Kaohsiung Journal of Medical Sciences (2013) 29, 646e647
Available online at www.sciencedirect.com
journal homepage: http://www.kjms-online.com
LETTER TO THE EDITOR
Sinonasal inverted papilloma with intracranial extension Dear Editor, Inverted papilloma is a benign epithelial tumor with locally aggressive behavior, with the potential for malignant transformation into squamous cell carcinoma at a rate of around 10% [1]. The most common presenting symptom of an inverted papilloma is unilateral nasal obstruction, followed by rhinorrhea and epistaxis. Not much is known about the etiology of this tumor; however, allergy, human papilloma virus, chronic rhinosinusitis, environmental carcinogens, and tobacco smoking have been implicated. An 89-year-old female patient with type 2 diabetes mellitus, hypertension, left-sided breast cancer, and uterine cancer came to our emergency room due to the sudden onset of convulsions and lower limb weakness. She had a history of nasal inverted papilloma managed by endoscopic operation more than 10 years ago. Brain computed tomography was performed, which revealed a tumor arising from her frontal and ethmoid sinuses. Magnetic resonance imaging was arranged 2 days after admission, and frontal lobe invasion was noted (Fig. 1). Under nasal endoscopy, a granulomatous mass arising from the right ethmoid sinus was found. A biopsy was performed, and the pathology showed the presence of an inverted papilloma with cellular atypia. Immunohistochemical stains revealed that the lesion were weakly positive for Ki-67. Considering the patient’s age and general condition, conservative treatment with anticonvulsants was adopted with complete remission of the major neurological symptoms. Inverted papilloma arises most frequently from the lateral nasal wall and ethmoid and maxillary sinuses. The tumor extends outside the nasal cavity in 7% of cases, and sometimes into the nasopharynx and the pterygopalatine and intracranial fossae. Intracranial extensions are rare. In the study by Miller et al. [2], 1469 cases were reviewed and only five cases demonstrated extension into the anterior cranial fossa. Inverted papilloma with intracranial extension is usually seen in recurrent cases, and this is especially
true if the lesion affects the cribriform plate, fovea ethmoidalis, or orbits [3]. In a recent report by Visvanathan et al. [4], the authors claimed to have reported the first case of an inverted papilloma presenting with sudden neurological deterioration. Nevertheless, with the same sudden neurologic symptoms, no frontal sinus mucoceles were found in our case. Interestingly, many reported cases of intracranial extensions of inverted papillomas have experienced some typical neurological symptoms [2]. Taking our case into consideration, it is possible that even without the development of a mucocele, sudden neurological deterioration may occur.
Figure 1. Tumor arising from the right frontal and ethmoid sinuses with frontal lobe invasion (arrow) is revealed by magnetic resonance imaging.
1607-551X/$36 Copyright ª 2013, Kaohsiung Medical University. Published by Elsevier Taiwan LLC. All rights reserved. http://dx.doi.org/10.1016/j.kjms.2013.05.001
Letter to the Editor Currently, it is widely accepted that extradural intracranial disease should be treated with radical excision, which usually requires a craniofacial approach [3]. However, dural invasion of inverted papillomas is associated with a decreased survival rate, regardless of the method of treatment. Chen et al. [5] found that the correct diagnosis prior to surgery is a determinant of outcome. The authors even recommended that using frozen sections may improve outcome. In conclusion, especially in recurrent cases, clinicians should be aware of the intracranial extensions of inverted papillomas, even if the patient appears to not have symptoms.
References [1] Eggers G, Muhling J, Hassfeld S. Inverted papilloma of paranasal sinuses. J Craniomaxillofac Surg 2007;35: 21e9. [2] Miller PJ, Jacobs J, Roland Jr JT, Cooper J, Mizrachi HH. Intracranial inverting papilloma. Head Neck 1996;18:450e3. discussion 454. [3] Vural E, Suen JY, Hanna E. Intracranial extension of inverted papilloma: an unusual and potentially fatal complication. Head Neck 1999;21:703e6.
647 [4] Visvanathan V, Wallace H, Chumas P, Makura ZG. An unusual presentation of inverted papilloma: case report and literature review. J Laryngol Otol 2010;124:101e4. [5] Chen CM, Tsai YL, Chang CC, Chen HC, Chen MK. Is planned surgery important in sinonasal inverted papilloma? B-ENT 2009;5:225e31.
