European Journal of Radiology, 10 (1990) 134-l 39 Elsevier
134
EURRAD
00022
Radiologic aspects of inverted papilloma C. Buchwald ‘v4,L.H. Nielsen ‘, P. Ahlgren3, P.L. Nielsen2 and M. Tos
’
Departments of ‘ENT and 2PathoIogv,Gentofie Hospital and ‘Department of ‘Radiology and 4ENT, GlostrupHospital, Copenhagen, Denmark (Received 31 July 1989; accepted 25 October
Key words: Computed tomography,
nasal; Computed
tomography,
1989)
papilloma; Papilloma, inverted;
Papilloma, radiography
Abstract
A series of 42 patients with inverted papilloma is presented. Of these, 38 patients had radiologic examinations. Thirty patients had comparable radiologic examinations in the form of X-ray of the sinuses and/or tomography and/or CT scan. The preoperative fmdings were compared and related to the extent of the tumor at surgery. Clinical examination combined with CT appears to be the optimal preoperative procedure. Follow-up should include CT in order to allow comparison with postoperative status and, preferably, also with preoperative radiologic findings.
Introduction
Material and Methods
Inverted papilloma (IP) in the nose or paranasal sinuses is a rare tumor which often exhibits rapid growth with bone destruction and a high recurrence rate. Furthermore, an association with nasal carcinoma is present [ 1,7 3. In most cases, the histologic diagnosis of IP is obtained in the out-patient’s clinic by a simple biopsy from the nasal cavity, but since the choice of surgical procedure depends on the location and extent of the tumor, radiologic examination is important for the fmther preoperative work-up. The surgical procedure required may vary from simple endonasal resection to sinusectomy or lateral rhinotomy. The objectives of the present retrospective study are to compare CT, tomography and ordinary X-ray in cases of histologically confirmed IP and to relate the findings to those made at surgery. These results form the basis for a discussion of the radiologic strategy for patients with IP, especially stressing the value of postoperative CT for the detection of possible residual or recurrent IP.
In 1986 we reviewed the files in the departments of pathology of the two Copenhagen hospitals in Gentofte and Glostrup containing all histologically examined tissue from the nose and paranasal sinuses over the 12-year period from 1975 to December 1986. The uptake population comprises the 600 000 inhabitants in Copenhagen County. A total of 42 patients were diagnosed as having IP [4]. In 1986, 37 patients (88%) were re-examined clinically and radiologically. The drop-outs amounted to five patients: three died before 1986 from non-related diseases, one after intracranial growth of carcinoma associated with IP, and one dropped out because of old age. All 37 patients had a thorough clinical examination including fiberscopy and biopsy if indicated. Subsequently, CT scan was performed in all cases, in a few cases with additional tomography. In 1987 all previously performed radiologic examinations and CT scans were reviewed and the clinical files thoroughly analysed by an experienced radiologist. The radiologic examinations comprised either a combination of plain X-ray of the sinuses, tomography with or without CT, or CT alone (Table I). If surgery had been performed or if more than 2 months had elapsed between two examinations, the latter were considered
Address for reprints: Chr. Buchwald, M.D., ENT Department, Gentofie Hospital, DK-2900 Hellerup, Copenhagen, Denmark. 0720-048X/90/$03.50 Q 1990 Elsevier Science Publishers
B.V. (Biomedical
Division)
135 TABLE
85 % of the cases (Table III). Generally, involvement of
I
Number of patients investigations
with different
combinations
of radiologic
No. CT + tomography + X-ray of the sinus CT + X-ray of the sinus CT + tomography Tomography + X-ray of the sinus CT only No radiologic investigations
I 11 3 9 8 4
Total No. of patients
42
as separate examinations. Tomography was performed on either a Philips polytome or CGRs planigraf with a scan distance of 5 mm. The CT examinations were mainly performed on Siemens Siretom 2000 with 5 mm thick scans. Results
