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Diagnostic Procedures
See the list below:
Biopsy is the most important diagnostic tool when a sinonasal papilloma is suspected.
If intracranial pathology may be manifesting in the sinonasal cavity (ie, encephalocele,
meningocele, meningoencephalocele), perform imaging studies before biopsy.
Histologic Findings
SPs can be divided into 3 histologic subtypes: inverted, fungiform, and cylindrical (columnar). Inverted
papillomas have an endophytic growth pattern found almost exclusively on the lateral nasal wall; these
account for 47% of all cases of SPs. On the contrary, fungiform papillomas constitute approximately 50% of
sinonasal SPs and have an exophytic type of growth. They are found mainly on the nasal septum.
Cylindrical papillomas are the rarest type (3-5%) and are also called oncocytic SPs.
On gross examination, SPs originate from a narrow or broad-based stalk. Sinonasal papillomas have an
irregular, friable appearance and bleed easily. On microscopy, the fungiform type is mainly composed of
thick squamous epithelium and, less frequently, respiratory epithelium arranged in papillary fronds with
exophytic type of growth. By comparison, the inverted type, which has an endophytic or inverted growth
pattern, consists of thickened squamous epithelium admixed with mucocytes and intraepithelial mucous
cysts. The cylindrical papilloma is composed of multilayered epithelium with an eosinophilic cytoplasm
among which intraepithelial mucin cysts are identified.
Treatment & Management
Medical Therapy
Recognition of the propensity for recurrence and the association with malignancy has led to the evolution of
treatment of sinonasal papillomas (SPs). The role of medical therapy is limited; it is used mainly as an
adjunct to specific complications such as sinusitis.
Radiotherapy
Radiation therapy is generally not indicated in the treatment of benign papillomatous lesions. It is ineffective
in the treatment of SPs, and it carries the presumed risk of malignant transformation in an otherwise benign
lesion. However, radiation therapy can be used in the treatment of advanced and biologically aggressive
SPs of the sinonasal tract or in those patients in whom the morbidity of the radical surgery would be
intolerable. In cases in which SPs are associated with squamous cell carcinoma, radiation therapy appears
to be an effective adjunctive procedure.[11, 12]
Surgical Therapy
Most clinicians agree that surgery is the treatment of choice for SPs. However, no consensus has been
reached on the type or extent of surgical intervention.
The 3 goals of an adequate surgical procedure are to (1) allow exposure sufficient for complete resection of
the tumor, (2) provide an unobstructed view for postoperative surveillance of the cavity, and (3) minimize
cosmetic deformities and functional disabilities.
Early attempts to treat inverting papillomas with simple and conservative procedures frequently resulted in
recurrence rates of 40-80%. Included among the conservative procedures were the intranasal approach
(alone or combined with the Caldwell-Luc operation) and Denker rhinotomy. This high recurrence rate
combined with the possibility of the multicentric origin of SPs led many surgeons to advocate aggressive
early management with medial maxillectomy by using either lateral rhinotomy or midfacial degloving. A
review of the surgical anatomy in the areas of recurrences show that the most common sites of recurrence
are the lateral nasal wall in the middle meatus, the nasofrontal duct area, the supraorbital ethmoid cells, the
region of the lacrimal fossa, and the infraorbital or prelacrimal recess of the maxillary sinus.
