The endoscopic approach worked well not only to remove large inverted papillomas in 18 patients ages 36 to 74 but also to watch for regrowth of the tumors that have a high recurrence rate and a small chance of becoming cancer. Patients were treated as outpatients and 56 percent remained disease-free at 29 months.
“If there is a chance to cure benign disease using minimally invasive techniques, it always works best for the patient,” says Dr. Stil E. Kountakis, vice chair of the Medical College of Georgia Department of Otolaryngology-Head and Neck Surgery and director of the Georgia Sinus and Allergy Center. “Endoscopic techniques allow you to support the ancient dictum of do no harm and, at the same time, provide care to the patient.”
Like a crawling vine, inverted papillomas grow slowly but steadily along the lining of the sinuses, taking root along the way. The cause is unknown but inverted papillomas are associated with the contagious, wart-producing human papillomavirus; trauma and irritation of the nasal lining are suspects as well, Dr. Kountakis says. Males tend to be at higher risk; 14 of the patients profiled in the September/October issue of the American Journal of Rhinology are male.
“Without treatment, it can grow big,” says Dr. Kounakis, corresponding author on the study. “Tumors may come from the wall of the sinuses behind the cheekbone that is next to the nose. They can spread out into the sinuses between the eyes. They can go over the surface of the eye socket, go up to the skull base. It’s a slow-growing tumor but it’s a destructive tumor.”
Patients may complain of nasal obstruction, or primary care physicians may notice the growths on annual exams. Once found, a computerized tomography scan helps determine the extent of the tumor.
Previous studies have looked at removing less-extensive tumors endoscopically but rhinologists, such as Dr. Kountakis, are pushing the envelope, looking at its potential in advanced disease.
“Operative risk and post-operative morbidity are significantly less than with open procedures,” study authors write. “Recurrences are more frequent, but are detected early and are easily resected with minimally invasive techniques.” Study patients had about a 50 percent recurrence rate compared to the usual recurrence rate of up to 44 percent, a fact that did not surprise Dr. Kountakis.
“When you deal with a tumor, even a benign tumor, sometimes it’s better to cut it out with clean margins, do what’s called an oncologic surgery. In this paper we are discussing tumors that are very large. To be able to do that, you would have to take half the face off these patients. For the largest of these tumors, there is no such thing as an oncologic procedure where you have enough room to have clean margins.”
In fact, two of the study patients had previously undergone open procedures. More than half the study patients were still disease-free after two years with only one endoscopic procedure; two patients required three procedures. Patients need close follow- up for five years to be considered disease-free, Dr. Kountakis notes. Scarring and tissue destruction caused by the open procedure can impede follow up.
Open procedures involve incisions made along the nose or under the lip, lifting the face in a technique called facial degloving, and moving bone - potentially the upper jaw and cheekbone – and sometimes brain out of the way. Complications include eye loss, cerebral spinal fluid leaks and disfigurement, which may require reconstructive surgery.
With the endoscopic approach, Dr. Kountakis uses tiny scopes and cameras to enter the natural opening of the nose where he obliterates the growth with a device that pulverizes and suctions. At points where it adheres to the sinus lining, he also removes the lining then uses a diamond drill to eliminate errant cells in the immediate underlying bone. Patients take antibiotics and anti-inflammatory agents and regularly irrigate their sinuses in the following weeks. One of the 18 study patients had a cerebral spinal fluid leak, which was repaired endoscopically.
“Patients with large tumors have had no real alternative,” Dr. Kountakis says. “Large tumors require big, destructive surgery to be removed and, even when you do that, you cannot reassure the patient that the tumor will not come back. So you create huge morbidity. With the endoscopic approach, I also cannot guarantee that with the first procedure I am going to cure the patient. I can guarantee that I will follow the patient persistently with the endoscope and if a tumor is found, we’ll get it.”
Dr. Mark J. Jameson from the University of Virginia Health System Department of Otolaryngology – Head and Neck Surgery is co-author of the study.
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