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rated from the maxilla, and the anterior bony lateral
wall is removed with chisels or a diamond burr,
exposing but preserving the nasolacrimal duct.
This provides excellent access to remove inverted
papilloma from the maxillary sinus. Finally, the
anterior mucosal ap is returned to the lateral nasal
wall and the posteriorly displaced inferior turbinate
is repositioned back to its normal position. It is
however advisable to leave an access window into
the maxillary sinus for post-operative clinic review
should the tumour recur.
Frontal Sinus Surgery
Sinonasal papillomas within the frontal sinus
may arise from protrusion of an anterior ethmoid
mass that passes through the frontal os.
Alternatively, the tumor can arise directly from
the mucosa within the frontal sinus. The preoperative evaluation is assisted greatly by a combination of a CT sinus scan as well as an MRI sinus
scan.
Resection poses several challenges that are
determined by the anatomy and size of the frontal
sinus, tumor size and attachment, residual effects
from previous surgery, and extension beyond the
connes of the frontal sinus.
Large frontal sinus tumors are typically
removed by piecemeal resection. The principles
of attachment-orientated surgery apply and
include identication of the tumor attachment,
subperiosteal dissection, and drilling of the
underlying bone. Drilling underlying bone in
tumors attached to the cribriform plate or the posterior frontal sinus wall may risk a CSF leak.
Should a CSF leak occur, repair is best done at
the time or soon after the tumor surgery.
Whether a papillomatous dural lesion should
be excised and repaired is debatable and may
lead to intracranial spread. Bipolar diathermy of
the tumor attachment may be a safer effective
approach. Frozen section of the mucosal margins
may be helpful and should be considered in this
situation.
Detailed surgical planning is essential [52].
Key decisions are determined by the local anatomy, pneumatization, extent of tumor attachment, and tumor extension.
Endonasal endoscopic Draf IIa and IIb frontal sinusotomy: Suitable for tumors affecting a
small frontal sinus or those limited to the medial
aspect of the frontal sinus (Video 30.6).
Endonasal endoscopic Draf III frontal sinusotomy/sinuplasty: Inverted papilloma within an
extensively pneumatized frontal sinus.
Extended transorbital-transnasal endoscopic
technique: For more extensive tumors as an alter-
native to an external approach.
Coronal incision and osteoplastic bone ap:
Indicated where the tumor attachment within the
frontal sinus is extensive; for multifocal disease;
in tumors that extend laterally; and for tumor
recurrence after a previous Draf type III procedure [53].
External or combined external/endoscopic
surgery: Indicated for tumors located in superior
or lateral sites within the frontal sinus. External
trephination of the frontal sinus should provide a
good endoscopic view within the frontal sinus,
especially where an obstructed frontal os is being
opened.
Radical external or combined external/endoscopic surgery: Indicated for tumors extending
beyond the connes of the bony sinus walls into
the orbit of intracranial cavity; where there is
involvement of the dura; or where malignant
transformation has occurred. Craniofacial resection is an option in such tumors [54].
Techniques to avoid: Frontal sinus cranialization, obliteration, or occlusion with bone wax or
other resorbable material should be avoided as
evaluation for recurrence will be impaired.
Relative contraindications and suggestions
with regard to endoscopic frontal sinus surgery
are shown in Table30.6.
Sinonasal papilloma may be an extensive disease that necessitates complex surgery to obtain
complete clearance. A series of procedure plans
and surgical options is demonstrated in Table30.7.