Many surgeons consider lateral rhinotomy with en bloc ethmoidectomy and medial maxillectomy the
treatment of choice for SPs. This surgical procedure is associated with a recurrence rate lower than that of
other conservative procedures. Michaux first described the lateral-rhinotomy approach in 1848, and
popularized it in Moure in 1902. Wong and Heeneman refined the approach with 4 subtypes. [13]
In the last 10 years, increasing numbers of authors have reported on endoscopic resection of SP. When
appropriately performed, these procedures have success and recurrence rates similar to those of open
medial maxillectomy. In many institutions, endoscopic or endoscopy-assisted resection, including
transnasal endoscopic medial maxillectomy (TEMM), tailored to the extent of disease is becoming a
common treatment. The authors recently reported on the anatomic basis for TEMM as an oncologic
approach for sinonasal neoplasms.[14] A recent meta-analysis and another systematic literature review
support endoscopic approach as a favorable treatment option compared with open approaches. [15, 16, 17, 18]
Intraoperative Details
Lateral rhinotomy approach
The lateral rhinotomy approach involves a curvilinear incision between the medial canthus and the dorsum
of the nose. For this procedure, start the incision under the medial end of the eyebrow, extend the incision
inferiorly between the medial canthus and the nasal dorsum and along the deep nasal-cheek groove
adjacent to the ala of nose. Then, swing the incision up onto the floor of the nose. The incision includes the
full thickness of skin down to the periosteum. A gentle W- or Z-plasty incision can be incorporated into the
medial canthus region to help prevent postoperative webbing of the soft tissue.
After the skin incision is made, elevate the periosteum to expose the medial orbital wall, the anterior
maxillary wall up to the infraorbital foramen, and the pyriform aperture. The nasal bones can be retracted
medially after medial and lateral osteotomies are performed. To achieve en bloc resection, perform
osteotomies through the inferior and anterior aspects of the medial wall of the maxilla, through the medial
wall of the orbit just inferior to the frontoethmoid suture line, and through the inferior orbital rim and orbital
floor. By connecting these osteotomies, the specimen can be mobilized by using a heavy, curved Mayo
scissors, which can be used separate the specimen from the posterior wall of the maxillary sinus.
For medial maxillectomy, include the region of the lacrimal fossa, the infraorbital rim, and the prelacrimal
recess of the maxillary sinus. Divide the lateral nasal wall along the floor of the nose. Amputate the middle
turbinate below its superior attachment, and remove the entire lateral wall intact after its detachment from
the rest of the infraorbital rim.
To avoid epiphora, which is a common postoperative complication of this procedure, always
incorporate dacryocystorhinostomy. Dacryocystorhinostomy can be accomplished by catheterization of the
lacrimal duct by using an indwelling silicone tube (Guibor tube) or by incising the lacrimal sac vertically and
sewing the edges to the adjacent tissues.
The medial canthus is usually displaced from its insertion and should be fixed to prevent unsightly
telecanthus. If the tendon elevated is attached to the periosteum, it resumes its normal position after careful
closure of the periosteum. Sometimes, the tendon is transected and should be tagged and approximated at
the end of the procedure. Transnasal wiring is required if the lacrimal crest and adjacent bone are included
in the resection.
After general endotracheal anesthesia is administered, perform topical intranasal decongestion with 2%
oxymetazoline-soaked neurosurgical pledgets. Transorally infiltrate 1% lidocaine with 1:100,000
epinephrine into the sphenopalatine foramen. Inject the medication intranasally along the inferior meatal
wall, into the turbinates, along the maxillary crest, up to the attachment of the middle turbinate, and into the
tumor. Make the initial incision along the superior resection margin, which includes the ethmoids as seen in
the image below. Apply bipolar cautery, then sever the attachment of the middle turbinate to the lateral
nasal wall with endoscopic scissors.
By using a Freer elevator, perform the dissection along the roof of the ethmoids up to the sphenoid rostrum.
Identify the ethmoid arteries, and cauterize them with bipolar cautery. Next, perform inferior resection, as
seen in the image below, at the inferior meatus. Cut the mucosa with the electrocautery device at the
junction of the lateral wall and the floor of the nose. Perform inferior meatotomy at the anterior end of the
meatus. By using a straight osteotome, osteotomize the inferior meatus up to the posterior wall of the
maxillary sinus.
Anterior resection, as seen in the image below, includes a cut made inferiorly from the anterior attachment
of the middle turbinate to include the uncinate process and the maxillary crest. The cut is continued anterior
to the inferior turbinate head to connect to the inferior meatotomy cuts.
