cell carcinoma.

significantly increased in neoplastic lesions (87.5 vs.

3.2%). In addition, nasal discharge, facial pain and
Computed tomography scan, coronal cut, bone window, showing epistaxis were significantly increase in neoplastic when
opacity of left maxillary and ethmoid sinuses of proved inverted
papilloma. compared with inflammatory group (Table 3).

When comparing IP with other unilateral lesions, there

3.4%. The lesion was inflammatory in 79.5% and
neoplastic in 20.5% (Table 1).
Regarding clinical and pathological diagnosis, the
inflammatory lesions were in the form of chronic
rhinosinusitis in 47.8% of total samples,
antrochoanal polyp in 19.7%, fungal sinusitis in
9.0% and mucocele in 2.6%. On the contrary,
neoplastic lesions were in the form of IP in 10.3%,
squamous cell carcinoma (SCC) in 4.3%,
adenocarcinoma in 3.4%, and non Hodgkin’s
lymphoma (NHL) in 2.6% (Table 2).
Comparing inflammatory with neoplastic lesions, there
was no significant difference between both groups
regarding patient age and eye symptoms. However,
the number of males was significantly increased among
those having neoplastic when compared with
inflammatory lesions, and nasal obstruction was
was no significant difference regarding patient age and
eye symptoms; however, the number of males was
significantly increased in those with IP, and nasal
obstruction, nasal discharge, facial pain and epistaxis
were significantly increased in IP when compared with
other lesions (Table 4).
Discussion
A patient presenting with unilateral nasal lesion
represents a clinical challenge owing to variation in
the underlying etiology. Thorough evaluations of the
patient age, the presenting symptoms, and endoscopic
and radiological examination help in the diagnosis of
unilateral nasal disease [6].
Results of the present study revealed that unilateral
nasal lesions were slightly common in females than
males. These results are in contradiction to Lathi et al.
[Downloaded free from http://www.azmj.eg.net on Sunday, March 22, 2020, IP: 36.68.239.68]

36 Al-Azhar Assiut Medical Journal, Vol. 16 No. 1, January-March 2018

Table 3 Comparison between inflammatory and neoplastic lesions regarding patient age, sex, and presenting symptom(s)
Inflammatory (93) Neoplastic (24) Statistics
Test P value
Sex [n (%)]
Male 38 (40.9) 15 (62.5) 3.60 0.048*
Female 55 (59.1) 9 (37.5)
Age 44.19±11.07 43.95±9.93 0.094 0.92
Symptoms [n (%)]
Nasal obstruction 3 (3.2) 21 (87.5) 83.09 <0.001*
Nasal discharge 9 (9.7) 11 (45.8) 17.95 <0.001*
Facial pain 1 (1.1) 6 (25.0) 19.41 <0.001*
Epistaxis 4 (4.3) 10 (41.7) 25.28 <0.001*
Eye symptoms 2 (2.2) 2 (8.3) 2.20 0.13
*Significant.

Table 4 Comparison between inverted papilloma and other unilateral lesions regarding studied variables
Inverted papilloma (12) Other unilateral lesions (105) Statistics
Test P value
Sex [n (%)]
Male 10 (83.3) 43 (41.0) 7.80 0.005*
Female 2 (16.7) 62 (59.0)
Age 45.08±7.25 44.03±11.16 0.31 0.75
Symptoms [n (%)]
Nasal obstruction 10 (83.3) 14 (13.3) 32.36 <0.001*
Nasal discharge 6 (50.0) 14 (13.3) 10.21 0.001*
Facial pain 3 (25.0) 4 (3.8) 8.95 0.003*
Epistaxis 4 (33.3) 10 (9.5) 5.78 0.016*
Eye symptoms 1 (8.3) 3 (2.9) 0.97 0.32