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Table 30.6 Contraindications to endoscopic frontal sinus surgery
Relative contraindications to endoscopic resection Mandatory avoidance of endonasal endoscopic surgery
Narrow frontal os (AP diameter <1cm) Very narrow or unidentied frontal os
Extension of tumor through the anterior skull base or
posterior wall
Lateral attachment of tumor, especially in a well-
pneumatized frontal sinus
Extensive scar tissue from previous surgery or post-
traumatic bony anatomical anomalies
Histological evidence of squamous cell carcinoma (biopsy
or frozen section)
Tumor attachment to the anterior or the upper half of the
posterior frontal sinus wall
Table 30.7 Summary of surgical plans according to the extent of sinonasal papilloma
Surgical
plan Tumor site Extent of surgery
Plan 1 Conned to middle
meatus, ethmoid complex,
sphenoid, frontonasal
recess
Plan 2 Involves lateral, inferior,
anterior wall of maxillary
sinus
Plan 3 Extends to skull base,
nasolacrimal region, and
orbit
Plan 4 Tumor within frontal
sinus with mucosal
involvement up to
midpoint of orbit
Plan 5 Tumor within frontal
sinus with mucosal
involvement past
midpoint of orbit
Endoscopic medial maxillectomy with extended frontal sinusotomy and
sphenoidectomy
Extended endoscopic medial maxillectomy±intranasal endoscopic
prelacrimal recess approach to maxillary sinus or±modied Denker
operation or combined anterior antrostomy and Caldwell-Luc procedure (if
endoscopic experience is limited or not available)
Extended endoscopic medial maxillectomy with resection of inferior
turbinate±preservation or resection of nasolacrimal duct±endoscopic skull
base repair or craniofacial approach
Endoscopic frontal sinusotomy (Draf IIa or IIb) or Draf III procedure or
combined with endoscopic frontal trephine approach
Endoscopic endonasal orbital transposition technique (120) or endoscopic
frontal access via frontal trephine or frontal access via an osteoplastic ap
Massive erosion of the anterior skull base or
posterior wall, with intradural invasion
Intraorbital extension (consider transorbital
endoscopic surgery)
Massive scar tissue formation after previous frontal
sinus surgery
Extensive squamous cell carcinoma
Extensive tumor within a pneumatized frontal sinus
U. Hadi and A. C. Swift
Sphenoid Sinus Surgery
Sinonasal papilloma is least common in the sphenoid sinus and sphenoethmoid recess. The tumor
may be in proximity to vital structures such as the
internal carotid artery, the optic nerve, and the
pituitary gland, making complete resection much
more challenging (Fig.30.10).
Good exposure is achieved by removing the
anterior wall of the sphenoid sinus bilaterally,
together with the rostrum and posterior third of
the nasal septum. Lateral recess tumors in a
pneumatized sphenoid sinus may need a wider
extended exposure via a trans-ethmoid-pterygoid
sphenoid approach.
Subperiosteal dissection for attachment-orientated surgery may be compromised by the risk to
the integrity of the carotid artery and/or injury to
the optic nerve.
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Frontal sinus lesion
Nasal endoscopy – Imaging (CT, MRI) – biopsy
Inverted papilloma
(+/– dysplasia)
Lesion vegetating in FS but
originating anywhere else
Origin from lower half of
PW or from MW
Large AP diameter and
interorbital distance
Endoscopic endonasal
approach
(EEA)
Extension to
pneumatized
supraorbital recess
(far lateral)
EEA + orbital
transposition
Attachment to AW upper half of PW
Small AP diameter,
Short interorbital distance
Massive involvement of FS
Massive lateral supraorbital attachment
in laterally pneumatized FS
Scar tissue or anatomical distortion
from previous surgery
Fig. 30.10 Algorithm for planning surgical resection of
frontal sinonasal papilloma. AP anteroposterior, FS frontal sinus, PW posterior wall, MW medial wall, AW anterior
Surgical Planning
Sinonasal papilloma may be an extensive disease
that necessitates complex surgery to obtain complete clearance. An option of surgical options and
procedure plans is demonstrated in Table30.7.
Adjuvant Therapy
Inverted papilloma with squamous cell
carcinoma (invasive)
Lesions encroaching
EEA + OPF
and transpassing the
anterior or posterior
bony wall of the
frontal sinus with
intracranial or
subcutaneous
involvement
Craniofacial approaches
Based on the
involvement
of the bony
walls of the
frontal sinus
wall, OPF osteoplastic ap, EEA endoscopic endonasal
approach [52]
therapy after discussion at a head and neck
cancer multidisciplinary team (MDT)
meeting.
Interferon has been described for multiple
recurrences, advanced disease, or spread to the
orbit and skull base. Antiviral therapy against
human papillomavirus has also been reported.
Both modalities lack a strong evidence base and
are considered experimental [57].
Radiotherapy should be considered if the risk of
surgery is too high, if recurrence is likely after
surgery, or when complete tumor resection is
unachievable. Such situations may arise with
extensive disease, multifocal tumor seeding, or
involvement of challenging sites such as the cavernous sinus and lateral wall of the sphenoid
sinus [55]. Radiotherapy should also be considered with features of histological concern such as
a high mitotic index, hyperkeratosis, and squamous epithelial hyperplasia [56].