A total of 42 patients met the histological criteria for IP [3,6]. This corresponds to an incidence of 0.6 patients per 100000 inhabitants per year. At the time of diagnosis, the median age was 48 years, ranging from 19 to 86 years. Initialsymptoms. The most common initial symptom was nasal obstruction, present in 78% of the patients. Epistaxis was present in 16% (Table II). The duration of symptoms prior to diagnosis ranged from 1 day to 26 years, median value 2.5 years. Localization. Based on the radiologic, physical and intraoperative fmdings with subsequent histologic examination, the most common tumor site was the lateral wall of the nasal cavity, which was involved in
the paranasal sinus was combined with affection of the lateral nasal wall, but in one case the tumor was located exclusively in the maxillary sinus. Location in the ethmoid and the maxillary sinuses was equally common. Extension to the frontal sinus and the sphenoidal sinus occurred secondary to affection of the ethmoid sinuses. The lateral nasal wall was the sole site in ten cases, the septum in five and the vestibulum in one case. The tumor was unilateral in 41 of the 42 cases, including recurrent cases. Initial surgicaljhdings. At the time of initial surgery bone destruction and penetration seen intraoperatively was a feature in 13 patients, the principal site being the lateral wall of the nasal cavity. In all of these patients, bone destruction could be demonstrated upon reviewing the CT scans or tomography. In four cases an additional destruction of the orbital wall was present, but in only one case was there projection of tumorous growth into the orbit (Fig. 1). In the latter patient, a change of facial appearance was the initial symptom. Radiological examinations. A total of 38 patients had radiological examination (Table I); 30 had one or more combined examinations and eight had CT alone. Four patients with IP located in the septum were not examined radiologically (Table I). All 38 patients initiallyunderwent plain sinus X-ray, revealing in 35 cases an opacification of the nasal cavity and ipsilateral sinuses (usually the ethmoid sinus and the maxillary sinus). CT generally afforded a better mapping of the tumor size and location than tomography and appeared to be a more precise tool for the surgeon in cases of bone destruction, owing to a better delineation of the tumor with CT (Figs. 2 and 3). TABLE III The location and extent of tumor in the 42 patients with inverted papilloma, based on clinical, radiologic and intra-operative findings with histologic confirmation
TABLE
II
Initial symptoms
in 42 patients with inverted papilloma
Initial symptoms
No.
%
Unilateral nasal obstruction Unilateral nasal obstruction and rhinorrhea Unspecified nasal obstruction Purulent nasal discharge Epistaxis Epistaxis and unspecified nasal obstruction Epistaxis and purulent discharge Change of facial appearance Occasional finding
16 11 3 3 3 3 1 1 1
38 26 I 7 I I 2 2 2
Total
42
98
Location
Single No.
Cumulative No.
Nasal septum Lateral nasal wall Maxillary sinus Ethmoidal sinus Frontal sinus Sphenoidal sinus Orbit Nasal vestibulum
5 10 1 0 0 0 0 1
5 36 21” 19s 1” 2” 1” 1
a Concomitant involvement of the lateral nasal wall in 20 patients. b Concomitant involvement of the lateral nasal wall in all 19 patients and of the maxillary sinus in 13 patients. ’ Extension from ethmoidal cells.
136
Fig. 1. All from the same patient. (a) Frontal tomogram, level corresponding to central part of the nasal cavity. Pronounced opacification of the left antrum and ethmoidaf cells with resolution (arrows) of the medial orbital wall. (b) Axial CT scan (Siretom 2000). Tumor in anterior aspects of the nasal cavity with projections (arrow) through the lateral wall to the medial canthus and to the antrum. Soft tissue mass in the bony defects (c) As b, more cranial section. Bony defect in medial orbital wall with tumor (arrow heads) seen in the nasal cavity as well as in subcutaneous tissue. No displacement of the bulbus. (d) Most cranial section demonstrating tumor in the anterior ethmoid. Comment: at subsequent lateral rhinotomy, tumor tissue was present in anterior ethmoidal cells with invasion of lamina papyracea, periorbita intact. Tumor tissue was also confirmed in the antrum and the nasal cavity.
Our retrospective analysis proved plain X-ray of the sinuses to be of no particular value in the follow-up of patients subjected to surgery, since opacifkation of the
sinuses was a frequent finding also in patients with no recurrence. Thus, opacification of the sinuses was seen in 16 patients with no recurrence.
