|Year : 2018 | Volume
| Issue : 1 | Page : 33-37
Incidence of nasal inverted papilloma in unilateral nasal lesions in Damietta Governorate
Wael F Ismaeil, Mohamed H Abd El Azim
Otorhinolaryngology Department, Faculty of Medicine, Al Azhar University, New Damietta, Egypt
|Date of Submission||08-Apr-2018|
|Date of Acceptance||19-Jun-2018|
|Date of Web Publication||20-Nov-2018|
Wael F Ismaeil
Otorhinolaryngology Department, Faculty of Medicine, Al Azhar University, New Damietta, 34517
Source of Support: None, Conflict of Interest: None
Background Unilateral nasal lesions are a characteristics group that need special attention from ear, nose and throat surgeons. Inverted nasal papilloma is one of such lesions. However, its incidence and pattern are not well-defined in Egypt.
Aim To estimate the incidence of inverted nasal papilloma among patients with unilateral nasal lesions.
Patients and methods A prospective analysis of patients presented and treated owing to unilateral nasal lesion was conducted in a 2-year duration. Patient demographics, clinical presentation, and histopathological diagnoses were document.
Results There were 117 (53 males and 64 female) patients with unilateral nasal lesions. The mean age was 44.14 (±10.80) years. Nasal obstruction was reported in 50.4%, nasal discharge in 17.1%, epistaxis in 12%, and facial pain in 5.1%. The lesion was inflammatory in 79.5% and neoplastic in 20.5%. The most common inflammatory lesion was chronic rhinosinusitis (44.4%), whereas the most common neoplastic lesion was inverted papilloma in 10.3%, and squamous cell carcinoma in 4.3%. However, males were significantly higher in neoplastic and inverted nasal papilloma. Nasal obstruction was increased in inflammatory lesions, whereas nasal discharge, facial pain, and epistaxis were increased in neoplastic group.
Conclusion Inverted nasal papilloma was reported in 10.3%. It had male predilection and usually presented in the fifth decade, and nasal discharge, epistaxis, and facial pain were significantly associated with the disease.
Keywords: chronic rhinosinusitis, inverted papilloma, mucocele, nasal polyp, unilateral nasal disease
|How to cite this article:|
Ismaeil WF, Abd El Azim MH. Incidence of nasal inverted papilloma in unilateral nasal lesions in Damietta Governorate. Al-Azhar Assiut Med J 2018;16:33-7
|How to cite this URL:|
Ismaeil WF, Abd El Azim MH. Incidence of nasal inverted papilloma in unilateral nasal lesions in Damietta Governorate. Al-Azhar Assiut Med J [serial online] 2018 [cited 2019 Oct 16];16:33-7. Available from: http://www.azmj.eg.net/text.asp?2018/16/1/33/244143
| Introduction|| |
Unilateral sinonasal symptoms, nasal mass or polyp or sinus opacity, are common presentations in the otolaryngological department. The etiology is usually an inflammatory condition that can be managed conservatively with medical treatment, with few patients requiring surgical intervention .
The presence of unilateral symptoms or pathology is regarded with caution, as sinonasal neoplasms may also present during their early stages with subtle symptoms that mimic an inflammatory pathology .
Sinonasal inverted papilloma (IP) is a benign tumor arising in the Schneiderian membrane, lining the nasal cavity and paranasal sinuses. IP is clinically important owing to its high rate of recurrence (20–47%), locally aggressive nature, and association malignancy (∼2–7%) .
According to the WHO, sinonasal papilloma is classified into three different histopathological groups: exophytic papilloma (fungiform, septal, and squamous papilloma), inverted (inverting) papilloma, and oncocytic papilloma (cylindrical cell and columnar papilloma). IP is the most common among these groups and generally appears as a large, polypoid mass with a grayish color and an uneven multinodular surface .