Patients with malignant change should be
offered curative radiotherapy or chemoradio-
Recurrence
Sinonasal inverted papillomas have a reputation for tumor recurrence. Most recurrences of
sinonasal inverted papilloma occur within
2 years of surgery [58]. A review period of
3–4 years following comprehensive endoscopic sinus surgery will diagnose >80% of
recurrences, but some patients with tumours
that display more aggressive unusual behaviour or tumours where residual disease is suspected will require longer follow-up.
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External vs. endoscopic surgery: A meta-
analysis review described recurrence of endoscopically resected inverted papilloma in the
frontal sinus as being relatively high (22%) compared to external approach surgery, suggesting
that combination surgery would be more effective [59].
Recurrence in the frontal recess and ethmoidal
roof is more likely as tumor remnants cannot be
easily seen or cleared.
Recurrence after revision surgery: Recurrence
rates after revision surgery may range from 15 to
20% according to the individual series and type
of surgery performed [60]. The higher rates are
explained by limited identication of the attachment site, confusing anatomy, and lack of landmarks [4, 61]. Early recurrence may reect
residual disease rather than suspicious tumor
behavior, and this needs to be considered and
accepted by the individual surgeon. The differentiation of inammatory polypoid tissues from
tumor may also be unclear (Figs. 30.11 and
30.12).
Fig. 30.11 Inverted papilloma of left sphenoid, posterior
ethmoid, and olfactory cleft
U. Hadi and A. C. Swift
Fig. 30.12 Recurrence of inverted papilloma within
sphenoid sinus
Surveillance
The likelihood of recurrence together with the
low but potential risk of malignant transformation means that surveillance is necessary.
However, sinonasal papilloma lesions are benign,
and this leads to an aura of complacency, with
many patients being discharged after surgery
without subsequent review.
Surveillance in most patients can be relatively infrequent but should include serial endoscopic examination and MRI scans when
appropriate. Clinical review of about 3–5 years
will identify most recurrences. However, exceptions do occur, and patients with more aggressive tumors should have more frequent review
for a longer time period, according to clinical
circumstances.
If diagnostic endoscopy is suspicious, intraoperative biopsy should be considered, possibly
with frozen section if malignant change is suspected. Patients with rapid recurrence and odd
tumor behavior following resection, or those with
known subtotal resection, will require closer,
more frequent review.
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Conclusions
The surgical management for excision of sinonasal papilloma is dependent on the tumor size, histological subtype, location, and expertise of the
surgeon.
The greatest most frequent challenge is recurrence after resection of sinonasal inverted
papilloma.
Whilst the overall risk of malignant transformation is small, abnormally aggressive unusual
behavior should alert the surgeon to possible
malignant change.
All removed tissue should be subject to
detailed histopathology, and the surgeon and histopathologist should work closely together in this
challenging but fascinating condition.
Prolonged review is recommended. The latter
depends on clinical acumen as we currently do
not have reliable biological markers for recurrence or malignant transformation.
Key Learning Points
• The main types as described by the WHO
Classication are based on the histological
pattern and exophytic papilloma, oncocytic
papilloma, and inverted papilloma.
• The evidence for a clinically signicant asso-
ciation of HPV with sinonasal papilloma is
variable and weak.
• An inverted papilloma is the most common
type and typically appears as an irregular uni-
lateral polyp within the nasal cavity that can
be difcult to differentiate from a simple
inammatory polyp.
• The classic characteristics of sinonasal
inverted papilloma include tumor recurrence
and a risk of malignant transformation.
• Malignant transformation is unusual, but
pathology can be challenging. A need for vigi-
lance is therefore essential.
• The ideal management is complete surgical
resection that can be achieved endoscopically
in most cases.
• Attachment-orientated surgery by subperios-
teal dissection and drilling of underlying bone
is the optimum technique to prevent tumor
recurrence.
• More complex surgery may be necessary for
large extensive tumors. Procedures will
include surgery to the frontal, sphenoid, or
maxillary sinus. Operations may be endoscopic, external, or a combination of the
two.
• Regular clinical review over a period of at
least 3–5 years is recommended to identify
recurrence at an early stage. Longer review is
recommended for tumours that display
unusual or aggressive features.