[7] who reported that sinonasal lesions had predilection
for males, demonstrating a male to female ratio of 1.5 :
1. It was even higher in the study of Zafar et al. [8] (1.7 :
1). However, these results are in agreement with Bakari
et al. [9] who reported male : female ratio of 1 : 1.2.
In the present work, unilateral inflammatory lesions
were the most common (79.5%), whereas neoplastic
lesions represented 20.5%. These findings are in
accordance with those reported by Euteneuer et al.
[10] who reported that most sinonasal lesions are
mainly inflammatory in nature.
Regarding symptoms, nasal obstruction was the most
common, reported in 20.5% of studied participants,
nasal discharge in 17.1%, epistaxis in 12%, and facial
pain in 5.1%. These results are comparable to the
findings of Nair et al. [11] who reported that
patients with unilateral nasal lesions presented with
different nasal symptoms like nasal obstruction, nasal
discharge, epistaxis, hyposmia, and headache. They
added nasal obstruction was the commonest
symptom in both the inflammatory and neoplastic
groups. Epistaxis and extranasal symptoms were
found to be higher in the neoplastic conditions.
However, in the neoplastic group, nasal discharge
was the most common followed by facial pain and
then nasal discharge. Lathi et al. [7] also reported that
the most common presentations of the sinonasal
masses were nasal obstruction (97.3% cases),
rhinorrhea (49.1%), hyposmia (31.3%), and headache
(16.9%).
On the contrary, Tritt et al. [12] studied unilateral nasal
polyposis and found epistaxis is significantly
association with neoplastic lesions.
In the present work, the inflammatory lesions were in
the form of chronic rhinosinusitis in 47.8% of total
populations, antrochoanal polyp in 19.7%, fungal
sinusitis in 9.0%, and mucocele in 2.6%. On the
contrary, neoplastic lesions were in the form of IP in
10.3%, SCC in 4.3%, adenocarcinoma in 3.4%, and
NHL in 2.6%. These results are in agreement with
Nair et al. [11] who found that inflammatory
conditions like acute and chronic rhinosinusitis
(bacterial or fungal) were the most common diagnosis.
In the present study, neoplastic lesions and inverted
nasal papilloma were more prevalent among male
[Downloaded free from http://www.azmj.eg.net on Sunday, March 22, 2020, IP: 36.68.239.68]
Incidence of nasal IP in unilateral nasal lesions in Damietta Governorate Ismaeil and Abd El-Azim
patients. However, the age was nonsignificantly
different (both were prevalent in the fifth decade).
These results are in accordance with Ungari et al.
[13] who reported that IP prevails in the fifth
decades and males are affected 4–5 times than females.
In the present work, the incidence of inverted nasal
papilloma was 10.3% of all unilateral nasal lesions. In
their work, Nowosielska-Grygiel et al. [5] reported
that, of 3,574 patients who underwent endoscopic
sinus surgery owing to chronic inflammatory
diseases, IPs were found in 80 patients (2.23%; 31
women, 38.75%; 49 men, 61.25%). Sex distribution in
their study was comparable to the present work.
However, the incidence of IP is very low when
compared with the present study. This can be
attributed to different inclusion criteria, as we
included only unilateral nasal lesions, whereas
Nowosielska-Grygiel et al. [5] included both
unilateral and bilateral chronic inflammatory lesions.
In addition, the authors reported that 96.25% of
patients with IP had unilateral whereas 3.75% had
bilateral papillomas. These findings reflected that
the nature of IP is usually unilateral; hence, the
importance to search its incidence in the unilateral
lesions.
Dammann et al. [14] reported that IP comprises ∼4%
of all nasal polyps. Barnes et al. [15] reported that IP in
sinonasal cavity tumors represents 0.4–7.0%. Again the
low incidence than the present work is owing to
different inclusion criteria.
The importance of this study relied on the fact that, it
included only unilateral nasal lesions, which represent a
specific group that needs special attention from
otorhinolaryngologists. The characterization of
inverted nasal papilloma can help in early
intervention with favorable outcome.
Conclusion
Inverted nasal papilloma represented 10.3% of all
unilateral nasal lesions reported in the present work.
37
It is more common in males, usually presented in fifth
decade of life, and nasal discharge, epistaxis, and facial
pain were significantly associated with the disease.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
1 Kaplan BA, Kountakis SE. Diagnosis and pathology of unilateral maxillary
sinus opacification with or without evidence of contralateral disease.
Laryngoscope 2004; 114:981–5.
2 Karthikeya P, Mahima VG, Bhavna G. Sinonasal verrucous carcinoma with
oral invasion. Indian J Dent Res 2006; 17:82–6.
3 Yu MS, Lim WS, Lee BJ, Chung YS. Squamous cell carcinoma associated
with inverted papilloma of the maxillary sinus: our experience with 21
patients. Clin Otolaryngol 2017; 42:1048–1052.
4 Shanmugaratnam K, Sobin LH. The World Health Organization histological
classification of tumours of the upper respiratory tract and ear. A
commentary on the second edition. Cancer 1993; 71:2689–97.
5 Nowosielska-Grygiel J, Pietkiewicz P, Owczarek K, Olszewski J, Miłoński J.
Diagnosis and treatment of nasal and paranasal inverted papillomas −
epidemiology and own experience. Otolaryngol Pol 2017; 71:27–32.
6 Lee JY. Unilateral paranasal sinus diseases: analysis of the clinical
characteristics, diagnosis, pathology, and computed tomography
findings. Acta Otolaryngol 2008; 128:621–6.
7 Lathi A, Syed MM, Kalakoti P, Qutub D, Kishve SP. Clinico-pathological
profile of sinonasal masses: a study from a tertiary care hospital of India.
Acta Otorhinolaryngol Ital 2011; 31:372–7.
8 Zafar U, Khan N, Afroz N, Hasan SA. Clinicopathological study of non-
neoplastic lesions of nasal cavity and paranasal sinuses. Indian J Pathol
Microbiol 2008; 51:26–9.
9 Bakari A, Afolabi OA, Adoga AA, Kodiya AM, Ahmad BM. Clinico-
pathological profile of sinonasal masses: an experience in national ear
care center Kaduna, Nigeria. BMC Res Notes 2010; 3:186.
10 Euteneuer S, Sudhoff H, Bernal-Sprekelsen M, Theegarten D, Dazert S.
Malignomas of the nasal cavity and the paranasal sinuses: clinical
characteristics, therapy and prognosis of different tumor types.
Laryngorhinootologie 2004; 83:33–9.
11 Nair S, James E, Awasthi S, Nambiar S, Goyal S. A review of the
clinicopathological and radiological features of unilateral nasal mass.
Indian J Otolaryngol Head Neck Surg 2013; 65(Suppl 2):199–204.
12 Tritt S, McMains KC, Kountakis SE. Unilateral nasal polyposis: clinical
presentation and pathology. Am J Otolaryngol 2008; 29:230–2.
13 Ungari C, Riccardi E, Reale G, Agrillo A, Rinna C, Mitro V, et al.
Management and treatment of sinonasal inverted papilloma. Ann
Stomatol (Roma) 2015; 6:87–90.
14 Dammann F, Pereira P, Laniado M, Plinkert P, Löwenheim H, Claussen
CD. Inverted papilloma of the nasal cavity and the paranasal sinuses: using
CT for primary diagnosis and follow-up. Am J Roentgenol 1999; 172:543–8.
15 Barnes L, Eveson J, Reichart P, Sidransky D. World Health Organization
Classification of Tumors. Pathology and genetics of head and neck tumors.
Lyon: IARC Press 2005.