IPs are found mostly in the maxillary sinus, the ethmoid sinus, and the lateral nasal wall. The medical treatment has no or limited role in inverted nasal papilloma. In addition, surgery type is not always fixed, for example, open or endoscopic. However, surgery type could be chosen according to tumor size, location, invasion of surrounding tissues, or surgeon expertise .
| Aim|| |
This study aimed to assess the incidence of IPs in the nose and paranasal sinuses among patients with unilateral nasal lesions in Damietta Governorate.
| Patients and methods|| |
A prospective study of all cases of unilateral nasal lesion in the Department of Otorhinolaryngology (Al-Azhar University Hospital, New Damietta) during the period from January 2016 to January 2018 was carried out.
In our institution, all patients with unilateral sinonasal symptoms were documented by detailed history taking followed by complete ear, nose and throat examination, which included detailed nasal examination by anterior and posterior rhinoscopy and diagnostic nasal endoscopy. Patients with unilateral nasal mass/polyp were further assessed radiologically by computed tomography scan of paranasal sinuses ([Figure 1],[Figure 2],[Figure 3],[Figure 4]).
|Figure 1 Computed tomography scan, coronal cut, bone window, showing unilateral mucosal thickening of the maxillary sinus (chronic sinusitis).|
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|Figure 2 Computed tomography scan, axial cut (a) and coronal cut (b) showing maxillary sinus expansion (mucocele).|
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|Figure 3 Computed tomography scan, coronal cut, bone window showing left antrochoanal polyp.|
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|Figure 4 Computed tomography scan, coronal cut, bone window, showing opacity of left maxillary and ethmoid sinuses of proved inverted papilloma.|
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Patients presenting with inflammatory conditions were managed medically or surgically by endoscopic sinus surgery. Neoplastic lesions were treated by endoscopic biopsy followed by definitive management depending on the histopathological diagnosis. The patients were grouped according to their clinical and histopathological diagnosis as inflammatory (sinusitis, antrochoanal polyp, and mucocele) and neoplastic. For each patient, the demographic data, presenting symptoms, and radiological findings were documented.
Data were documented on an excel sheet. They were coded and statistically analyzed by statistical package for social science (version 22; IBM SPSS Inc., Chicago, Illinois, USA). Numerical variables were presented as arithmetic mean and SD, whereas categorical variables were presented as relative frequency and percent distribution. The Student (t) and the χ2-tests were used for comparison. The level of significance was P value of less than 0.05.
| Results|| |
The present study included 117 participants who presented with unilateral nasal lesion; 53 (45.3%) were males and 64 (54.7%) were females. Patient age ranged from 12 to 65 years, and the mean (±SD) age was 44.05 (±11.04) years. Nasal obstruction was reported in 20.5% of studied participants, nasal discharge in 17.1%, epistaxis in 12%, facial pain in 5.1%, and eye symptoms in 3.4%. The lesion was inflammatory in 79.5% and neoplastic in 20.5% ([Table 1]).
Regarding clinical and pathological diagnosis, the inflammatory lesions were in the form of chronic rhinosinusitis in 47.8% of total samples, antrochoanal polyp in 19.7%, fungal sinusitis in 9.0% and mucocele in 2.6%. On the contrary, neoplastic lesions were in the form of IP in 10.3%, squamous cell carcinoma (SCC) in 4.3%, adenocarcinoma in 3.4%, and non Hodgkin’s lymphoma (NHL) in 2.6% ([Table 2]).