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Benign Tumours oftheNose
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andSinuses
CemMeco andHazanBasak
31
Introduction
Benign tumours of the sinonasal cavity are rare.
They encompass a wide variety of histopathological entities with a range of differing management strategies. The unilateral nature of
non-specic symptoms should trigger a high
level of suspicion that instigates an appropriate
diagnostic workup that includes imaging, biopsy
or histological analysis of the resected lesion.
The optimal management strategy can then be
applied to the individual pathology.
Benign and malignant tumours of the sinonasal cavity are rare and present in 1–1.5 per
100,000 population every year. The benign
tumours constitute the smallest portion of sinonasal tumours [1, 2].
C. Meco (*)
Department of Otorhinolaryngology—Head and
Neck Surgery, Ankara University, Medical School,
Ankara, Turkey
Department of Otorhinolaryngology—Head and
Neck Surgery, Salzburg Paracelsus Medical
University, Salzburg, Austria
H. Basak
Department of Otorhinolaryngology—Head and
Neck Surgery, Ankara University, Medical School,
Ankara, Turkey
The sinonasal cavity and its bordering anatomical regions, especially the skull base, not
only are an anatomically complex region but
also consist of fusion planes of all three embryonic layers, thus hosting an enormous variety
of neoplasms derived from a multitude of tissue types. Table31.1 shows the histopathologi-
cal classication of benign tumours of the
nasal cavity and paranasal sinuses according to
the World Health Organization (WHO) [3].
This chapter will review some of the most
common and clinically relevant benign tumours
of the sinonasal cavity like osteomas and others whilst omitting some like sinonasal papilloma and juvenile angiobroma (JA), as these
are reviewed in dedicated chapters within this
book [1].
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
A. C. Swift et al. (eds.), Contemporary Rhinology: Science and Practice,
https://doi.org/10.1007/978-3-031-28690-2_31
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C. Meco and H. Basak
Table 31.1
Benign tumours of the nasal cavity and paranasal
sinuses
Benign epithelial
tumours
Soft tissue tumours • Myxoma
Tumours of the bone
and cartilage
WHO classication [3]
• Sinonasal (Schneiderian)
papillomas
– Inverted papilloma
(Schneiderian
papilloma, inverted
type)
– Oncocytic papilloma
(Schneiderian
papilloma, oncocytic
type)
– Exophytic papilloma
(Schneiderian
papilloma, exophytic
type, everted type)
• Respiratory epithelial
adenomatoid hamartoma
• Salivary gland type
adenoma
– Pleomorphic adenoma
– Myoepithelioma
– Oncocytoma
• Leiomyoma
• Haemangioma
• Schwannoma
• Neurobroma
• Meningioma
Borderline and low malignant
potential tumours of soft tissue
• Desmoid-type bromatosis
• Inammatory
myobroblastic tumour
• Glomangiopericytoma
• Extrapleural solitary
brous tumour
• Fibrous dysplasia
• Ossifying broma
• Osteoma
• Osteoid osteoma
• Osteoblastoma
• Osteochondroma
(exostosis)
• Chondroma
• Chondroblastoma
• Chondromyxoid broma
• Giant cell lesion
• Giant cell tumour of the
bone
• Ameloblastoma
• Nasal
chondromesenchymal
hamartoma
Table 31.1 (continued)
Benign tumours of the nasal cavity and paranasal
sinuses
Haematolymphoid
tumours
Neuroectodermal
tumours
Germ cell tumours
• Extramedullary
plasmacytoma
• Langerhans cell
histiocytosis
• Juvenile xanthogranuloma
• Rosai-Dorfman disease
• Heterotopic central
nervous system tissue
(nasal glioma)
• Dermoid cyst
• Mature teratoma
Borderline and malignant
potential germ cell tumours
• Immature teratoma
• Sinonasal yolk sac tumour
The Diagnostic Challenge
Regardless of the malignant or benign nature of
the tumour, they all present with similar symptoms such as nasal obstruction, nasal discharge, a
spectrum of bleeding ranging from bloodstained
discharge to epistaxis, headache, facial pain and
hyposmia/anosmia. Most symptoms are similar to
those triggered by inammatory sinonasal diseases and may hinder a timely diagnosis. Perhaps
the most important concept to emphasise to all
physicians, and not just ENT specialists, is to
maintain a high level of suspicion and alertness so
as not to overlook such sinonasal tumours. It is
critical that unilateral sinonasal symptoms, especially nasal obstruction with discharge, should
ultimately induce the thought of a sinonasal
tumour and lead to further investigations including nasal endoscopy and appropriate imaging.