Fig. 2. All from the same patient. (a) Conventional sinus X-ray. A-P projection. Diffise opacification of the nasal cavity and the maxillary sinus. Ethmoid could not be evaluated. (b) Axial CT scan (Siretom 2000). Soft tissue mass in the nasal cavity (posterior aspect) and the maxillary sinus. Bony medial wall of the antrum intact. Comment: at subsequent lateral rhinotomy the integrity of the bony medial wall was confirmed. IP present in the nasal cavity, polypoid mucosa (no IP) present in the maxillary sinus.
Of the 27 patients seen at follow-up in 1986, recurrence was confirmed in 17 (63 %). In all cases the recurrence was demonstrated by CT at follow-up. Treatment and recurrence. The patients were divided into three groups: lateral rhinotomy, sinusectomy and ‘simple’ excision, according to the surgical procedure at the primary operative intervention. Lateral rhinotomy was the primary approach in 12 patients. The principle was removal of all visible tumor tissue, which, in case of ‘lateral’ lesions, included a total or partial medial maxillectomy and sinusectomy, according to the situation. The recurrence rate was 50 y0 (six patients).
Sinusectomy, comprising a Caldwell-Luc incision, transnasal antrostomy or transnasal ethmoidectomy with optional conchal resection was performed in 14 patients. The recurrence rate in the group of primary sinusectomy was 62% (eight patients). In one case neuralgiform pains developed on a level with the infraorbital nerve subsequent to a Luc-Caldwell procedure with removal of a sinus tumor. A CT scan (Fig. 4) revealed a recurrence in the roof of the antrum, at revision surgery found in immediate proximity to the infraorbital canal. Simple excision was the initial procedure in nine patients, with optional conchal resection. In four cases,
Fig. 3. All from the same patient. (a) Coronal tomogram, section corresponding to the posterior wall of the maxillary sinus. Opacification of the nasal cavity with indication of resolution of surrounding bony structures (b) Axial CT scan (Tomoscan 310), window level: + 45. Soft tissue mass in the nasal cavity and opaciftcation of the ipsilateral sphenoid sinus. No destruction of medial wall of the antrum. (c) as b: more caudal section, window level: + 264. Soft tissue mass in the nasal cavity extending to postnasal space. Inferior concha - including bony contents intact. Polypoid mucosa found in ipsilateral maxillary cavity, bottom and anterior as well as posterior parts of maxillary medial wall. Comment: at subsequent surgery IP was demonstrated in the nasal cavity only - other biopsies were negative. The medial wall was intact.
138
Fig. 4. All from the same patient. (a) Axial CT scan (Siretom 2000). A postoperative examination revealing a soft tissue mass in the upper aspect of the maxillary sinus. Medial wall of antrum is absent, representing postoperative changes. (b) Axial CT scan (GE 9800). Follow-up 1 year alter revision surgery. No indications of further recurrence. Comment: this patient had neuralgiform pains corresponding to the infraorbital nerve and subsequent revision surgery confirmed the presence of IP at the same level as the infraorbital nerve canal.