Comparing inflammatory with neoplastic lesions, there was no significant difference between both groups regarding patient age and eye symptoms. However, the number of males was significantly increased among those having neoplastic when compared with inflammatory lesions, and nasal obstruction was significantly increased in neoplastic lesions (87.5 vs. 3.2%). In addition, nasal discharge, facial pain and epistaxis were significantly increase in neoplastic when compared with inflammatory group ([Table 3]).
|Table 3 Comparison between inflammatory and neoplastic lesions regarding patient age, sex, and presenting symptom(s)|
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When comparing IP with other unilateral lesions, there was no significant difference regarding patient age and eye symptoms; however, the number of males was significantly increased in those with IP, and nasal obstruction, nasal discharge, facial pain and epistaxis were significantly increased in IP when compared with other lesions ([Table 4]).
|Table 4 Comparison between inverted papilloma and other unilateral lesions regarding studied variables|
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| Discussion|| |
A patient presenting with unilateral nasal lesion represents a clinical challenge owing to variation in the underlying etiology. Thorough evaluations of the patient age, the presenting symptoms, and endoscopic and radiological examination help in the diagnosis of unilateral nasal disease .
Results of the present study revealed that unilateral nasal lesions were slightly common in females than males. These results are in contradiction to Lathi et al.  who reported that sinonasal lesions had predilection for males, demonstrating a male to female ratio of 1.5 : 1. It was even higher in the study of Zafar et al.  (1.7 : 1). However, these results are in agreement with Bakari et al.  who reported male : female ratio of 1 : 1.2.
In the present work, unilateral inflammatory lesions were the most common (79.5%), whereas neoplastic lesions represented 20.5%. These findings are in accordance with those reported by Euteneuer et al.  who reported that most sinonasal lesions are mainly inflammatory in nature.
Regarding symptoms, nasal obstruction was the most common, reported in 20.5% of studied participants, nasal discharge in 17.1%, epistaxis in 12%, and facial pain in 5.1%. These results are comparable to the findings of Nair et al.  who reported that patients with unilateral nasal lesions presented with different nasal symptoms like nasal obstruction, nasal discharge, epistaxis, hyposmia, and headache. They added nasal obstruction was the commonest symptom in both the inflammatory and neoplastic groups. Epistaxis and extranasal symptoms were found to be higher in the neoplastic conditions. However, in the neoplastic group, nasal discharge was the most common followed by facial pain and then nasal discharge. Lathi et al.  also reported that the most common presentations of the sinonasal masses were nasal obstruction (97.3% cases), rhinorrhea (49.1%), hyposmia (31.3%), and headache (16.9%).
On the contrary, Tritt et al.  studied unilateral nasal polyposis and found epistaxis is significantly association with neoplastic lesions.
In the present work, the inflammatory lesions were in the form of chronic rhinosinusitis in 47.8% of total populations, antrochoanal polyp in 19.7%, fungal sinusitis in 9.0%, and mucocele in 2.6%. On the contrary, neoplastic lesions were in the form of IP in 10.3%, SCC in 4.3%, adenocarcinoma in 3.4%, and NHL in 2.6%. These results are in agreement with Nair et al.  who found that inflammatory conditions like acute and chronic rhinosinusitis (bacterial or fungal) were the most common diagnosis.
In the present study, neoplastic lesions and inverted nasal papilloma were more prevalent among male patients. However, the age was nonsignificantly different (both were prevalent in the fifth decade). These results are in accordance with Ungari et al.  who reported that IP prevails in the fifth decades and males are affected 4–5 times than females.
In the present work, the incidence of inverted nasal papilloma was 10.3% of all unilateral nasal lesions. In their work, Nowosielska-Grygiel et al.  reported that, of 3,574 patients who underwent endoscopic sinus surgery owing to chronic inflammatory diseases, IPs were found in 80 patients (2.23%; 31 women, 38.75%; 49 men, 61.25%). Sex distribution in their study was comparable to the present work. However, the incidence of IP is very low when compared with the present study. This can be attributed to different inclusion criteria, as we included only unilateral nasal lesions, whereas Nowosielska-Grygiel et al.  included both unilateral and bilateral chronic inflammatory lesions. In addition, the authors reported that 96.25% of patients with IP had unilateral whereas 3.75% had bilateral papillomas. These findings reflected that the nature of IP is usually unilateral; hence, the importance to search its incidence in the unilateral lesions.
