The Journal of Laryngology and Otology

October 1988. Vol. 102. pp. 938-940

Squamous carcinoma of the sphenoid sinus in association

with inverted papillomatosis
J. H. DEMPSTER, F.R.C.S., and K. MACKENZIE, F.R.C.S. (Glasgow)

Introduction
Malignant lesions of the nose and paranasal sinuses are uncommon, accounting for less than two per cent of human
cancers (Lewis and Castro, 1972). The commonest sites of origin of these tumours are the maxillary sinus (58 per cent),
nasal fossa (31 per cent) and ethmoid sinus (10 per cent). Carcinomas originating in the frontal sinus (0.6 per cent) or
sphenoid sinus (0.4 per cent) are rare.
A number of cases of sphenoid carcinoma have been previously reported. However, there are no publications
recording its occurrence in association with inverted papillomatosis, although this association has been previously
documented in other paranasal sinuses (Woodson etal., 1985). In view of this, we feel it worthwhile reporting the
following case.

Case report 2.5 mmol./l. Standard skull radiology demonstrated extensive

A 67-year-old man was referred by his general practitioner
for investigation of weight loss. He was otherwise asympto-
matic. Examination revealed a pale, cachectic man with
mucopurulent nasal discharge. Further examination of his nose
revealed complete obstruction of his left nasal cavity by a
polypoid tumour which extended into the naso- and oro-
pharynx. The right nasal cavity contained small polyps posteri-
orly. On neurological examination, he had paralysis of the right
III, IV and VI cranial nerves in addition to a left VI nerve palsy.
Preliminary investigations revealed an ESR of 132 mm., a
haemoglobin of 8gm./dl. and a serum potassium of
destruction of the pituitary fossa floor and dorsum sella, with
marked expansion of the nasopharynx. In addition, the mucosa
of the maxillary sinuses was thickened but the ethmoid and
frontal sinuses appeared normal. Axial CT confirmed exten-
sive skull base destruction with erosion of the petrous apices.
A large mass of polypoid tumour tissue was removed from
the anterior and posterior nares of the left nostril, under local
anaesthesia, to reveal a large left nasal airway and
nasopharynx, with a posterior septal perforation. Histology of
the polypoid nasal tissue demonstrated features typical of an
inverted papilloma.
Following improvement in the patient's general condition, a

FIG. 1
Histology of nasal tissue demonstrating areas of inverted papilloma (A), dysplasia (B) and progression to invasive squamous carcinoma (C).
938
CLINICAL RECORDS
FIG. 2
Histology of nasal tissue demonstrating areas of inverted papilloma (A), dysplasia (B) and progression to invasive squamous carcinoma (C).
further examination and biopsy of the area was performed
under general anaesthesia. Further polypoid tissue, pedicled in
the midline, was removed from the left posterior nares. The
anterior wall of the sphenoid sinus was eroded by solid tumour-
like tissue, and multiple biopsies were taken.
Subsequent histology of the nasal tissue demonstrated inver-
ted papillomatosis with areas of severe dysplasia progressing,
in parts, to invasive squamous cell carcinoma (Figs. 1 and 2).
The tissue removed from the sphenoid sinus was shown to be
frankly invasive squamous cell carcinoma.
Discussion
The majority of polypoid nasal lesions are simple and inflam-
matory in nature. However, a wide spectrum of tumours can
arise in this region and a recent publication (Lumsden et al.,
1986) reported an alternative histological diagnosis in 1.8 per
cent of a series of 1,000 patients.
Inverted papillomatosis is relatively uncommon, accounting
for less than one per cent of nasal surgical specimens (Snyder
and Perzin, 1972). The tumour arises almost exclusively from
the lateral nasal wall or maxillary sinus (Vrabec, 1975; De
Santo, 1986) although they have been described arising from
the nasal septum (Geschickter, 1935). From these sites, it may
extend into the maxillary or ethmoid sinuses, with spread into
the sphenoid sinus being much less likely (De Santo, 1986).
Management of the condition may be difficult because of its
marked propensity for recurrence and its possible progression
to malignancy. There is uncertainty as to the exact incidence of
its association with carcinoma, figures in the literature varying
between two per cent and 50 per cent (Lawson et al., 1983).
The nature of any association is also a subject of debate. It is a
commonly held theory that inverted papilloma is potentially
pre-malignant, the alternative being that carcinoma and inver-
ted papilloma occupy the same anatomical region without his-
tological evidence that one gave rise to the other (Batsakis,
939
1981). Histology of the case which has been reported shows
clear evidence of inverted papillomatosis, dysplasia and inva-
sive carcinoma in the same specimen, supporting the theory
that malignant transformation can occur.
In this case, sphenoid carcinoma was suspected as a possi-
bility from the clinical picture. These tumours are likely to
present with advanced disease, and tumour extension to the
skull base with neuro-opthalmological signs can be expected at
initial presentation in the majority of patients (Harbison et al.,
1984).
Acknowledgement
We would like to acknowledge the help of Dr. F. D. Lee and
Dr. R. Jackson, who were the pathologists involved in report-
ing the histology.
References
Batsakis, J. G. (1981) Nasal (Schneiderian) papillomas. Annals of
Otology, Rhinology and Laryngology, 90: 190-191.
De Santo, L. W. (1986) In Otolaryngology—Head and Neck Sur-
gery (Cumming, C. W., Fredrickson, J. M., Harker, L. A.,
Krause, C. J., Schuller, D. E., eds.), pp. 645-648. The C. V.
Mosby Company, Missouri.
Geshickter, C. F. (1935) Tumours of the nasal and paranasal cav-
ities. American Journal of Cancer, 24: 637-660.
Harbison, J. W., Lessell, S., and Selhorst, J. B. (1984) Neuro-
opthalmology of sphenoid sinus carcinoma. Brain, 107:855-870.
Lawson, W., Biller, H. F., Jacobsen, A., and Som, P. (1983) The
role of conservative surgery in the management of inverted
papilloma. Laryngoscope, 93: 148-155.
Lewis, J. S., and Castro, E. B. (1972) Cancer of the nasal cavity
and paranasal sinuses. Journal of Laryngology and Otology, 86:
255-262.
Lumsden, A., Wilson, J. A., McLaren, K., and Maran, A. G. D.
(1986) Unusual polypoid tumours of the nasal cavity. Clinical
Otolaryngology, 11: 31-36.
940 J. H. DEMPSTER AND K. MACKENZIE

Snyder, R. N., and Perzin, K. H. (1972) Papillomatosis of the nasal Address for correspondence:
cavity and paranasal smuses. Cancer, 30: 668-690. J. H. Dempster, F.R.C.S.,
Vrabec, D. P. (1975) The inverted Schneiderian papilloma. Department of Otolaryngology,
Laryngoscope, 85: 186-220. Royal Infirmary,
Woodson.G. E.,Robbins,K. T., and Michaels, L. (1985) Inverted Glasgow G40SF.
papilloma: considerations in treatment. Archives of
Otolaryngology, 111: 0O6-8II.