• Clinical science

Nasal papilloma

Abstract

Nasal papillomas are benign epithelial tumors of the nasal cavity which mainly affect males between 40–60 years of age. The exact etiology is unknown, but human papillomavirus infection, smoking, and chronic sinusitis are predisposing factors for the development of nasal papillomas. There are three types of nasal papillomas. Inverted papilloma is the most common, arises from the lateral nasal wall and has the highest risk of malignant degeneration. Fungiform and oncocytic nasal papillomas are less common. Patients often present with unilateral nasal obstruction, anosmia, and intermittent epistaxis. On examination, nasal papillomas appear dull gray/pink and are friable. CT or MRI delineate the extent of the papilloma; diagnosis is established on biopsy. All nasal papillomas should be completely excised. Although benign, nasal papillomas are locally aggressive and have a high recurrence rate if incompletely excised.

Definition

  • Nasal papillomas are benign epithelial tumors of the nasal cavity mucosa; , which can be locally aggressive, have malignant potential, and a high propensity for recurrence if incompletely excised.

Epidemiology

  • Incidence: rare; ∼ 1 case per 100,000 population per year
  • Sex: > (5:1)
  • Age: 40–60 years

References:[1][2]

Epidemiological data refers to the US, unless otherwise specified.

Etiology

References:[1][2][3]

Classification

Types of nasal papillomas Frequency Site of attachment Gross appearance Histology
Inverted papilloma
  • Most common
  • Lateral nasal wall or paranasal sinuses In the region of the middle turbinate
  • Dull pink/gray opaque masses with an irregular surface
  • Epithelium: nonkeratinizing cylindrical (transitional) cells with intracellular mucin
  • Endophytic growth
Fungiform papilloma
  • Uncommon
  • Nasal septum
  • Exophytic, warty appearance; sessile
  • Stratified squamous epithelium
  • Papillary fronds present on the surface
  • Fibrovascular core
  • Exophytic growth
Oncocytic papilloma (cylindrical cell papilloma)
  • Rare
  • Oncocytic epithelium: columnar cells with dark nuclei
  • Mixed (exo- and endophytic) pattern of growth

References:[3][4][5]

Clinical features

  • Unilateral nasal obstruction (most common symptom); → unilateral anosmia; difficult nasal breathing
  • Epistaxis
  • Unilateral nasal discharge
  • Unilateral epiphora
  • On examination:
    • Unilateral dull pink/gray polypoid lesion which completely fills the nasal cavity → pushes the septum to the contralateral side
    • Friable (bleeds on touch)
  • Symptoms of chronic sinusitis

References:[1][2][6]

Diagnostics

  • CT scan with contrast: Indicated in unilateral nasal masses to differentiate benign from malignant masses; findings include:
    • Nonspecific unilateral mass displacing or distorting the nasal septum/paranasal sinus (PNS)
    • Areas of calcification
    • Bony destruction
  • MRI: : shows a cerebriform pattern
  • Nasal endoscopy: indicated in all unilateral nasal masses to confirm the site of origin and obtain a sample for histopathological examination
  • Biopsy: : most important to confirm the diagnosis based on histology

References:[1][3][7][8][9][6]

Differential diagnoses

A patient with unilateral difficulty breathing through the nose may have a malignant tumor!

References:[10][5]

The differential diagnoses listed here are not exhaustive.

Treatment

  • Complete surgical excision: treatment of choice for benign papilloma in good surgical candidates (because of high rates of recurrence if incompletely excised)
  • Radiation: : considered only in inoperable disease with malignant transformation or in poor surgical candidates

References:[2][3]

Complications

  • Chronic sinusitis
  • Malignant deterioration (mostly squamous cell carcinoma)
  • Intracranial extension (rare)

References:[4][11][12][5]

We list the most important complications. The selection is not exhaustive.

Prognosis

  • High recurrence rates in incompletely resected nasal papillomas (up to 70%)

References:[5]

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  • 2. GPnotebook. Nasal Papilloma. http://www.gpnotebook.co.uk/simplepage.cfm?ID=-1254817761. Updated January 1, 2016. Accessed May 22, 2017.
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  • 9. Abdullah B, Abdullah K, Khan S, Hamzah M. Surgical outcomes of inverted papilloma: a retrospective review of endoscopic and external approaches. The Internet Journal of Head and Neck Surgery. 2006; 1(1). url: http://ispub.com/IJHNS/1/1/4881.
  • 10. Pitak-Arnnop P, Bertolini J, Dhanuthai K, Hendricks J, Hemprich A, Pausch NC. Intracranial extension of Schneiderian inverted papilloma: a case report and literature review. Ger Med Sci. 2012; 10. doi: 10.3205/000163.
  • 11. Lawson W, Kaufman MR, Biller HF. Treatment outcomes in the management of inverted papilloma: an analysis of 160 cases. Laryngoscope. 2003; 113(9): pp. 1548–1556. doi: 10.1097/00005537-200309000-00026.
  • 12. Mendenhall WM, Hinerman RW, Malyapa RS, et al. Inverted papilloma of the nasal cavity and paranasal sinuses. Am J Clin Oncol. 2007; 30(5): pp. 560–563. doi: 10.1097/COC.0b013e318064c711.
last updated 11/19/2018
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