Dammann et al.  reported that IP comprises ∼4% of all nasal polyps. Barnes et al.  reported that IP in sinonasal cavity tumors represents 0.4–7.0%. Again the low incidence than the present work is owing to different inclusion criteria.
The importance of this study relied on the fact that, it included only unilateral nasal lesions, which represent a specific group that needs special attention from otorhinolaryngologists. The characterization of inverted nasal papilloma can help in early intervention with favorable outcome.
| Conclusion|| |
Inverted nasal papilloma represented 10.3% of all unilateral nasal lesions reported in the present work. It is more common in males, usually presented in fifth decade of life, and nasal discharge, epistaxis, and facial pain were significantly associated with the disease.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Kaplan BA, Kountakis SE. Diagnosis and pathology of unilateral maxillary sinus opacification with or without evidence of contralateral disease. Laryngoscope 2004; 114:981–5.
Karthikeya P, Mahima VG, Bhavna G. Sinonasal verrucous carcinoma with oral invasion. Indian J Dent Res 2006; 17:82–6.
] [Full text]
Yu MS, Lim WS, Lee BJ, Chung YS. Squamous cell carcinoma associated with inverted papilloma of the maxillary sinus: our experience with 21 patients. Clin Otolaryngol 2017; 42:1048–1052.
Shanmugaratnam K, Sobin LH. The World Health Organization histological classification of tumours of the upper respiratory tract and ear. A commentary on the second edition. Cancer 1993; 71:2689–97.
Nowosielska-Grygiel J, Pietkiewicz P, Owczarek K, Olszewski J, Miłoński J. Diagnosis and treatment of nasal and paranasal inverted papillomas − epidemiology and own experience. Otolaryngol Pol 2017; 71:27–32.
Lee JY. Unilateral paranasal sinus diseases: analysis of the clinical characteristics, diagnosis, pathology, and computed tomography findings. Acta Otolaryngol 2008; 128:621–6.
Lathi A, Syed MM, Kalakoti P, Qutub D, Kishve SP. Clinico-pathological profile of sinonasal masses: a study from a tertiary care hospital of India. Acta Otorhinolaryngol Ital 2011; 31:372–7.
Zafar U, Khan N, Afroz N, Hasan SA. Clinicopathological study of non-neoplastic lesions of nasal cavity and paranasal sinuses. Indian J Pathol Microbiol 2008; 51:26–9.
] [Full text]
Bakari A, Afolabi OA, Adoga AA, Kodiya AM, Ahmad BM. Clinico-pathological profile of sinonasal masses: an experience in national ear care center Kaduna, Nigeria. BMC Res Notes 2010; 3:186.
Euteneuer S, Sudhoff H, Bernal-Sprekelsen M, Theegarten D, Dazert S. Malignomas of the nasal cavity and the paranasal sinuses: clinical characteristics, therapy and prognosis of different tumor types. Laryngorhinootologie 2004; 83:33–9.
Nair S, James E, Awasthi S, Nambiar S, Goyal S. A review of the clinicopathological and radiological features of unilateral nasal mass. Indian J Otolaryngol Head Neck Surg 2013; 65(Suppl 2):199–204.
Tritt S, McMains KC, Kountakis SE. Unilateral nasal polyposis: clinical presentation and pathology. Am J Otolaryngol 2008; 29:230–2.
Ungari C, Riccardi E, Reale G, Agrillo A, Rinna C, Mitro V et al.
Management and treatment of sinonasal inverted papilloma. Ann Stomatol (Roma) 2015; 6:87–90.
Dammann F, Pereira P, Laniado M, Plinkert P, Löwenheim H, Claussen CD. Inverted papilloma of the nasal cavity and the paranasal sinuses: using CT for primary diagnosis and follow-up. Am J Roentgenol 1999; 172:543–8.
Barnes L, Eveson J, Reichart P, Sidransky D. World Health Organization Classification of Tumors. Pathology and genetics of head and neck tumors. Lyon: IARC Press 2005.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4]