the septum was the sole site. The recurrence rate at the time of follow-up was 43% in this group. In the total series, 15 patients had no recurrence, nine patients had one recurrence and eight patients had two or multiple recurrences. Inverted papilloma associated with carcinoma : as stated, two of the 42 patients had a concomitant carcinoma. In one case, the tumor was unilateral, located at a level with the lateral nasal wall, the ethmoid and the sphenoid sinus. Destruction of the perpendicular plate of the ethmoidal bone was found radiologically and at surgery. Intracranial growth was present at the time of death. The other patient was the only one in this series having a bilateral tumor inasmuch as IP with carcinoma was present in the left nasal cavity, with involvement of the ethmoid, and the left maxillary sinus. At the same time, the right nasal cavity was blocked by severely dysplastic IP. Preoperative plain sinus X-ray showed opacification of the nasal cavity, the maxillary sinuses and the left ethmoid sinus, but no bone destruction, as confirmed at subsequent surgery. The patient is asymptomatic and has been free of recurrence for 2 years after a bilateral Caldwell-Luc procedure followed by radiotherapy and chemotherapy. Postoperative CT showed no indication of residual tumor. Discussion
In accordance with previous studies, the present series did not reveal specific radiologic features in cases with IP when examined by plain sinus X-ray. Thus, the radiologic findings resemble those found in common
infectious or allergic polyps and in mucoceles as well as in malignant nasal tumors [9,10,13]. Some investigators have felt it possible with CT to distinguish between benign and malignant tumors on the basis of tumor appearance alone, although both benign and malignant tumors have been known to cause bone destruction. In benign cases, bone resorption is probably the result of mechanical pressure, whereas in malignant tumors the bone is infiltrated by the tumor itself [ 11,121. Plain X-ray of the sinuses does not significantly contribute to the surgeons choice of surgical procedure, since it is impossible to map the full extent of the tumor on such films [2,5,10,13]. Similarly, bone destruction is not visualized by X-ray of the sinuses [ lo]. Like us, Abildgaard et al. [l] found that CT or tomography allowed determination of tumor growth, whereas ordinary X-ray of the sinuses merely informed on ‘loss of translucency’. Abildgaard et al. [ 1] found no difference in the diagnostic value of CT and tomography. None of the cases reported by them, however, had bone destruction or malignancy. In agreement with Momose et al. [lo] we found the osseous demarcations of the tumor better visualized by CT than by tomography. Furthermore, owing to the axial plane, CT gives a better view of the anatomical condition of the sinuses [ 81. In our hands previous trials with enhancement of sinus structures by i.v. contrast have not revealed any benefits. Accordingly, contrast CT was utilized in only two cases in the present series [lo]. In neither of the cases was any contrast enhancement obtained - a predictable result considering the poor vascularization of the tumor. All scans of inverted papillomas showed uniform absorption values in the entire tumor area. With regard to frequency of recurrence, there were
139
no significant differences between our three surgical procedures. Therefore, the least extensive and radical procedure should be favoured. In our opinion, patients with IP having undergone CT will profit most from sinusectomy if the inverted papillomas are located laterally. The tumor must be of moderate size and within full view during the operation. Based on our radiological findings we advise that CT be performed in all patients with IP, except when the papillomas are located exclusively on the septum, in which case they can be inspected at the clinical examination supplemented by liberendoscopy. Patients with septal IP that can be surveyed by inspection of the nasal cavity need not be subjected to CT. In view of the high recurrence rate and risk of mahgnancy the patients should be seen regularly. We recommend follow-up every 6 or 12 months comprising clinical examination, fiberendoscopy, and, in patients with laterally located inverted papillomas, CT. Our study emphasizes the great value of CT at follow-up, whereas X-ray of the sinuses at postoperative follow-up gave no definitive information. We conclude that CT should be continuously used, also at follow-up. Acknowledgement
The authors acknowledge the support of S. Brttnner M.D., Department of Radiology, Gentofte Hospital, Copenhagen.
