Randy Richards underwent surgery in 2008 for removal of a nasal polyp and repair of a deviated septum. During the procedure, his ENT discovered that what he had originally thought was an inflammatory polyp was actually an inverted papilloma (IP). Unprepared to resect the IP at that time, the ENT recommended a secondary procedure that Richards did not pursue.
By the time he was referred to Martin J. Citardi, MD, FACS, in April 2010, Richards’ inverted papilloma had enlarged to fill the entire maxillary sinus and most of the nasal cavity. “Mr. Richards’ case is a common story in our practice,” says Dr. Citardi, professor and chair of the Department of Otorhinolaryngology—Head and Neck Surgery at The University of Texas Medical School at Houston and chief of otorhinolaryngology at Memorial Hermann-Texas Medical Center. “Often, IP can be an accidental diagnosis, and when that occurs, its treatment may be incomplete. Inverted papilloma shouldn’t be ignored because the larger, more aggressive tumors have a higher propensity for recurrence and because of the risk of malignant transformation. The good news for patients is that IPs can be resected in a minimally invasive procedure.”
Dr. Citardi was the senior author for a 2007 publication that aimed to develop a clinically relevant staging system for IP managed with the endoscopic approach as the primary surgical modality, based on a review of English literature between 1985 and 2006.1 He has been a co-author of other articles on the origin of IP as well as various treatment techniques
“Over the past 15 years, there has been a clear move from medial maxillectomy requiring a facial incision or midfacial degloving toward the endoscopic approach,” says Samer Fakhri, MD, an associate professor in the Department of Otorhinolaryngology—Head and Neck Surgery at the UT Medical School and a rhinologist affiliated with Memorial Hermann-TMC. “Our ability to perform endoscopic resection has improved to the point that even large inverted papillomas can be resected using a pure endoscopic technique. We can now access sinuses for removal of bulky tumors that even a few years ago would have required open surgery.
“Typically, the inverted papilloma is relatively easy to access because it’s in the ethmoid or medial portion of the maxillary sinus,” he says. “The sphenoid, frontal and lateral maxillary sinuses can present a challenge but even those can be tackled using an endoscopic route.”
IP removal involves debulking the tumor and following it back to the point of attachment to ensure complete resection. “Typically, there are inflamed polyps nearby,” Dr. Citardi says. “We use Coblation® technology to melt away the polyps and view the tumor itself more closely.” Coblation applies radiofrequency energy through a conductive medium of water and salt to create a plasma discharge that causes molecular dissociation and tissue disintegration on contact.
Complete removal of the tumor is key to the success of endoscopic resection of inverted papilloma. “If removal is incomplete, it’s difficult to distinguish the original site from pathology that may have been caused by changes in the architecture during surgery,” says Amber Luong, MD, PhD, an assistant professor of otorhinolaryngology—head and neck surgery at the UT Medical School. “A definitive endoscopic procedure will result in the best outcome. It’s difficult to salvage a partial resection.”
The endoscopic approach offers significant patient benefits, including avoidance of a facial incision and quicker patient recovery. “We get good visualization, magnification and illumination and can focus in on the pathology without disrupting adjacent tissues,” Dr. Citardi says. “We use the endoscope in the office postoperatively to ensure we’re getting good healing and to confirm the absence of recurrence.”
Richards is happy that he found Dr. Citardi. “I’ve always operated under the assumption that a doctor is a doctor, and that they all have the same equipment,” he says. “But they don’t. Because I live in Sugar Land, I tend to go for convenience but I’m thankful I went to the medical center to see Dr. Citardi. You get scoped right away in the office. They are able to see more and make a better diagnosis. He’s very professional. That gives you a comfort level that you’re in the right place and they’re doing it the right way.”
Richards will return in follow-up every three to four months for the first year and every six months thereafter for three to five years. “His outlook is very good,” Dr. Citardi says. “The key prognostic factor is always complete removal of the tumor, and we believe we removed it all so we expect him to do well over a long period of time.”
Drs. Citardi, Fakhri and Luong are the core physicians for the Texas Sinus Institute and Texas Skull Base Physicians. For more information, visit www.texassinus.org . To refer a patient, please call 713.486.5000.
1 Cannady SB, Batra PS, Sautter NB, Roh H-J, Citardi MJ. New Staging System for Sinonasal Inverted Papilloma in the Endoscopic Era. The Laryngoscope 117:1283-1287, July 2007.