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115]

E-JCRT Correspondence

Inverted papilloma of atypical origin with

unusual extension into the oropharynx
ABSTRACT M. Panduranga
Inverted papilloma is a benign tumor with malignant potential that commonly arises from the lateral wall of the nose. We present Kamath,
a case of inverted papilloma, in a premalignant stage, of unusual origin and with oropharyngeal extension. The patient presented S. Vijendra
with complaints of a nasal mass arising from the left nasal cavity and progressively increasing in size since 2years. On examination Shenoy,
a fleshy, firm, sensitive mass was noted, which was attached to the medial wall, and extending posteriorly and inferiorly into the Vishnu Prasad,
oropharynx. Diagnostic nasal endoscopy and complete excision of the mass was performed with a stable postoperative period. Kiran Bhojwani,
Histopathology of the mass revealed an inverted nasal papilloma of the septum with carcinoma insitu. Radha Pai1,
Neethu Mary
Mathew
KEY WORDS: Inverted papilloma, oropharynx, nasal septum
Departments of
ENT and Head and
Neck Surgery and
INTRODUCTION On examination, the vitals and systemic examination 1
Pathology, Kasturba
were within normal limits. Examination of the nose Medical College,
Manipal University,
Inverted papilloma of the nasal cavity is a benign revealed a fleshy polypoidal firm mass protruding Mangalore, Karnataka,
neoplasm where the epithelium grows inwards, out from the left nares, the bulk of the mass filling India
exhibiting certain aggressive features such as the entire left nasal cavity. On probing, the mass
recurrence, and localized destruction of tissues and was fleshy and firm in consistency. The mass was For correspondence:
Dr.S. Vijendra Shenoy,
the possibility of malignant degeneration. It usually insensitive to touch and not bleeding on touch.
Department of
arises from the lateral nasal wall and seldom involves On examination of the oral cavity and oropharynx, Otorhinolaryngology,
the frontal or sphenoid sinuses. Inverted papillomas the fleshy mass from the nasal cavity was seen Kasturba
comprise 0.5-4% of primary nasal tumors, with no hanging from the nasopharynx, and it was up Medical College
specific side predilection.[1] The incidence of inverted to the level of the tip of the uvula within the Hospital, Manipal
University, Attavar,
papilloma on the nasal septum is further less. oropharynx[Figure2]. Mangalore575001,
Inverted papilloma of the nasal septum accounts for Karnataka, India.
between 5.5%[2] and 16.7%[2] of inverted papillomas. A contrastenhanced computed tomography scan of Email:drvijendras@
Here, we report a case of an inverted papilloma of the nose, paranasal sinuses and nasopharynx was gmail.com
the nasal septum with changes of carcinoma insitu, taken, which revealed a soft tissue density filling
managed by endoscopic resection of the tumor along bilateral nasal cavities with mild heterogeneous
with a portion of the septum. enhancement causing complete obliteration of
the left nasal cavity and partial obliteration of the
CASE REPORT right nasal cavity with extension into the posterior
nasal choana, and nasopharynx up to the upper
An 83yearold male patient with no comorbid limit of the oropharynx with obliteration of the
illnesses presented with complaints of left sided nasopharynx[Figures3 and 4]. The patient was
nasal obstruction for 2years and a nasal mass posted for endoscopic excision of the mass under
arising from the left nasal cavity since 1year. general anesthesia. The patient was induced with
The nasal obstruction was insidious in onset, general anesthesia, and a throat pack was secured. Access this article online
gradually progressing along with a mass within The nasal cavity was topically decongested with Website: www.cancerjournal.net
the left nasal cavity, which is filling the entire cottonoids soaked in 4% lignocaine mixed with DOI: 10.4103/0973-1482.140830
cavity and minimally protruding out of the anterior adrenaline. Local infiltration of the septum was PMID: ***

nares[Figure1]. He also had a hyponasal voice done with 2% lignocaine mixed with adrenaline. Quick Response Code:

and persistent mucopurulent, nonblood stained
nasal discharge on the same side. There was
no associated ear, throat, or ophthalmological
complaints. The patient also had no history of
weight loss or appetite loss.
A4mm 0 rigid nasal endoscope connected to
the camera was passed into the nasal cavity,
and the site of origin of the mass was localized.
Intraoperatively, the mass was noted to be arising
from the posterior end of the bony nasal septum

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Kamath, etal.: Inverted papilloma with oropharyngeal extension

