The endoscopic approach worked wellnot only to remove large inverted papillomas in 18 patients ages 36 to74 but also to watch for regrowth of the tumors that have a highrecurrence rate and a small chance of becoming cancer. Patients weretreated as outpatients and 56 percent remained disease-free at 29months.
“If there is a chance to cure benign disease usingminimally invasive techniques, it always works best for the patient,”says Dr. Stil E. Kountakis, vice chair of the Medical College ofGeorgia Department of Otolaryngology-Head and Neck Surgery and directorof the Georgia Sinus and Allergy Center. “Endoscopic techniques allowyou to support the ancient dictum of do no harm and, at the same time,provide care to the patient.”
Like a crawling vine, invertedpapillomas grow slowly but steadily along the lining of the sinuses,taking root along the way. The cause is unknown but inverted papillomasare associated with the contagious, wart-producing humanpapillomavirus; trauma and irritation of the nasal lining are suspectsas well, Dr. Kountakis says. Males tend to be at higher risk; 14 of thepatients profiled in the September/October issue of the AmericanJournal of Rhinology are male.
“Without treatment, it can growbig,” says Dr. Kounakis, corresponding author on the study. “Tumors maycome from the wall of the sinuses behind the cheekbone that is next tothe nose. They can spread out into the sinuses between the eyes. Theycan 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.”
Patientsmay complain of nasal obstruction, or primary care physicians maynotice the growths on annual exams. Once found, a computerizedtomography scan helps determine the extent of the tumor.
Previousstudies have looked at removing less-extensive tumors endoscopicallybut rhinologists, such as Dr. Kountakis, are pushing the envelope,looking at its potential in advanced disease.
“Operative risk andpost-operative morbidity are significantly less than with openprocedures,” study authors write. “Recurrences are more frequent, butare detected early and are easily resected with minimally invasivetechniques.” Study patients had about a 50 percent recurrence ratecompared to the usual recurrence rate of up to 44 percent, a fact thatdid not surprise Dr. Kountakis.
“When you deal with a tumor,even a benign tumor, sometimes it’s better to cut it out with cleanmargins, do what’s called an oncologic surgery. In this paper we arediscussing tumors that are very large. To be able to do that, you wouldhave to take half the face off these patients. For the largest of thesetumors, there is no such thing as an oncologic procedure where you haveenough room to have clean margins.”
In fact, two of the studypatients had previously undergone open procedures. More than half thestudy patients were still disease-free after two years with only oneendoscopic procedure; two patients required three procedures. Patientsneed close follow- up for five years to be considered disease-free, Dr.Kountakis notes. Scarring and tissue destruction caused by the openprocedure can impede follow up.
Open procedures involve incisionsmade along the nose or under the lip, lifting the face in a techniquecalled facial degloving, and moving bone - potentially the upper jawand cheekbone – and sometimes brain out of the way. Complicationsinclude eye loss, cerebral spinal fluid leaks and disfigurement, whichmay require reconstructive surgery.
With the endoscopic approach,Dr. Kountakis uses tiny scopes and cameras to enter the natural openingof the nose where he obliterates the growth with a device thatpulverizes and suctions. At points where it adheres to the sinuslining, he also removes the lining then uses a diamond drill toeliminate errant cells in the immediate underlying bone. Patients takeantibiotics and anti-inflammatory agents and regularly irrigate theirsinuses in the following weeks. One of the 18 study patients had acerebral spinal fluid leak, which was repaired endoscopically.
“Patientswith large tumors have had no real alternative,” Dr. Kountakis says.“Large tumors require big, destructive surgery to be removed and, evenwhen you do that, you cannot reassure the patient that the tumor willnot come back. So you create huge morbidity. With the endoscopicapproach, I also cannot guarantee that with the first procedure I amgoing to cure the patient. I can guarantee that I will follow thepatient persistently with the endoscope and if a tumor is found, we’llget it.”
Dr. Mark J. Jameson from the University of VirginiaHealth System Department of Otolaryngology – Head and Neck Surgery isco-author of the study.
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