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Pictorial Essay

R
Inverted Papilloma of the Nasal Vault and Paranasal
Sinuses: Spectrum of CT Findings
William W. Woodruff1 and Donald P. Vrabec2

Inverted papilloma is a benign epithelial neoplasm that Squamous cell carcinoma is the most commonly associated
arises within the nasal vault and, less commonly, in the parana- malignant neoplasm.
sal sinuses. It is relatively uncommon, accounting for less than
4% of mucosal tumors in this region. The tumor is character-
ized by a high recurrence rate (emphasizing the importance of Clinical Features
accurate tumor mapping and total tumor extirpation), associ- Inverted papilloma most often affects patients 50-70
ated epithelial malignant tumors (5-8%), and bone destruction.
years old, although it has been reported in patients from 6 to
The CT appearance of inverted papilloma is variable and non-
9i years old [3]. The tumor occurs two to four times more
specific. Nonetheless, inverted papilloma is the most likely
diagnosis when a unilateral mass in the nasal vault, producing often in males than in females [2, 3].
benign bony changes, extends centrifugally into the maxillary Unilateral nasal obstruction is the most common present-
and ethmoidal sinuses and through the nasal choana into the ing sign, noted in 78-iOO% of patients [2]. Epistaxis, rhinon-
nasopharynx in an elderly patient with chronic nasal obstruc- rhea, sinusitis, facial pain or pressure, anosmia, frontal
tion. The purpose of this essay is to illustrate the CT features of headache, epiphora, diplopia, proptosis, otalgia, and facial
inverted papilloma. numbness have also been reported in patients with inverted
papilloma [2]. The duration of signs and symptoms ranges
from weeks to decades; the average is 2-3 years [2, 3].
Pathologic Findings
Physical examination reveals a firm soft-tissue mass
The histologic feature that distinguishes inverted papil- within the nasal vault. The mass can extend into the
loma from other mucosal lesions is the propensity of the nasopharynx through the choana or into the nasal vestibule.
neoplasm to invert, proliferating into the underlying stroma, The tumor is friable and often hemorrhages when manipu-
rather than growing in an exophytic pattern as commonly lated [1 4]. ,

seen with squamous papilloma [1]. Mucin-containing micro-

cysts are also characteristic. This multipotent epithelial neo-
plasm can differentiate into respiratory, transitional, or CT Findings
squamous cell lines. Inverted papilloma most commonly arises from the lateral
Although inverted papilloma is benign, the neoplasm can nasal wall [4], adjacent to the middle turbinate, posterior to
undergo malignant transformation. The reported prevalence the uncinate process (Fig. i). Intranasal tumor is depicted
of carcinoma in patients with inverted papilloma varies from most accurately on coronal CT scans. The mass is homoge-
2% to 53% (average, 5-8%) [i 2]. Carcinomas
, typically neous, has a density like that of soft tissue, and may contain
occur in older patients. The tumor may be detected in the ni- calcium. The mass enhances heterogeneously after injection
tial biopsy or may be diagnosed after multiple recurrences. of contrast material. The tumor can vary considerably in size

Received August 1 7, 1993: accepted after revision October 13, 1993.

1 Department of Radiology, Geisinger Medical Center, 100 N. Academy Ave., Danvitle, PA 1 7822. Address correspondence to W. W. Woodruff.
2Department of Otolaryngology, Head and Neck Surgery, Geisinger Medical Center, Danville, PA 17822.
AJR i994;i62:4i9-423 0361-803X/94/1622-0419 ©Amenican Roentgen Ray Society
 420 WOODRUFF AND VRABEC AJR:162, February 1994
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at the time of detection, ranging from a few millimeters to 10

cm on larger.
As the tumor enlarges, the adjacent bone may be thinned,
bowed, eroded, on, less commonly, sclerotic [4]. Bony
changes are most evident along the lateral nasal wall, the
turbinates, and the inferior body of the ethmoid bone, with
relative preservation of the nasal septum until late in the
course of the disease (Fig. 2). Lange tumors can erode the
medial pterygoid plate, cnibniform plate, lamina papynacea,
hard palate, and nasolacnimal canal [2].
Centrifugal tumor growth results in direct extension into
the pananasal sinuses and nasopharynx [1-4]. The ethmoi-
dal and maxillary sinuses are most frequently involved (Fig.
3). The frontal and, less commonly, sphenoidal sinuses can
be involved, generally via direct extension from the ethmoi-
dal sinus (Fig. 4). Extension through the choana into the
nasopharynx is common with larger tumors (Fig. 5). The
resulting soft-tissue mass can completely fill the nasophar-
Fig. 1 .-Focal lateral nasal wall mass, surgically confirmed to be an
inverted papilloma, in a 60-year-old woman with a i-year history of rhin- ynx. Direct orbital extension from the ethmoidal on maxillary
orrhea and facial pain. Coronal CT scan shows a focal soft-tissue mass sinus can result in commensurate proptosis.
(straight arrow) arising from lateral wall of nasal vault, juxtaposed
between middle and inferior turbinates. Note incidental inflammatory
Accurate tumor delineation is critical in planning appropni-
disease (curved arrow) in right maxillary sinus. ate surgical extirpation of the tumor. Functional endoscopic