After the soft tissue is elevated, perform anterior osteotomy along the maxillary crest into the maxillary
sinus. Then, sever the nasolacrimal duct with endoscopic scissors and include the duct in the specimen.
Mobilize the lateral wall medially with progressive dissection until it is pedicled on the sphenopalatine artery
(as seen in the image below). Likewise, mobilize any tumor in the sinus.
Clip, cauterize, and cut the sphenopalatine artery. Cut the posterior attachment of the inferior turbinate, and
remove the lateral wall along with the tumor. Remove the remaining mucosa of the ethmoids superiorly,
and laterally if needed, for margin control, and remove the lining of the maxillary sinus if needed for margin
control. If necessary, the lamina papyracea and adjacent medial wall of the orbit may be removed. By using
30 and 70 scopes, the entire lining of the superior and lateral wall of the maxillary sinus can be visualized,
and the mucosa can be removed to clear potential multicentric disease. The anterior wall of the sphenoid
sinus can easily be resected if needed.
Follow-up
Important in the management of sinonasal SPs is long-term follow-up. Many authors believe that most
recurrences occur within the first 2 years of treatment. However, most recurrences are observed 5-10 years
after treatment. Start follow-up care at regular intervals for at least 5 years after initial management. Nasal
endoscopy is essential for follow-up and monitoring for disease recurrence.
Complications
Complications can occur after surgical resection of sinonasal papillomas (SPs). The most serious
complications are related to the orbit. Blepharitis, diplopia, and intermittent dacryocystitis have been
reported after lateral rhinotomy and medial maxillectomy. Ectropion can result secondary to scarring with a
downward pull of the lower lid. CSF leak can develop if the base of the skull is violated during surgery.
Late complications include prolonged crusting, infection, nasocutaneous fistula, vestibular stenosis, and
nasal-valve collapse.
The most common complication after the midfacial degloving procedure is vestibular stenosis. Oroantral
fistula, intermittent paresthesia, and prolonged crusting can also occur.
Endoscopic resection poses the same risk of any endoscopic sinus surgery. Potential complications include
CSF leak, orbital complications (orbital or periorbital hematoma, diplopia, injury to the optic nerve, injury to
the extraocular muscle, epiphora) prolonged crusting, bleeding, infection, and synechia.
Many reports in the literature support successful treatment of SPs with endoscopic sinus surgery.
Preoperative CT scanning and MRI allow for an accurate assessment of the extent of the lesion and,
hence, allow for improved selection of the lesions appropriate for endoscopic resection. MRI can help in
clearly distinguishing a tumor from opacification secondary to obstructive sinusitis. Endoscopic resection
may include total sphenoethmoidectomy, wide meatotomy, resection of the middle turbinectomy, and
visualization of the frontal sinus. Some have advocated sampling of the margins. All specimens should be
sent for histopathologic examination to ensure complete removal of papillomatous lesions.
Authors of a new study advocate the use of a microdebrider with endoscopic sinus surgery to resect SPs.
The various tissues resected and suctioned through the microdebrider must be collected in a separate
container and sent for histopathologic study to rule out malignancy. The different tissue entities resected by
using the microdebrider do not lose their important morphologic features.
Investigators continue to endorse the endoscopic approach as a feasible and effective approach for the
treatment of sinonasal papilloma. The technique is increasing refined and tailored to the extent of the
disease, and systematic and well-defined steps to reproducibly perform endoscopic medial maxillectomy
are defined. Authors with long-term experience with the open approaches are also performing endoscopic
approaches with comparable or improved success.
The advantages of the endoscopic transnasal approach over traditional medial maxillectomy are the lack of
an external scar and its related potential for cosmetic deformity; shortened hospitalization; decreased blood
loss; and ability to directly visualize the precise extent of the tumor, which increases the likelihood of
complete resection. Furthermore, the reported recurrence rate of SPs after endoscopic resection
(approximately 17%) is comparable with that of the standard technique of lateral rhinotomy and medial
maxillectomy.