References 1 Abildgaard-Jensen J, Greisen 0. Inverted papillomas of the nose and the paranasal sinuses. Clin Otolaryngol 1985; 10: 135-143. K, Uhlenbrock D. Invertiertes 2 Appel W, Schulte-Mattler Papillom der Nase und Nasennebenhohlen. Fortschr Rontgenstr 1983; 138: 322-330. 3 Batsakis JG. Tumors of the head and neck, 2nd Edn. Baltimore: Williams & Wilkins 1979; 132-137. 4 Buchwald C, Nielsen LH, Nielsen PL, Ahlgren P, Tos M. Inverted papilloma: a follow-up study including primarily unacknowledged cases. Am J Otolaryngol 1989; 10: 273-281. 5 Dubois PJ, Schultz JC, Perrin RL, Dastur KJ. Tomography in expansile lesions of the nasal and paranasal sinuses. Radiology 1977; 125: 149-158. 6 Hyams VJ. Papillomas ofthe nasal cavity and paranasal sinuses. A clinicopathological study of 315 cases. Ann Otol Rhino1 Laryngol 1971; 80: 192-206. S, Vorre P, Elbrond 0, Ssgaard H. Nasal 1 Kristensen Schneiderian papillomas: a study of 83 cases. Clin Otolaryngol 1985; 10: 125-134. 8 Kuhn JP. Editorial. Imaging of the paranasal sinuses: current status. J Allergy Clin Immtmol 1986; 77: 6-8. 9 Lawson W, Biller HF, Jacobson A, Som P. The role of conservative surgery in the management of inverted papilloma. Laryngoscope 1983; 93: 148-155. M, MacMillan AS, 10 Momose KJ, Weber AL, Goodman Roberson GH. Radiological aspects of inverted papilloma. Radiology 1980; 134: 73-79. 11 Som P, Sacher M, Lawson W, Biller HF. CT appearance distinguishing benign nasal polyps from malignancies. J Comput Assist Tomogr 1987; 11: 129-133. 12 Thomsen J, Tos M, Nielsen M, Balslev Jorgensen M. Bone destruction in intlammatory diseases of the ear. In (Sad& J, ed) Cholesteatoma and mastoid surgery, Kugler, Amsterdam 1982; 397-411. 13 Weissler MC, Montgomery WW, Montgomery SK, Turner PA, Joseph MP. Inverted papilloma. Ann Otol Rhino1 Laryngol 1986; 95: 215-221.
134
EURRAD
00022
Radiologic aspects of inverted papilloma C. Buchwald ‘v4,L.H. Nielsen ‘, P. Ahlgren3, P.L. Nielsen2 and M. Tos
’
Departments of ‘ENT and 2PathoIogv,Gentofie Hospital and ‘Department of ‘Radiology and 4ENT, GlostrupHospital, Copenhagen, Denmark (Received 31 July 1989; accepted 25 October
Key words: Computed tomography,
nasal; Computed
tomography,
1989)
papilloma; Papilloma, inverted;
Papilloma, radiography
Abstract
A series of 42 patients with inverted papilloma is presented. Of these, 38 patients had radiologic examinations. Thirty patients had comparable radiologic examinations in the form of X-ray of the sinuses and/or tomography and/or CT scan. The preoperative fmdings were compared and related to the extent of the tumor at surgery. Clinical examination combined with CT appears to be the optimal preoperative procedure. Follow-up should include CT in order to allow comparison with postoperative status and, preferably, also with preoperative radiologic findings.
Introduction
Material and Methods
Inverted papilloma (IP) in the nose or paranasal sinuses is a rare tumor which often exhibits rapid growth with bone destruction and a high recurrence rate. Furthermore, an association with nasal carcinoma is present [ 1,7 3. In most cases, the histologic diagnosis of IP is obtained in the out-patient’s clinic by a simple biopsy from the nasal cavity, but since the choice of surgical procedure depends on the location and extent of the tumor, radiologic examination is important for the fmther preoperative work-up. The surgical procedure required may vary from simple endonasal resection to sinusectomy or lateral rhinotomy. The objectives of the present retrospective study are to compare CT, tomography and ordinary X-ray in cases of histologically confirmed IP and to relate the findings to those made at surgery. These results form the basis for a discussion of the radiologic strategy for patients with IP, especially stressing the value of postoperative CT for the detection of possible residual or recurrent IP.
