2. Papilloma of the nose
Definition
Benign locally aggressive neoplasm originating from the
schneiderian membrane of nasal cavity
Male : female 3:1
Age group –30-50
3. Most common site – lateral wall (70%)
ethmoid complex
septum
4. Papilloma are of three types
Fungiform/ papillary/exophytic/everted papilloma
Inverted papilloma
Cylindrical papilloma
6. DEFINITION
A Benign epithelial neoplasm arising from
Schneiderian membrane of nose and paranasal
sinuses.
The mucosal lining of nose and paranasal sinuses is
known as Schneiderian membrane .
Papillomas arising from this membrane is very unique
in that they are found to be growing inwardly and
hence the term inverted papilloma .
7. Inverted papillomas behave like neoplasms, arising
from reserve / replacement cells located at the
basement membrane of the mucosa due to
UNKNOWN stimulus .
The resulting thickening of the epithelium assumes an
inverting, fungiform or combination growth pattern
8. Depending on the degree of metaplasia varying
amounts of respiratory / cylindrical cells may be seen
in Schneiderian papillomas .
Rarely the papilloma may be composed entirely of
cylindrical cells, and hence the term cylindrical cell
papillomas is used to describe this subtype.
9. ANATOMIC CLASSIFICATION OF SCHNEIDERIAN
PAPILLOMA
Inverted papilloma can be classified according to its
site of occurrence i.e. Lateral wall and septal
papillomas .
Septal papillomas remain confined to the nasal
septum and may very rarely involve the roof and floor
of the nasal cavity. Carcinomatous transformation is
rare in septal papillomas & Vice versa in lateral wall
papillomas
10. INCIDENCE
M > F, 20 to 70 yrs .
Mean age is 50 yrs .
ETIOLOGY
HPV (with mutation of genes) 6,11,16,57b
11. GROSS APPREARANCE
1. Papillary and exophytic.
2. Inverted with inwardly invaginating epithelial
growth into underlying stroma.
A combination of both patterns also can occur
The papillary form/fungiform papilloma tends to
commonly occur in the nasal septum, while the
inverted form often occurs in the lateral wall of the
nose and sinuses
13. MICROSCOPY
Papillary form : epithelial proliferation over a thin core of
connective tissue. Inversion of epithelial masses is
usually not present .
In inverted papilloma of lateral wall –
Proliferation of the covering epithelium & extensive
finger like inversion in to the underlying stroma of the
epithelium
When they undergo malignant transformation the
stroma is found to be breached .
The predominant cell type in these papillomas is
epidermoid in nature .
15. Intercellular bridges can be clearly demonstrated.
Microscopic mucous cysts can also be identified in
both these types.
It shows complex ,arborescent exoendophytic growth
pattern with primary ,secondary & tertiary
ramifications in to underlying stroma
Keratinisation is very minimal. Excessive
keratinisation is very rare, and should prompt the
pathologist to other diagnosis like malignant
transformation
17. Clinical features
Unilateral nasal mass .
Commonly fleshy in nature .
Sometimes it may occur behind a sentinel nasal polyp
It commonly involves the nasal cavity, erodes the
medial wall of maxilla and may present inside the
maxillary sinus
19. KROUSE STAGING SYSTEM
(1) Tumour confined to nasal cavity with no evidence
of malignancy.
(2) Tumour involving the ostiomeatal complex,
ethmoid sinuses, and/or medial portion of maxillary
sinus ,with no evidence of malignancy .
(3) Tumour involving the lateral, inferior, superior,
anterior, or posterior walls of maxillary sinus, the
sphenoid sinus, and/or the frontal sinus with or
without involvement of the nasal cavity.
(4) All malignant tumours and those tumours with
extra nasal and extra sinus extension.
20. Schwals staging
T1 –Confined to nasal cavity
T2 &T3– Progressive involvement of PNS
T4– Tumour extended in to orbit or intra cranial cavity
21. Skolnick et al
T1 – Tumour confined to one anatomical site with in
the nose
T2 – Tumour involves two sites with in the nose
T3– Involvement of sinuses
T4—Extension outside the nose and sinuses
22. Can get transformed to
Transitional cell carcinoma
Squamous cell carcinoma
Inverted papilloma can coexist with squamous cell
carcinoma in 27% (synchronous)
28. Treatment
Choice –surgery with marginal clearance
Endoscopic medial maxillectomy
Recurrance ..Lateral rhinotomy (moure”s incision) &
Medial maxillectomy+ with spheno ethmoidal
clearance (en-bloc dissection) depending on extent of
tumour
29. Endoscopic medial maxillectomy
Indications
Inverted Papilloma (Schneiderian Papilloma)
Benign sinonasal neoplasms arising from the lateral
nasal wall or maxillary sinus
Highlights:
Sinonasal landmarks are identified, including the
maxillary sinus ostium, middle & inferior turbinates,
and ethmoid roof
Attachment of the tumor (stalk) is identified and
transected
Bulk of the tumor is excised
30. Bone at the base of the tumor (stalk attachment site) is
drilled and/or resected in order to clear microscopic
disease
The entire lateral nasal wall, including the inferior
turbinate, is resected
At the completion of surgery the maxillary sinus and
nose should be a common cavity, enhancing
postoperative surveillance for tumor recurrence
31. Keep in mind:
If the nasolacrimal duct is transected during surgery, a
lacrimal stent is placed to decrease the likelihood of
postoperative epiphora. This stent is removed one
week after surgery.
Postoperative nasal saline irrigations are helpful to
clear crusts which commonly form after this surgery
35. Sub cranial approach Lateral rhinotomy is generally
reserved if exenteration of the orbit is needed
simultaneously
BEST Endoscopic Resection
Caldwell-Luc or the “limited open approach” was
initially used but has fallen out of favour , given the
poor visualization and higher rates of recurrence
associated with this technique