The endoscopic approach had already been successful in papillomatous lesions confined to the lateral
nasal wall or minimally extending into adjacent paranasal sinuses. Reports also suggest its effectiveness in
more advanced disease. Involvement of the maxillary sinus is no longer considered a contraindication to
endoscopic or endoscopy-assisted surgery. Some authors have suggested the addition of the Caldwell-Luc
procedure to the endoscopic approach when the anterior or posterolateral maxillary sinus is involved. The
presence of carcinoma in the endoscopically resected specimen likely indicates a need for more
aggressive treatment, depending on the size and location of the carcinomatous foci. For tumors that arise
from the frontal sinus, endoscopic sinus surgery is similarly contraindicated.
Detailed preoperative assessment of the extent of the lesion with CT and/or MRI helps in selecting and
individualizing the approach for each patient. In addition, the skill and experience of the surgeon with
regard to a particular procedure are important factors in selecting the right approach for each patient.
For additional information, see Human Papillomavirus.
Studi pencitraan
Lihat daftar di bawah ini:
penilaian radiografi preoperatif papiloma sinonasal (SPs) memainkan peran
penting dalam menentukan perpanjangan penyakit dan keterlibatan struktur
yang berdekatan; oleh karena itu, memilih pendekatan yang tepat adalah
penting.
Coronal dan aksial CT kontras ditingkatkan dianggap studi pilihan untuk menilai
lesi intranasal.
o Sebanyak 75% dari pasien dengan SPs memiliki bukti berbagai tingkat
kerusakan tulang. Ini mungkin termasuk penipisan, renovasi, erosi, dan (jarang)
berdarah. Pada mikroskop, jenis fungiform terutama terdiri dari epitel tebal
skuamosa dan, lebih jarang, epitel pernapasan diatur dalam daun papiler dengan
jenis exophytic pertumbuhan. Sebagai perbandingan, jenis terbalik, yang
memiliki endofit atau pola pertumbuhan terbalik, terdiri dari epitel skuamosa
menebal dicampur dengan mucocytes dan kista mukosa intraepitel. Silinder
papilloma terdiri dari epitel berlapis-lapis dengan sitoplasma eosinofilik
antaranya kista musin intraepithelial diidentifikasi.
Pengobatan & Manajemen
Terapi medis
Pengakuan kecenderungan untuk kambuh dan asosiasi dengan keganasan telah
menyebabkan evolusi pengobatan papiloma sinonasal (SPs). Peran terapi medis
terbatas; itu digunakan terutama sebagai tambahan untuk komplikasi tertentu
seperti sinusitis.
Radioterapi
Terapi radiasi umumnya tidak diindikasikan dalam pengobatan lesi papillomatous
jinak. Hal ini tidak efektif dalam pengobatan SPs, dan itu membawa risiko
dugaan transformasi ganas di lesi dinyatakan jinak. Namun, terapi radiasi dapat
digunakan dalam pengobatan SPs maju dan biologis agresif saluran sinonasal
atau pada pasien-pasien di antaranya morbiditas dari operasi radikal akan
ditolerir. Dalam kasus di mana SPs berhubungan dengan karsinoma sel
skuamosa, terapi radiasi tampaknya menjadi prosedur ajuvan yang efektif. [11,
12]
Terapi bedah
Kebanyakan dokter setuju bahwa operasi adalah pengobatan pilihan untuk SPs.
Namun, tidak ada konsensus telah dicapai pada jenis atau tingkat intervensi
bedah.
The 3 gol dari prosedur bedah yang memadai untuk (1) memungkinkan paparan
cukup untuk reseksi lengkap tumor, (2) memberikan pandangan yang terhalang
untuk pengawasan pasca operasi rongga, dan (3) meminimalkan cacat kosmetik
dan cacat fungsional.