In 1986 we reviewed the files in the departments of pathology of the two Copenhagen hospitals in Gentofte and Glostrup containing all histologically examined tissue from the nose and paranasal sinuses over the 12-year period from 1975 to December 1986. The uptake population comprises the 600 000 inhabitants in Copenhagen County. A total of 42 patients were diagnosed as having IP [4]. In 1986, 37 patients (88%) were re-examined clinically and radiologically. The drop-outs amounted to five patients: three died before 1986 from non-related diseases, one after intracranial growth of carcinoma associated with IP, and one dropped out because of old age. All 37 patients had a thorough clinical examination including fiberscopy and biopsy if indicated. Subsequently, CT scan was performed in all cases, in a few cases with additional tomography. In 1987 all previously performed radiologic examinations and CT scans were reviewed and the clinical files thoroughly analysed by an experienced radiologist. The radiologic examinations comprised either a combination of plain X-ray of the sinuses, tomography with or without CT, or CT alone (Table I). If surgery had been performed or if more than 2 months had elapsed between two examinations, the latter were considered
Address for reprints: Chr. Buchwald, M.D., ENT Department, Gentofie Hospital, DK-2900 Hellerup, Copenhagen, Denmark. 0720-048X/90/$03.50 Q 1990 Elsevier Science Publishers
B.V. (Biomedical
Division)
135 TABLE
85 % of the cases (Table III). Generally, involvement of
I
Number of patients investigations
with different
combinations
of radiologic
No. CT + tomography + X-ray of the sinus CT + X-ray of the sinus CT + tomography Tomography + X-ray of the sinus CT only No radiologic investigations
I 11 3 9 8 4
Total No. of patients
42
as separate examinations. Tomography was performed on either a Philips polytome or CGRs planigraf with a scan distance of 5 mm. The CT examinations were mainly performed on Siemens Siretom 2000 with 5 mm thick scans. Results
A total of 42 patients met the histological criteria for IP [3,6]. This corresponds to an incidence of 0.6 patients per 100000 inhabitants per year. At the time of diagnosis, the median age was 48 years, ranging from 19 to 86 years. Initialsymptoms. The most common initial symptom was nasal obstruction, present in 78% of the patients. Epistaxis was present in 16% (Table II). The duration of symptoms prior to diagnosis ranged from 1 day to 26 years, median value 2.5 years. Localization. Based on the radiologic, physical and intraoperative fmdings with subsequent histologic examination, the most common tumor site was the lateral wall of the nasal cavity, which was involved in
the paranasal sinus was combined with affection of the lateral nasal wall, but in one case the tumor was located exclusively in the maxillary sinus. Location in the ethmoid and the maxillary sinuses was equally common. Extension to the frontal sinus and the sphenoidal sinus occurred secondary to affection of the ethmoid sinuses. The lateral nasal wall was the sole site in ten cases, the septum in five and the vestibulum in one case. The tumor was unilateral in 41 of the 42 cases, including recurrent cases. Initial surgicaljhdings. At the time of initial surgery bone destruction and penetration seen intraoperatively was a feature in 13 patients, the principal site being the lateral wall of the nasal cavity. In all of these patients, bone destruction could be demonstrated upon reviewing the CT scans or tomography. In four cases an additional destruction of the orbital wall was present, but in only one case was there projection of tumorous growth into the orbit (Fig. 1). In the latter patient, a change of facial appearance was the initial symptom. Radiological examinations. A total of 38 patients had radiological examination (Table I); 30 had one or more combined examinations and eight had CT alone. Four patients with IP located in the septum were not examined radiologically (Table I). All 38 patients initiallyunderwent plain sinus X-ray, revealing in 35 cases an opacification of the nasal cavity and ipsilateral sinuses (usually the ethmoid sinus and the maxillary sinus). CT generally afforded a better mapping of the tumor size and location than tomography and appeared to be a more precise tool for the surgeon in cases of bone destruction, owing to a better delineation of the tumor with CT (Figs. 2 and 3). TABLE III The location and extent of tumor in the 42 patients with inverted papilloma, based on clinical, radiologic and intra-operative findings with histologic confirmation
TABLE
II
Initial symptoms
in 42 patients with inverted papilloma
Initial symptoms
No.
%
Unilateral nasal obstruction Unilateral nasal obstruction and rhinorrhea Unspecified nasal obstruction Purulent nasal discharge Epistaxis Epistaxis and unspecified nasal obstruction Epistaxis and purulent discharge Change of facial appearance Occasional finding
16 11 3 3 3 3 1 1 1
38 26 I 7 I I 2 2 2
Total
42
98
Location
Single No.
Cumulative No.
Nasal septum Lateral nasal wall Maxillary sinus Ethmoidal sinus Frontal sinus Sphenoidal sinus Orbit Nasal vestibulum
5 10 1 0 0 0 0 1
5 36 21” 19s 1” 2” 1” 1
a Concomitant involvement of the lateral nasal wall in 20 patients. b Concomitant involvement of the lateral nasal wall in all 19 patients and of the maxillary sinus in 13 patients. ’ Extension from ethmoidal cells.
