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A 59-year-old male patient presented with recurrent left nasal obstruction. He had a history of prior sinus surgery, 5 years and 1 month prior to evaluation, at an outside hospital. The pathology for his most recent sinus surgery returned positive for inverted papilloma without dysplasia or carcinoma. After each surgery, his nasal obstruction had improved. He was referred for further management

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    Curetting the inverted papilloma would have solved the recurrent nasal obstruction

    1. David W Kennedy

      Curetting the lesion would only have provided a short-term relief of the nasal obstruction and, at least in the United States, would not be a medicolegally acceptable form of management for this tumor because of the inevitable recurrence. Complete removal requires drilling of the underlying bone of the site of attachment, and recurrent lesions have a significantly higher risk of incomplete removal and further recurrences. Additionally, the risk that the lesion will become malignant significantly increases over time. The goal should be complete removal and drilling of the underlying bone at the site of attachment at the initial procedure even if this requires an open approach.

      1. Elisabeth Ference

        As Dr. Kennedy stated, drilling the bone is necessary to remove the site of attachment and prevent recurrence. A paper by Chiu et al [“Radiographic and histologic analysis of the bone underlying inverted papillomas.” Laryngoscope. 2006; 116(9): 1617-20] found that the bony surface underlying the inverted papilloma was irregular in 100% of cases and in 22% of cases there was isolated rests of salivary gland and/or mucosal tissue embedded in the bone. Therefore, the irregular bone at the site of attachment should be removed to destroy any microscopic rests of mucosa hidden in the crevices. In this case, in order to reach the site of attachment, we chose an endoscopic Denker’s approach because the site of attachment was lateral and anterior and could not be reached with a curette or drill through a regular or mega antrostomy.


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