Chiang Sun Department of Otolaryngology, Taipei Medical University Hospital, Taipei, Taiwan En-Yuan Lin Department of Neurosurgery, Taipei Medical University Hospital, Taipei, Taiwan Shih-Han Hung* Department of Otolaryngology, Taipei Medical University Hospital, Taipei, Taiwan *Corresponding author. Department of Otolaryngology, Taipei Medical University Hospital, Number 252, Wu-Hsing Street, Taipei City 110, Taiwan. E-mail address: [email protected] (S.-H. Hung)
Available online at www.sciencedirect.com
journal homepage: http://www.kjms-online.com
LETTER TO THE EDITOR
Sinonasal inverted papilloma with intracranial extension Dear Editor, Inverted papilloma is a benign epithelial tumor with locally aggressive behavior, with the potential for malignant transformation into squamous cell carcinoma at a rate of around 10% [1]. The most common presenting symptom of an inverted papilloma is unilateral nasal obstruction, followed by rhinorrhea and epistaxis. Not much is known about the etiology of this tumor; however, allergy, human papilloma virus, chronic rhinosinusitis, environmental carcinogens, and tobacco smoking have been implicated. An 89-year-old female patient with type 2 diabetes mellitus, hypertension, left-sided breast cancer, and uterine cancer came to our emergency room due to the sudden onset of convulsions and lower limb weakness. She had a history of nasal inverted papilloma managed by endoscopic operation more than 10 years ago. Brain computed tomography was performed, which revealed a tumor arising from her frontal and ethmoid sinuses. Magnetic resonance imaging was arranged 2 days after admission, and frontal lobe invasion was noted (Fig. 1). Under nasal endoscopy, a granulomatous mass arising from the right ethmoid sinus was found. A biopsy was performed, and the pathology showed the presence of an inverted papilloma with cellular atypia. Immunohistochemical stains revealed that the lesion were weakly positive for Ki-67. Considering the patient’s age and general condition, conservative treatment with anticonvulsants was adopted with complete remission of the major neurological symptoms. Inverted papilloma arises most frequently from the lateral nasal wall and ethmoid and maxillary sinuses. The tumor extends outside the nasal cavity in 7% of cases, and sometimes into the nasopharynx and the pterygopalatine and intracranial fossae. Intracranial extensions are rare. In the study by Miller et al. [2], 1469 cases were reviewed and only five cases demonstrated extension into the anterior cranial fossa. Inverted papilloma with intracranial extension is usually seen in recurrent cases, and this is especially
true if the lesion affects the cribriform plate, fovea ethmoidalis, or orbits [3]. In a recent report by Visvanathan et al. [4], the authors claimed to have reported the first case of an inverted papilloma presenting with sudden neurological deterioration. Nevertheless, with the same sudden neurologic symptoms, no frontal sinus mucoceles were found in our case. Interestingly, many reported cases of intracranial extensions of inverted papillomas have experienced some typical neurological symptoms [2]. Taking our case into consideration, it is possible that even without the development of a mucocele, sudden neurological deterioration may occur.
Figure 1. Tumor arising from the right frontal and ethmoid sinuses with frontal lobe invasion (arrow) is revealed by magnetic resonance imaging.
1607-551X/$36 Copyright ª 2013, Kaohsiung Medical University. Published by Elsevier Taiwan LLC. All rights reserved. http://dx.doi.org/10.1016/j.kjms.2013.05.001
Letter to the Editor Currently, it is widely accepted that extradural intracranial disease should be treated with radical excision, which usually requires a craniofacial approach [3]. However, dural invasion of inverted papillomas is associated with a decreased survival rate, regardless of the method of treatment. Chen et al. [5] found that the correct diagnosis prior to surgery is a determinant of outcome. The authors even recommended that using frozen sections may improve outcome. In conclusion, especially in recurrent cases, clinicians should be aware of the intracranial extensions of inverted papillomas, even if the patient appears to not have symptoms.
References [1] Eggers G, Muhling J, Hassfeld S. Inverted papilloma of paranasal sinuses. J Craniomaxillofac Surg 2007;35: 21e9. [2] Miller PJ, Jacobs J, Roland Jr JT, Cooper J, Mizrachi HH. Intracranial inverting papilloma. Head Neck 1996;18:450e3. discussion 454. [3] Vural E, Suen JY, Hanna E. Intracranial extension of inverted papilloma: an unusual and potentially fatal complication. Head Neck 1999;21:703e6.
647 [4] Visvanathan V, Wallace H, Chumas P, Makura ZG. An unusual presentation of inverted papilloma: case report and literature review. J Laryngol Otol 2010;124:101e4. [5] Chen CM, Tsai YL, Chang CC, Chen HC, Chen MK. Is planned surgery important in sinonasal inverted papilloma? B-ENT 2009;5:225e31.
Chiang Sun Department of Otolaryngology, Taipei Medical University Hospital, Taipei, Taiwan En-Yuan Lin Department of Neurosurgery, Taipei Medical University Hospital, Taipei, Taiwan Shih-Han Hung* Department of Otolaryngology, Taipei Medical University Hospital, Taipei, Taiwan *Corresponding author. Department of Otolaryngology, Taipei Medical University Hospital, Number 252, Wu-Hsing Street, Taipei City 110, Taiwan. E-mail address: [email protected] (S.-H. Hung)