Upaya awal untuk mengobati pembalik papiloma dengan prosedur sederhana
dan konservatif sering mengakibatkan tingkat kekambuhan 40-80%. Termasuk di
antara prosedur konservatif pendekatan intranasal (sendiri atau dikombinasikan
dengan operasi Caldwell-Luc) dan Denker rhinotomy. tingkat kekambuhan tinggi
ini dikombinasikan dengan kemungkinan asal multisenter SPs menyebabkan
banyak ahli bedah untuk melakukan advokasi manajemen awal agresif dengan
medial maxillectomy dengan menggunakan salah rhinotomy lateral atau
degloving midfasial. Sebuah tinjauan anatomi bedah di bidang kekambuhan
menunjukkan bahwa situs yang paling umum kekambuhan adalah dinding lateral
hidung di meatus tengah, daerah saluran nasofrontal, sel-sel ethmoid
supraorbital, wilayah fosa lakrimal, dan infraorbital atau reses prelacrimal dari
sinus maksilaris.
Banyak ahli bedah menganggap rhinotomy lateralis dengan en bloc
ethmoidectomy dan medial maxillectomy pengobatan pilihan untuk SPs.
Prosedur bedah ini dikaitkan dengan tingkat kekambuhan lebih rendah dari
prosedur konservatif lainnya. Michaux pertama kali dijelaskan pendekatan lateral
rhinotomy pada tahun 1848, dan dipopulerkan dalam Moure pada tahun 1902.
Wong dan Heeneman disempurnakan pendekatan dengan 4 subtipe. [13]
Dalam 10 tahun terakhir, semakin banyak penulis telah melaporkan reseksi
endoskopik dari SP. Ketika tepat dilakukan, prosedur ini sukses dan kekambuhan
tarif mirip dengan maxillectomy medial terbuka. Dalam banyak lembaga,
endoskopi atau endoskopi dibantu reseksi, termasuk transnasal maxillectomy
medial endoskopik (TEMM), disesuaikan dengan luasnya penyakit menjadi
pengobatan umum. Para penulis baru-baru ini dilaporkan atas dasar anatomi
untuk TEMM sebagai pendekatan onkologi untuk neoplasma sinonasal. [14]
Sebuah meta-analisis dan sistematis literatur pendekatan dukungan endoskopik
lain sebagai pilihan pengobatan yang menguntungkan dibandingkan dengan
pendekatan terbuka. [15, 16, 17 , 18]
Detail intraoperatif
Pendekatan rhinotomy Lateral
Pendekatan rhinotomy lateral yang melibatkan sayatan lengkung antara canthus
medial dan dorsum hidung. Untuk prosedur ini, mulai sayatan di bawah ujung
medial alis, memperpanjang sayatan inferior antara canthus medial dan dorsum
nasal dan sepanjang dalam alur hidung-pipi berdekatan dengan ala hidung.
Kemudian, ayunan sayatan naik ke lantai hidung. sayatan termasuk ketebalan
penuh kulit ke periosteum. Sebuah lembut W atau Z-plasty sayatan dapat
dimasukkan ke dalam wilayah canthus medial untuk membantu mencegah
anyaman pasca operasi dari jaringan lunak.
Setelah irisan kulit dibuat, meningkatkan periosteum untuk mengekspos dinding
medial orbital, anterior rahang atas dinding sampai ke foramen infraorbital, dan
aperture pyriform. Tulang hidung dapat ditarik medial setelah medial dan
osteotomies lateral dilakukan. Untuk mencapai en bloc reseksi, melakukan
osteotomies melalui aspek inferior dan anterior dinding medial dari rahang atas,
melalui dinding medial orbit hanya kalah dengan garis jahitan frontoethmoid,
dan melalui pelek orbital inferior dan lantai orbital. Dengan menghubungkan
osteotomies ini, spesimen dapat dimobilisasi dengan menggunakan berat,
melengkung Mayo gunting, yang dapat digunakan terpisah spesimen dari
dinding posterior sinus maksilaris.
