British Journal of Plastic Surgery (1983) 36.254251 0 1983 The Trustees of British Association of Plastic Surgeons

Inverted papilloma of the nose: an unusual cause of a medial canthal mass

A. L. H. MOSS

Plastic Surgery Unit, Frenchay Hospital, Bristol

Summary-Inverted papillomata usually rise from the mucosa of the nose and/or sinuses and present with signs and symptoms indistinguishable from those produced by ordinary nasal polyps. This benign neoplasm rarely arises from the nasolacrimal system or presents as an external mass. A case is described that demonstrated both these rare features. It is being reported to draw attention to the existence of this type of tumour and to illustrate its characteristic tendency to local recurrence. A brief review of the literature is given together with a recommended surgical approach.

Case report at the right inner canthus. Investigations including A 40-year-old Caucasian woman presented with a tomography and CAT scanning showed clouding of the 6-month history of a swelling at the right medial canthus ethmoid sinuses without any bony erosion. (Fig. 1). She complained of intermittent bouts of At operation the hard nodule measuring 2 x 2.5 cm at epiphora and “conjunctivitis”. Four years earlier she the inner canthus was found to involve the lacrimal sac

Fig. 1

Figure I-Pre-operative view to show the swelling at the right inner canthus.

had fractured her nose. Clinically, the lump was thought and the upper part of the nasolacrimal duct (Fig. 2) both to be a mucous retention cyst but the histology report of which were resected. A formal lateral rhinostomy and following its removal proved the lesion to be an antrostomy were performed but no abnormalities were “inverted papilloma” of the nasolacrimal system. found. The ethmoid sinuses were then explored and Within 2 months she presented with a recurrent swelling some thickened mucosa was excised.

254

INVERTED PAPILLOMA OF THE NOSE 255

The medial canthal ligament was reconstructed using medially-based orbicularis muscle flaps from the upper and lower lids sutured to the frontal process of the maxilla. A silastic tube was then passed via both canaliculi down through the stump of the nasolacrimal duct and left in the nose (Fig. 3A, B).

Fig. 2

Figure 2-Intra-operative view to show the tumour and its surgical excision.

Histological examination confirmed a recurrence of the “inverted papilloma” with no evidence of malignancy. No other foci of disease were found in multiple separate biopsies. Three months later she had an acceptable appearance with no recurrence (Fig. 4).

Discussion

The “inverted papilloma” is described in the literature under at least 20 different names (Hyams, 1971; Snyder and Perzin, 1972). The lesion is regarded as a benign epithelial tumour with a local recurrence rate reported to vary between 30-74% (Hyams, 1971; Snyder and Perzin, 1972). There are no known specific aetio- logical factors though it is three times more

common in men and occurs between the fourth and seventh decades. There is uncertainty about its association with malignancy although squamous cell carcinoma may be seen in 5-15% of cases of inverted papilloma of the nose (Hyams, 1971).

These neoplasms may be found incidentally, but usually they are accompanied by the symptoms and signs of ordinary nasal polyps, which occur 25 times more commonly (Hyams, 1971). However, only six reported cases of inverted papilloma could be found presenting as an external swelling at the inner canthus (Osborn, 1970; Schoub et al., 1973; Fechner and Sessions, 1977; Ryan and Font, 1973). The lesion usually arises from the mucosa of the lateral wall of the nose or the paranasal sinuses. It is commonly unilateral but may be bilateral and multifocal. It has been described in the renal pelvis, bladder, posterior pharyngeal wall and minor salivary glands but only five reported cases arising from the nasolacrimal system could be found (Hyams, 1971; Ryan and Font, 1973; Fechner and Sessions, 1977). Radiological examination shows no abnormality in 50% of the cases: signs of “sinusitis”, with bone rarefaction or erosion occur in 10% of patients, usually indicating malignant change (Snyder and Perzin, 1972).

