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Discussion
Although most of the lesions arise from the lateral wall, middle meatus and ethmoid complex, they may sometimes arise from the septum and underlying perichondrium, the cartilage, lateral nasopharyngeal wall, maxillary sinus, sphenoid sinus and may involve the base skull. The distribution is: lateral wall 68%, ethmoid complex 57%, septum 28% intracranium 4%. The highest recurrence rate 70%.
The microscopic features that distinguishes a papilloma from an allergic polyp is the proliferation of the covering epithelium and extensive finger like inversions into the underlying stoma of the epithelium. The lesions are commonly seen in males more than females, and the ratio being 3:1. The age distribution is common between 30–50 years but lesions are also seen in the older age group of 60 plus.
The clinical appearance of the nasal mass resembles an allergic polyp looking like a gray and red nasal mass. Grading of inverted Papilloma shows:
| Grade I | Lesions involving nasal cavity only. |
| Grade II | Lesions involving nasal cavity + Paranasal sinuses. |
| Grade III | Lesions involving nasal cavity + Paranasal sinuses + skull base (intra cranial extension). |
Because of its varied presentation inverting papillomas can be difficult to distinguish from other nasal tumors and they tend to recur after limited operation and also tend to transform into carcinoma. Hence, it is impossible to predict which inverting papillomas will become malignant.
Management
A conservative surgical approach for septal and lateral wall tumors (intra–nasal surgery) is adopted. Tumors involving para nasal sinuses and ethmoids will need intranasal atronomies and Caldwell–lucs operation.
For recurrent masses a more radical surgery is advocated which includes – lateral rhinotomy along with medial maxillectomy with spheno–ethmoidal clearance (Enbloc Dissection). Because of its malignant transformation (3) in Ca (about 15%) some authorities recommended full radiotherapy courses (6000 rads) for six weeks (4).
Acknowledgement
I am thankful to the Chief Medical officer, Dr. Mrs. B. J. Coyaji for permitting me to publish this paper.
References
- Frank, C. A., Oliver D. J. and Jack, G (1985): Usual anatomic presentation of inverted papilloma – Head and neck Surgery, 243:45.
- Feinmessar, R., Goy. I., Weessel, J. M. and Ben–Bessat H. (1985): Malignant Transformation of inverted Papilloma. Ann Otol 94:39–43.
- William, M. Menden, H., Rodney, R., Million, N. J. and Cassissi Kenal, P. K. (1985): Biological aggressive Papilloma of Nasal Cavity – Role of radiation therapy. Laryngoscope, 95:344–347.
- Thomas, C. and Calceterra, W. T. (1980): Varied presentation of inverted Papilloma, 90:53–60.
South Zone conference of AOI, was held in Madras on the 14,15, 16th of March 1997. The theme of the Conference was “Recent Advances in Otolaryngology”. Eminent international invitees attended the conference. The conference will also have a one day live surgical workshop, and feature prize winning papers by post–graduates.
Contributed by Dr. K. K. Desarda