Untuk maxillectomy medial, termasuk wilayah fosa lakrimal, pelek infraorbital,
dan reses prelacrimal dari sinus maksilaris. Membagi dinding lateral hidung
sepanjang lantai hidung. Mengamputasi konka bawah lampiran superior, dan
menghapus seluruh dinding lateral utuh setelah detasemen nya dari sisa tepi
infraorbital.
Untuk menghindari epifora, yang merupakan komplikasi pasca operasi umum
dari prosedur ini, selalu menggabungkan dacryocystorhinostomy.
Dacryocystorhinostomy dapat dilakukan dengan kateterisasi duktus lakrimal
dengan menggunakan tabung berdiamnya silikon (Guibor tube) atau dengan
menggores kantung lakrimal vertikal dan menjahit tepi ke jaringan yang
berdekatan.
The kantus medial biasanya dipindahkan dari penyisipan dan harus tetap untuk
mencegah telecanthus sedap dipandang. Jika tendon ditinggikan melekat
periosteum, resume posisi normal setelah penutupan hati-hati periosteum.
Kadang-kadang, tendon transected dan harus ditandai dan diperkirakan pada
akhir prosedur. Transnasal kabel diperlukan jika puncak lakrimal dan tulang yang
berdekatan termasuk dalam reseksi tersebut.
Pendekatan degloving midfasial
Alternatif, serbaguna, dan pendekatan yang direkomendasikan adalah degloving
midfasial total eksisi SP. Pendekatan ini terdiri dari mengangkat jaringan lunak
dari bagian pertengahan wajah dengan cara sayatan sublabial.
Empat jenis sayatan yang diperlukan dalam pendekatan degloving midfasial: (1)
sayatan intercartilaginous bilateral, (2) a penusukan septocolumellar lengkap
sayatan, (3) bilateral insisi sublabial dari tuberositas maksila ke tuberositas, dan
(4) piriformis bilateral aperture sayatan memperluas ke ruang depan. sayatan ini
memfasilitasi paparan dari aperture piriformis dan dinding lateral hidung. En bloc
reseksi dari dinding lateral hidung mudah untuk melakukan, dan itu memberi
kemungkinan memperpanjang prosedur untuk menyertakan
sphenoethmoidectomy dan dinding orbital medial sebagai didikte oleh luasnya
lesi.
Keuntungan dari pendekatan ini termasuk tidak ada jaringan parut eksternal,
visibilitas yang baik dari bidang operasi, dan paparan bilateral simultan. Selain
itu, tingkat kekambuhan SP dipotong dengan menggunakan prosedur degloving
midfasial adalah mirip dengan rhinotomy lateral dan maxillectomy medial.
Seperti dengan rhinotomy lateral, pendekatan degloving midfasial dapat
dikombinasikan dengan pendekatan kraniofasial untuk mengobati lesi yang
melibatkan dasar tengkorak atau fossa kranial anterior.
Keterbatasan utama dari pendekatan degloving midfasial adalah ketika operasi
diperlukan untuk tumor yang lebih luas yang menyerang sel-sel ethmoid
supraorbital atau sinus frontalis, yang memerlukan insisi terpisah. translokasi
septal melalui sayatan sublabial adalah pendekatan lain yang berbagi
keuntungan yang sama dari pendekatan degloving midfasial. Ini memberikan
paparan luas tanpa jaringan parut eksternal.
Endoskopi maxillectomy medial
karsinomatosa. Untuk tumor yang muncul dari sinus frontal, bedah sinus
endoskopi juga sama kontraindikasi.
penilaian pra operasi rinci sejauh mana lesi dengan CT dan / atau MRI membantu
dalam memilih dan individualistis pendekatan untuk setiap pasien. Selain itu,
keterampilan dan pengalaman dokter bedah berkaitan dengan prosedur tertentu
merupakan faktor penting dalam memilih pendekatan yang tepat untuk setiap
pasien.
Untuk informasi tambahan, lihat Human Papillomavirus.