On review of the literature, Osborn (1970) appears to be the first to mention that one out of 168 cases of inverted papilloma of the nose presented with a medial canthal mass. This was associated with transitional cell and squamous cell carcinomata involving the antrum, orbit, frontal and ethnoid sinuses. Hyams (1971), in his series of 315 cases of inverted papilloma of the nose, mentioned that in one patient the nasolacrimal duct was involved by neoplasm.

In the case reports of Schoub et al. (1973) and of Fechner and Sessions (1977), both patients pre- sented with medial canthal masses which on biopsy confirmed the diagnosis of “inverted papilloma” of the ethmoid sinuses and of the lacrimal sac, respectively. However, the rare feature of these two reports is that, in spite of no evidence of malignancy in the surgical specimens, lymph node metastases of similar histology, were present. These patients were well at 1 and 5 years respectively.

Ryan and Font (1973) reported three cases of inverted papilloma of the lacrimal sac, all present- ing with medial canthal masses. One patient died of other causes, 1 was alive and tumour-free after 11 years and the third was alive with recurrences after 8 years.

256 BRITISH JOURNAL OF PLASTIC SURGERY

Fig. 3A

Figure 3A-lntra-operative view after resection of the tumour and ethmoidectomy.

Ethmotd SINUS Cavity

Upper Orbfcularls Muscle Flap

Hole in Nasal Process of MaxlIla

Sllastlc Tube

Lower Orblculans Muscle Flap

Slump of Nasolacrlmal Duct

. Fig. 3B

Figure 3B-Diagrammatic representation of the detail in Figure 3A to show the technique of reconstruction.

The high incidence of local recurrence with this benign tumour is usually due to inadequate excision, for example, simple polypectomy (Hyams, 1971). Although its multifocal nature may offer an explanation for some recurrences, most of these, however, occur at the site of previous excision (Hyams, 1971; Snyder and Perzin, 1972). When the diagnosis has been made on biopsy, tomography and CAT scanning may help to define the extent of the disease and to exclude any bone erosion. Treatment should include a lateral rhinotomy and a radical local excision: sometimes this may involve a medial maxillectomy and ethmoidectomy. This approach allows a good exposure of the nasal and sinus mucosa which should facilitate an adequate local resection with minimum cosmetic deformity.

Fig. 4

Figure 4-Appearance 3 months after operation, with the silastic tube still in place at the inner canthus. Note the old burn scar over the right side of the face.

INVERTED PAPILLOMA OF THE NOSE 257

Acknowledgements Ryan, S. J. and Font, R. L. (1973). Primary epithelial

I would like to thank Mr P. L. G. Townsend, FRCS, for neoplasms of the lacrimal sac. American Joubzal of

allowing me to report this patient and to the Photographic Ophthalmology (Chicago), 76, 73.

Department, Frenchay Hospital, for the illustrations. Schoub, L., Timme, A. H. and Uys, C. J. (1973). A well

differentiated inverted papilloma of the nasal space asso-

References ciated with lymph node-ietastases. South African Medical Journal (Cape Town). 47. 1663.

Fechner, R. E. and Sessions, R. B. (1977). Inverted papilloma Snyder, R.‘N.&and Per&, i. H. (1972). Papillomatosis of the of the lacrimal sac, the paranasal sinuses and the cervical nasal cavity and paranasal sinuses (inverted papilloma, region. Cancer (Philadelphia), 40, 2303. squamous papilloma): a clinico-pathological study. Cancer

Hyams, V. J. (1971). Papillomas of the nasal cavity and (Philadelphia), 30, 668. paranasal sinuses: a clinicopathological study of 315 cases. Annok of Otology, Rhinology and_Laryngoiogy (St Louis), 80. 192.

The Author

Osbdm, D. A. (1970). Nature and behaviour of transitional A. L. H. MOSS, MBBS, FRACS, Senior House Officer, tumours in the upper respiratory tract. Cancer (Phila- Plastic Surgical Unit, Frenchay Hospital, Frenchay, Bristol

delphia), 25, 50. BS16 1LE.