Due to the non-specic character of symptoms,
both patients and primary care physicians could easily overlook these rarely seen pathologies. However,
if unilateral symptoms do not resolve after a shortterm medical therapy or if orbital or neurological
symptoms emerge, no time should be wasted for
referral and specialist assessment. Only then, malignancy can be excluded and the optimal management
of a benign lesion could be instigated without delay.
31 Benign Tumours oftheNose andSinuses
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Diagnosing benign tumours at an earlier stage
may avoid potential complications and minimise
the morbidity associated with treatment.
Common symptoms and signs of sinonasal
tumours according to their location are listed in
Table 31.2 [1]. These are mostly related to the
nature of pathology, anatomical region and com-
Table 31.2 Common symptoms and signs of sinonasal
tumours according to their location [1]
Primary site Symptoms
Nasal cavity Nasal blockage, bleeding,
• Inferiorly into palate Mass, ulceration, stula
• Posteriorly into
nasopharynx and
Eustachian orice,
compression of
Eustachian tube
• Antero-superiorly
into the nasal bone
• Externally into the
skin
• Superiorly into
anterior cranial fossa
Maxillary sinus
• Medially into nasal
cavity
• Anteriorly into the
cheek directly or via
infraorbital canal
• Posteriorly into
pterygoid region and
infratemporal fossa
• Inferiorly into the
palate or alveolar
ridge
• Superiorly into orbit Proptosis, diplopia
Ethmoid sinuses
• Medially into nasal
cavity
• Inferolaterally into
maxilla
• Medially into orbit Proptosis, chemosis,
• Superiorly into the
anterior cranial fossa
Frontal sinus:
• Anteriorly Mass on the forehead or
discharge, hyposmia
Middle ear effusion/
deafness
Glabellar mass
Mass/ulceration
Minimal, personality
change? Headache,
neurological decit
cerebrospinal uid leak/
meningitis (rarely)
As above
Mass, ulceration of the
skin, paraesthesia
Trismus and pain
Mass, loosening of the
teeth, malignant oro-antral
stula
As above, can cross to
contralateral side
Mucus retention,
diplopia, visual loss,
epiphora
Minimal, personality
change?
Headache, neurological
decit, cerebrospinal uid
leak/meningitis (rarely)
glabella
Table 32.1
Primary site Symptoms
• Posteriorly into
• Inferiorly into nasal
• Medially to
(continued)
anterior cranial fossa
cavity, orbit
contralateral side
As above
As above
Nil of note till breaches
connes of sinus
partments affected by tumour origin and growth
and proximity to critical structures.
Once a sinonasal tumour is suspected, the ENT
examination should focus on the sinonasal region,
orbit and cranial nerves and should include an
urgent meticulous endoscopy of the nasal cavities
and nasopharynx. In most instances nasal endoscopy reveals the lesion straightaway, but in some
patients, topical nasal decongestants/anaesthetic
spray is required to visualise the middle and superior meati and the olfactory cleft, especially where
the access is narrow and limited.
Imaging
Should a sinonasal tumour be seen or further suspected, imaging should be organised. Highresolution computed tomography (CT) and
magnetic resonance imaging (MRI) complement
each other for precise assessment in axial, coronal and sagittal planes. These imaging modalities
establish a radiological diagnosis, reveal the
nature and extent of the tumour and delineate
which anatomic compartments are involved and
which neurovascular critical structures are
closely related to the tumour [4]. A CT sinus scan
is usually the rst examination acquired and provides bony detail that can determine areas of
bone erosion or attachment. The information that
CT provides for bro-osseous lesions (FOLS)
regarding texture, margins and critical areas is
usually adequate to establish the diagnosis and
extent of the lesion. However, for most other soft
tissue lesions, an MRI scan provides additional
essential information and is strongly recommended. Importantly, an MRI scan with gadolinium enhancement will enable differentiation of
tumour from adjacent soft tissues and retained
mucus. Additionally, it determines involvement
of adjacent structures including the periorbita
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