Inverted Papilloma/ Transitional cell papilloma/ squamous cell papilloma/ epithelial

papilloma/ Ringertz tumor/ Schneidarian tumor

Benign Epithelial Tumors of the nasal cavity:

Papillomas arise from:
A. squamous epithelium: Keratotic papilloma of the vestibule (vestibular wart)
B. Schneiderian (respiratory) epithelium.
1. Fungiform papillomas: arise from the nasal septum
2. Inverted papilloma: lateral nasal wall
3. Cylindrical papillomas: lateral nasal wall.
Characteristic:
1. benign in nature
2. Locally expansible and occasionally destructive
3. recur when not excised completely
4. may be ass with malignant tumors
 white males
 5th -7th (mean, 50 years).
Inverted papilloma:
 Incidence: 0.5%-7%
 Accounts for 2% of the sinonasal tumors
 M:F =5:1
 Ass with HPV (6 & 11)
 Usually unilateral
 Bilateral in 14%
 Multifocal tumor 4%
 Risk of squamous cell ca transformation 5-15%
Symptoms: The most common presentation is nasal obstruction
Origin:
 Arise from Schneiderian (respiratory) epithelium of the lateral nasal wall in the
middle meatus
 Involving at least one sinus cavity
 The most common sinuses involved are the maxillary and ethmoid sinuses, Followed
by the sphenoid and frontal sinuses
Examination:
 No clear distinguishing characteristics between an inverted papilloma and
an inflammatory polyp.
 Although an inverted papilloma may be firmer and less translucent (fleshy)
wrinkled than an “average” polyp.+ unilateral
 Can cause pressure necrosis of the bone
Usually Unilateral polypoidal mass
 Irregular, friable appearance
 Bleed when touched
 Reddish gray
 May completely fill the nasal cavity, extending from the vestibule to the
nasopharynx
 Nasal septum is often bowed to the contralateral side

© Summarized and modified by Dr. Diala Mardini, Dr. Mohammad Alsalem. For personal
reading only.
CT scan:
1. Mass arising from the lateral nasal wall
(middle meatus) with extension into the
nasal cavity/ sinus
2. Usually Expands the middle meatus
3. Calcification can be seen
4. Adjacent bone could be thinned, eroded or
sclerotic
MRI:
 Help differentiae tumor vs inflammatory
 T1: hypo-isotense
 T2: iso-hypertense
 Shows convoluted cerebriform pattern : alternating high and low
intensity parallel lines in the tumor
Histopathology:
 The respiratory epithelium is thickened
 Endophytic growth pattern (infolded) with stratified squamous
epithelium inverting into the underlaying stoma: Ribbons of respiratory epithelium
enclosed with basement membrane; Grows into sub adjacent stroma
 Some columnar epithelium
 10% shows dysplasia (small group became malignant)
Treatment:
 en bloc (complete) excision/ medial maxillectomy is curative and needed due to:
1. High recurrence rate
2. Risk of malignancy degeneration
3. Capacity for invasion of contiguous structures
 Approach according to the size of the tumor:
1. For Small-medium sized tumor: Fess with: (Endoscopic medial maxillectomy)
 Gingivobuccal approach for ant/lateral maxillary sinus
 Frontal osteoplastic flap for frontal IP
2. For large tumor: Open approach Medial maxillectomy with either
a) Lateral rhinotomy
b) Midface degloving
Note: Inverted papilloma is neither radiosensitive nor resistant
Recurrence rate: up to 70% in various literature
 Open: 18%
 Endoscopic 12%
 Most recurrences occur within the first 2 years of treatment
 Nasal endoscopy is essential for follow-up and monitoring for disease recurrence
Characteristic mimicking malignancy:
1. invasion into surrounding structures
2. recurrence after resection
3. can degenerate into or coexist with malignancy (5% to 15% of resected cases are
associated with sec)
4. intra-lesion calcification

© Summarized and modified by Dr. Diala Mardini, Dr. Mohammad Alsalem. For personal
reading only.