Figure 1: Nasal mass seen arising from and filling the left nasal cavity, Figure 2: Nasal mass noted to be extending posteriorly and hanging
extending until the anterior nares in the oropharynx

Figure 3: Contrast-enhanced computed tomography image of the nose Figure 4: Contrast-enhanced computed tomography image of the nose
and paranasal sinuses revealing the mass within the left nasal cavity and paranasal sinuses revealing the extent of the nasal mass into the
with haziness of the sinuses oropharynx through the nasopharynx

on the left side and extending into the oropharynx through
the nasopharynx. The attachment of the mass was released
along with a margin of the posterior nasal septum. The scope
was removed from the nasal cavity. The oral cavity was kept
open using a BoyleDavis mouth gag. The entire mass was
then delivered in toto through the oral cavity. Hemostasis was
achieved by the topical application of cottonnoids soaked in
4% lignocaine with adrenaline at the sites of bleeding. The
nasal cavity was then packed with Merocel bilaterally and
an external bolster was applied. The pack was removed on the
2ndpostoperative day, and the patient was started on topical
oxymetazoline nasal drops.
The specimen was sent for histopathological evaluation
[Figure5]. Grossly, the specimen consisted of large, bulky,
translucent, membranous mass of 8.55.03.0cm. The
surface showed polypoidal projections. On microscopy,
the sections showed respiratory mucosa with a tumor
consisting of invaginated, endophytic growth of no
keratinizing(transitional) squamous epithelial cells giving it
a lobulated appearance. Glycogenated squamous cells were
present. In one section, carcinomainsitu change was seen
with nuclear hyperchromatism and increased mitosis. There
was an extension of the papilloma into the seromucinous
glands. The stroma was edematous and showed minimal
inflammation. The surface epithelium was merging with the
transitional squamous epithelium. Initially, six sections were
studied. In view of the presence of carcinomainsitu in one of
the sections, further evaluation was done. Six more sections
from difference areas were studied and found to be negative
for malignancy. The final histopathological evaluation was
reported as inverted squamous papilloma(Schneiderian type)
with a single focus of carcinoma in one low power field. There
was no evidence of dysplasia or invasive malignancy in any of
the studied sections[Figures6 and 7].
On followup, endoscopic cleaning of the nasal cavities was
done, which showed no evidence of residual or remnant tumor,
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Kamath, etal.: Inverted papilloma with oropharyngeal extension
Figure 5: Excised nasal mass prior to dispatch for histopathological
evaluation
Figure 6: Inverted Schneiderian papilloma showing an endophytic
growth pattern of no keratinizing squamous epithelium (H and E, low
power)
Figure 7: Inverted papilloma showing the single focus of carcinoma-
insitu on the surface (H and E, high power)
and the patient felt symptomatically better. The patient has
been on regular followup for 6months, and no recurrence
has been noted.
DISCUSSION
The World Health Organization defines inverted papilloma as a
benign epithelial tumor composed of welldifferentiated columnar
or ciliated respiratory epithelium having variable squamous
differentiation.[3] They classify inverted papilloma as a subgroup of
Schneiderian papillomas. The term inverted papilloma describes
the histological appearance of the epithelium that is, inverting
into the stroma, with a distinct and intact basement membrane
that separates and defines the epithelial component from the
underlying connective tissue stroma.[4]
The most common nasal sites involved by inverted papilloma,
in order of descending prevalence, are: Lateral nasal wall,
ethmoid cells, maxillary sinus, and less often, the frontal and
sphenoid sinuses and nasal septum.[5] The lateral nasal wall
represents the most common site of origin, whereas paranasal
sinuses are quite frequently found to be involved by extension.
There have been no reported incidences of oropharyngeal
extension of an inverted papilloma.
Inverted papilloma poses many challenges clinically,
pathologically, and surgically in terms of management.
Various surgical techniques have been advocated for the
treatment of the same. Traditional lateral rhinotomy is
performed, which provides good access to the tumor and
ensures complete removal. Despite achieving complete
surgical removal, recurrences tend to occur. Recurrence
rates of inverted papilloma, when treated surgically are as
high as 71%.[5,6] Persistent disease is unacceptable due to
the possibility of malignant transformation in squamous
cell carcinoma, the incidence of which is as high as 10-15%,
according to one study by Roh etal.[7] In a literature review
by von Buchwald and Bradley the risk of transformation of
cases to squamous cell carcinoma was quoted as 10% with
the rates of synchronous and metachronous malignancy in
inverted papilloma being 7.1 and 3.6%, respectively.[8] Lawson