136
Fig. 1. All from the same patient. (a) Frontal tomogram, level corresponding to central part of the nasal cavity. Pronounced opacification of the left antrum and ethmoidaf cells with resolution (arrows) of the medial orbital wall. (b) Axial CT scan (Siretom 2000). Tumor in anterior aspects of the nasal cavity with projections (arrow) through the lateral wall to the medial canthus and to the antrum. Soft tissue mass in the bony defects (c) As b, more cranial section. Bony defect in medial orbital wall with tumor (arrow heads) seen in the nasal cavity as well as in subcutaneous tissue. No displacement of the bulbus. (d) Most cranial section demonstrating tumor in the anterior ethmoid. Comment: at subsequent lateral rhinotomy, tumor tissue was present in anterior ethmoidal cells with invasion of lamina papyracea, periorbita intact. Tumor tissue was also confirmed in the antrum and the nasal cavity.
Our retrospective analysis proved plain X-ray of the sinuses to be of no particular value in the follow-up of patients subjected to surgery, since opacifkation of the
sinuses was a frequent finding also in patients with no recurrence. Thus, opacification of the sinuses was seen in 16 patients with no recurrence.
Fig. 2. All from the same patient. (a) Conventional sinus X-ray. A-P projection. Diffise opacification of the nasal cavity and the maxillary sinus. Ethmoid could not be evaluated. (b) Axial CT scan (Siretom 2000). Soft tissue mass in the nasal cavity (posterior aspect) and the maxillary sinus. Bony medial wall of the antrum intact. Comment: at subsequent lateral rhinotomy the integrity of the bony medial wall was confirmed. IP present in the nasal cavity, polypoid mucosa (no IP) present in the maxillary sinus.
Of the 27 patients seen at follow-up in 1986, recurrence was confirmed in 17 (63 %). In all cases the recurrence was demonstrated by CT at follow-up. Treatment and recurrence. The patients were divided into three groups: lateral rhinotomy, sinusectomy and ‘simple’ excision, according to the surgical procedure at the primary operative intervention. Lateral rhinotomy was the primary approach in 12 patients. The principle was removal of all visible tumor tissue, which, in case of ‘lateral’ lesions, included a total or partial medial maxillectomy and sinusectomy, according to the situation. The recurrence rate was 50 y0 (six patients).
Sinusectomy, comprising a Caldwell-Luc incision, transnasal antrostomy or transnasal ethmoidectomy with optional conchal resection was performed in 14 patients. The recurrence rate in the group of primary sinusectomy was 62% (eight patients). In one case neuralgiform pains developed on a level with the infraorbital nerve subsequent to a Luc-Caldwell procedure with removal of a sinus tumor. A CT scan (Fig. 4) revealed a recurrence in the roof of the antrum, at revision surgery found in immediate proximity to the infraorbital canal. Simple excision was the initial procedure in nine patients, with optional conchal resection. In four cases,
Fig. 3. All from the same patient. (a) Coronal tomogram, section corresponding to the posterior wall of the maxillary sinus. Opacification of the nasal cavity with indication of resolution of surrounding bony structures (b) Axial CT scan (Tomoscan 310), window level: + 45. Soft tissue mass in the nasal cavity and opaciftcation of the ipsilateral sphenoid sinus. No destruction of medial wall of the antrum. (c) as b: more caudal section, window level: + 264. Soft tissue mass in the nasal cavity extending to postnasal space. Inferior concha - including bony contents intact. Polypoid mucosa found in ipsilateral maxillary cavity, bottom and anterior as well as posterior parts of maxillary medial wall. Comment: at subsequent surgery IP was demonstrated in the nasal cavity only - other biopsies were negative. The medial wall was intact.