Fig. 2.-Contiguous unilateral soft-

tissue mass with erosive bone alter-
ations, surgically confirmed to be an
inverted papilloma, in a 38-year-old
woman who had nasal obstruction
and facial pain for 5 months.
A, Coronal CT scan shows a large
soft-tissue mass filling right maxillary
sinus, eroding lateral wall of nasal
vault (straight solid arrow) as it
extends into nasal vault and middle
ethmoidal air cells (curved arrow).
Middle turbinate (open arrow) has
been destroyed. Nasal septum is
Intact. Note small focus of calcium
(arrowhead) within matrix of mass.
B, Axial CT scan shows contigu-
- .- I -,.1 , , ous extension of mass from nasal
vault to maxillary sinus.

Fig. 3.-Contiguous unilateral soft-

tissue mass with centrifugal exten-
sion into maxillary and ethmoidal
sinuses, surgically confirmed to be
an inverted papilloma, in a 60-year-
old woman with a i-year history of
left-sided nasal obstruction.
A, Coronal CT scan shows a soft-
tissue mass (straight solid arrow)
beneath middle turbinate with contigu-
ous extension into maxillary sinus
(open arrow) and middle ethmoidal air
cells (curved arrow). Obstructed eth-
V. moidal infundibulum (arrowhead) is
enlarged.
B, Coronal CT scan shows tumor in
anterior ethmoidal air cells (arrowhead)
[ and nasofrontal duct (arrow).
 Fig. 4.-Contiguous unilateral soft-
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tissue mass with centrifugal exten-

sion into maxillary, ethmoidal, sphe-
noidal, and frontal sinuses, surgically
confirmed to be an inverted papil-
loma, in a 68-year-old man with a 2-
year progressive history of nasal
obstruction and epiphora.
A, Coronal CT scan shows a soft-
tissue mass filling left maxillary sinus
and extending into nasal vault. Lat-
eral nasal wall (arrowhead) and mid-
die (straight solid arrow) and inferior
(curved arrow) turbinates have been
destroyed. Note contiguous soft-tis-
sue extension into ipsilateral sphe-
noidal sinus (open arrow).
B, Coronal CT scan shows effects
of centrifugal enlargement of mass.
Lateral nasal wall and uncinate pro-
cess are eroded. Mass extends into
middle ethmoidal air cells and has
remodeled basal lamella (arrow). Left
middle turbinate cannot be detected
with certainty. Nasal septum appears
to be normal.
C, Coronal CT scan shows contig-
uous extension into anterior ethmoi-
dal air cells (arrow) and frontal sinus
(arrowhead).
D, Axial T scan shows contigu-
ous soft-tissue mass in nasal vault
and maxillary sinus.

Fig. 5.-Contiguous unilateral soft-

tissue mass with choanal extension,
surgically confirmed to be an inverted
papilloma, in a 29-year-old woman
who had nasal obstruction for many
years.
A, Coronal CT scan shows tumor
extending anteriorly to level of unci-
nate process (solid arrow). Tumor
extends into anterior ethmoidal air
cells (open arrow).
B, Coronal CT scan shows soft tis-
sue (arrow) filling otherwise normal left
choana. Soft tissue is also detected
within right choana (arrowhead).

sinus surgery is contraindicated when tumor is detected in intervals. Malignancy is corroborated by aggressive bone
endoscopically inaccessible regions (penionbita, lacnimal sac, destruction, multicentnic soft-tissue extension, and nodal
supraorbital ethmoidal air cells, and frontal sinus) [2]. metastasis (Fig. 6).
High tumor recurrence rates and propensity for malignant Differentiation between intrasinus tumor extension and
transformation necessitate follow-up examinations at regular postobstructive sinusitis can be difficult on unenhanced CT
 422 WOODRUFF AND VRABEC AJR:162, February 1994
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Fig. 6.-Malignant transformation