etal., in their series of 112patients with inverted papilloma,
describes the overall rate of squamous carcinoma to be 5%.[9]
In yet another study by Saha etal.,[10] 23% of the patients had
recurrence without any specific histological patter, 12% had
recurrence with focal dysplasia and 4% had recurrence with
malignant transformation into squamous cell carcinoma.
The time from presentation with inverted papilloma to
malignant transformation is reported to be between 6 and
180months(mean 52months).[11] Hence, it is mandatory to
perform a close followup of all cases, with timely biopsies
when indicated. Lifelong followup is recommended.
Immunohistochemical studies have shown increased
expression of p21 and p53 in inverted papillomas associated
with dysplasia and squamous cell carcinoma. Human papilloma
virus(HPV) family 6/11 and 16/18 DNA has been observed
in inverted papilloma associated with severe dysplasia and
squamous cell carcinoma and HPV infection may be an early
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Kamath, etal.: Inverted papilloma with oropharyngeal extension
step in the process of malignant transformation.[12] Arndt etal.[13]
demonstrated the presence of HPV through polymerase chain
reaction in 69% of their cases with inverted papilloma. HPV
6/11 was seen in 48%, HPV 16 in 65% and both HPV 6/11 and
16 in 45%, and HPV 16 was implicated to be involved in the
malignant transformation of inverted papilloma. Similar results
were demonstrated in a study by Hwang etal.,[14] suggesting
a relation between malignant transformation and recurrence
of inverted papillomas with the presence of HPV infection.
The analytical overview by Lawson etal.[15] hypothesized that
low risk HV may induce the formation of inverted papilloma;
however, they are lost as the infected cells are shed, in a hit and
run phenomenon. Dysplasia in inverted papilloma however
has been attributed to either primary of secondary infection
with highrisk HPV. However, in one recent study by Jenko
etal., it was illustrated that the presence of HPV DNA was not
a statistically significant predictor of the recurrence of inverted
papilloma, nor was it a statistically significant risk factor for
associated squamous cell carcinoma and when compared with
the control cases represented an incidental colonization rather
than a causative factor for inverted papilloma.[16]
Lawson et al. in 1995[9] in a study on inverted papilloma
described septectomy as a method of treatment of isolated
septal inverted papillomas. Our patient underwent transnasal
endoscopic resection of the tumor with posterior septectomy.
Transnasal endoscopic surgery avoided aggressive surgery
and facial scarring in this patient, especially in view of
the limited growth within the nasal cavity. Kelly et al.[2]
described inverted papillomas of the nasal septum and the
advantages of the various methods of excision of the lesion.
Their review suggested that cautery of septal papillomas or
superficial excision and cautery of the base was insufficient
treatment. Adiagnosis of inverted papilloma necessitated a
wellconceived, wide, local excision. Small lesions are amenable
to be excised through a transnasal approach, but with the
inclusion of a generous margin of mucoperichondrium. If
cartilage invasion is questionable, then cartilage must also
be removed with the placement of a skin or mucosal graft.
The main differential diagnoses in this case are anterochoanal
polyps, rhinosporidiosis, olfactory neuroblastoma and
sinonasal carcinoma. Nasal polyps which are more frequent
than inverted papilloma, can commonly present as a single,
unilateral, nasal mass extending to the nasopharynx, and must
be considered as one of the first main differential diagnosis.
However, considering the advanced age of the patient and the
nature of the mass on examination(fleshy versus smooth and
polypoidal), inverted papilloma is more likely. Rhinosporidiosis
is a commonly encountered condition in South India and can
be considered a valid differential in this case. However, the
patient did not elicit a history of nasal bleed nor was the mass
friable or bleeding on probing, which led the author away from
this differential. Olfactory neuroblastoma and other sinonasal
carcinoma must also be kept in mind considering the patients
age, but the main point is diverting the examiner away from
malignancy as a differential is the slow growing nature of
the nasal mass.
CONCLUSION
Nasal mass arising from the medial wall, that is the septum,
should arouse the suspicion of a differential diagnosis of
inverted papilloma of the septum. Complete excision of the
growth with partial septectomy through transnasal endoscopy
may be performed for control of the limited disease.
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Cite this article as: Kamath MP, Shenoy SV, Prasad V, Bhojwani K,
Pai R, Mathew NM. Inverted papilloma of atypical origin with unusual
extension into the oropharynx. J Can Res Ther 2015;11:666.
Source of Support: Nil, Conflict of Interest: None declared.