138
Fig. 4. All from the same patient. (a) Axial CT scan (Siretom 2000). A postoperative examination revealing a soft tissue mass in the upper aspect of the maxillary sinus. Medial wall of antrum is absent, representing postoperative changes. (b) Axial CT scan (GE 9800). Follow-up 1 year alter revision surgery. No indications of further recurrence. Comment: this patient had neuralgiform pains corresponding to the infraorbital nerve and subsequent revision surgery confirmed the presence of IP at the same level as the infraorbital nerve canal.
the septum was the sole site. The recurrence rate at the time of follow-up was 43% in this group. In the total series, 15 patients had no recurrence, nine patients had one recurrence and eight patients had two or multiple recurrences. Inverted papilloma associated with carcinoma : as stated, two of the 42 patients had a concomitant carcinoma. In one case, the tumor was unilateral, located at a level with the lateral nasal wall, the ethmoid and the sphenoid sinus. Destruction of the perpendicular plate of the ethmoidal bone was found radiologically and at surgery. Intracranial growth was present at the time of death. The other patient was the only one in this series having a bilateral tumor inasmuch as IP with carcinoma was present in the left nasal cavity, with involvement of the ethmoid, and the left maxillary sinus. At the same time, the right nasal cavity was blocked by severely dysplastic IP. Preoperative plain sinus X-ray showed opacification of the nasal cavity, the maxillary sinuses and the left ethmoid sinus, but no bone destruction, as confirmed at subsequent surgery. The patient is asymptomatic and has been free of recurrence for 2 years after a bilateral Caldwell-Luc procedure followed by radiotherapy and chemotherapy. Postoperative CT showed no indication of residual tumor. Discussion
In accordance with previous studies, the present series did not reveal specific radiologic features in cases with IP when examined by plain sinus X-ray. Thus, the radiologic findings resemble those found in common
infectious or allergic polyps and in mucoceles as well as in malignant nasal tumors [9,10,13]. Some investigators have felt it possible with CT to distinguish between benign and malignant tumors on the basis of tumor appearance alone, although both benign and malignant tumors have been known to cause bone destruction. In benign cases, bone resorption is probably the result of mechanical pressure, whereas in malignant tumors the bone is infiltrated by the tumor itself [ 11,121. Plain X-ray of the sinuses does not significantly contribute to the surgeons choice of surgical procedure, since it is impossible to map the full extent of the tumor on such films [2,5,10,13]. Similarly, bone destruction is not visualized by X-ray of the sinuses [ lo]. Like us, Abildgaard et al. [l] found that CT or tomography allowed determination of tumor growth, whereas ordinary X-ray of the sinuses merely informed on ‘loss of translucency’. Abildgaard et al. [ 1] found no difference in the diagnostic value of CT and tomography. None of the cases reported by them, however, had bone destruction or malignancy. In agreement with Momose et al. [lo] we found the osseous demarcations of the tumor better visualized by CT than by tomography. Furthermore, owing to the axial plane, CT gives a better view of the anatomical condition of the sinuses [ 81. In our hands previous trials with enhancement of sinus structures by i.v. contrast have not revealed any benefits. Accordingly, contrast CT was utilized in only two cases in the present series [lo]. In neither of the cases was any contrast enhancement obtained - a predictable result considering the poor vascularization of the tumor. All scans of inverted papillomas showed uniform absorption values in the entire tumor area. With regard to frequency of recurrence, there were
139
no significant differences between our three surgical procedures. Therefore, the least extensive and radical procedure should be favoured. In our opinion, patients with IP having undergone CT will profit most from sinusectomy if the inverted papillomas are located laterally. The tumor must be of moderate size and within full view during the operation. Based on our radiological findings we advise that CT be performed in all patients with IP, except when the papillomas are located exclusively on the septum, in which case they can be inspected at the clinical examination supplemented by liberendoscopy. Patients with septal IP that can be surveyed by inspection of the nasal cavity need not be subjected to CT. In view of the high recurrence rate and risk of mahgnancy the patients should be seen regularly. We recommend follow-up every 6 or 12 months comprising clinical examination, fiberendoscopy, and, in patients with laterally located inverted papillomas, CT. Our study emphasizes the great value of CT at follow-up, whereas X-ray of the sinuses at postoperative follow-up gave no definitive information. We conclude that CT should be continuously used, also at follow-up. Acknowledgement
The authors acknowledge the support of S. Brttnner M.D., Department of Radiology, Gentofte Hospital, Copenhagen.
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