of inverted papilloma in a 61-year-old
woman with a 45-year history of nasal
obstruction, facial pain, and headache
and newly occurring proptosis. lnftial
surgery confirmed inverted papilloma
with cellular atypia and squamous cell
carcinoma.
A, Coronal CT scan shows a
destructive soft-tissue mass filling left
nasal cavity, left more than right max-
illary sinus, and right and left ethmoi-
dal sinuses, and extending into left
orbit (straight arrow). Cribniform plate
(curved arrow) Is intact.
B and C, Axial CT scans obtained
with narrow (B) and wide (C) windows
show confluent soft-tissue mass in left
nasal vault and maxillary sinus. Mass
fills nasal vestibule. Bony destructive
changes involve portions of left maxil-
lary sinus and nasal vault.
D, Axial CT scan shows bilateral
ethmoidal tumor with destruction of
lamina papyracea and orbital exten-
sion on right side (arrow). Tumor may
have focally destroyed lamina papy-
racea on left side (arrowhead).
E, Axial contrast-enhanced CT
scan shows a 2-cm necrotic jugulodi-
gastric node (arrow) on left, corrobo-
rating an epithelial malignant tumor.
F; Axial contrast-enhanced CT
scan obtained 4 months after A-E
shows marked proptosis on left due to
growth of tumor. Intraconal (straight
arrow) and extraconal (curved arrow)
tumor has extended from ethmoidal
air cells.

C D

E F

scans. Acute sinusitis is often hypodense relative to tumor. A variety of common inflammatory and neoplastic masses
Peripheral mucosal enhancement and lack of central can occur in the nasal fossa. Antrochoanal polyps are unilat-
enhancement may distinguish sinusitis from heteroge- eral masses that extend from the maxillary sinus through an
neously enhancing tumor (Fig. 7). enlarged infundibulum into the ipsilatenal nasal vault, sparing
 AJA:162, February 1994 NASAL AND PARANASAL INVERTED PAPAILLOMAS 423
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Fig. 7.-Contiguous bilateral soft-

tissue mass with advanced bone
destruction, surgically confirmed to
be an inverted papilloma, in a 91-year-
L
old woman who had nasal obstruc-
tion, rhinorrhea, and diplopia for
many years.
A, Coronal CT scan shows a large,
destructive soft-tissue mass filling
nasal cavity and extending into left
more than right maxillary sinus, eth-
moidal sinuses, and left orbit (straight
arrow). Bony architecture of nasal
vault and ethmoidal sinuses has been
destroyed. Cnibniform plate (curved
arrow) appears normal on soft-tissue
image.
B, Axial CT scan shows bilaterality
of nasal cavity disease. Mass extends
to nasal vestibule (straight arrow),
and portions of bony perimeter of left
maxillary sinus (arrowheads) have
been destroyed. Note soft tissue in
left pterygopalatine fossa (curved
arrow).
C, Axial CT scan just superior to B
obtained after injection of contrast
material shows heterogeneous en-
hancement of mass. Lack of enhance-
ment and intrinsic hypodensity of
material in right maxillary sinus
(straight arrow) corroborate postob-
structive inflammatory disease. Note
soft tissue in left pterygopalatine
fossa (curved arrow).
0, Axial obtained at wide
CT scan
window setting shows bony changes.
Note amorphous calcification (straight
arrow) within tumor matrix and erosion
of medial pterygoid plate (curved
arrow).

the ethmoidal sinus. The mass generally occurs in the destroy bone early, often before the tumor attains a signifi-
nasopharynx in teenagers and young adults. Nasal polyps cant size. Patients may have a history of exposure to a van-
tend to occur bilaterally in patients with a history of allergy. ety of carcinogens.
Juvenile nasopharyngeal angiofibromas may manifest as a
unilateral nasal vault mass. This tumor tends to occur in the
second decade of life, causing epistaxis and nasal conges- REFERENCES
tion. CT shows centrifugal tumor growth from the pterygopa- 1. Lawson W, Le Bengen J, Som P, Bernard PJ, Biller HF. Inverted papil-
latine fossa. Mucoceles, the most common expansile mass loma: an analysis of 87 cases. Laryngoscope 1 989:99:lil 7-1124
of the pananasal sinuses, can extend into the nasal cavity. 2. Vrabec DP. The inverted schneidenian papilloma: a 25-year study. Laryn-
Their site of origin (usually frontal and ethmoidal sinuses) is goscope (in press)
3. Weissler MC, Montgomery WW, Montgomery 5K, Turner PA, Joseph MP.
apparent. Epithelial and glandular malignant tumors can
Inverted papilloma. Ann Otol Rhinol Laryngol 1986:95:215-221
arise in the maxillary sinus, oral cavity, on, less commonly, 4. Momose KJ, Weber AL, Goodman M, MacMillan As, Robenson GH.
the nasal vault in elderly patients. These tumors tend to Radiological aspects of inverted papiltoma. Radiology 1980:134:73-79