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Treatment Guidelines

Surgery is unanimously considered the treatment of choice for inverted papilloma. Features repeatedly emphasized in the literature such as multicentricity, frequent association with squamous cell carcinoma, and high incidence of recurrences have prompted most of the authors to identify medial maxillectomy (by lateral rhinotomy or midfacial degloving) as the surgical technique of choice (Myers et al. 1990; Lawson et al. 1995; Outzen et al. 1996). However, the introduction in the early 1980s of microendo-scopic surgery, along with the subsequent refinement of instrumentation and the increasing experience in endonasal surgery for inflammatory diseases, have led to successful results in the treatment of inverted papilloma even with more conservative techniques (Brors and Draf 1999; Lund 2000; Winter et al. 2000). According to Lund (2000), there is no single right or wrong surgical solution but rather a range of procedures from which a choice should be made in any individual case.

In our experience, based on the management of 47 patients (Tomenzoli et al. 2004), a microendoscopic approach is contraindicated when one of the following situations is present: extensive involvement of the frontal sinus; massive bone erosion (except for the medial wall of the maxillary sinus and the anterior wall of the sphenoid sinus); intradural invasion; intraorbital invasion; abundant scar tissue due to previous surgery; association with squamous cell carcinoma. Different microendoscopic resections may be adopted in relation to the site of origin and the extent of the lesion. When inverted papilloma is limited to the middle meatus, anterior and posterior ethmoid, and/or spheno-ethmoid recess, a type 1 resection, including anterior ethmoidectomy with clearance of the frontal recess, posterior ethmoidectomy, a large middle antrostomy, sphenoidotomy, partial or middle turbinectomy (according to tumor extent) is performed. In such a situation, an "en bloc" resection is easily obtained, making sure that the dissection is carried out in the subperiosteal plane.

Whenever the lesion extends from the middle me-atus into the maxillary sinus or originates from the medial wall of the maxillary sinus, a type 2 resection is performed. In addition to all surgical steps of a type 1 resection, the operation includes a medial maxil-lectomy with or without section of the nasolacrimal duct, in relation to the anterior extent of the tumor.

Inverted papillomas that originate from or involve the posterolateral, anterior and/or inferior wall of the maxillary sinus are better managed through a type

3 resection, which corresponds to the technique indicated by Brors and Draf (1999) as an "endonasal Denker operation".

In patients undergoing a Type 2 or 3 resection, "en bloc" removal is rarely feasible due to the large extent of the lesion. Therefore, debulking of the nasal portion of the mass is first performed to subsequently focus on the most critical areas involved by the lesion, where dissection is always carried out in the subperi-osteal plane. Drilling of the bone underlying the diseased mucosa is then performed to ensure surgical radicality.

In the era when transnasal resection without mi-croendoscopic assistance was the only available technique, "recurrences" ranged from 40% (OBErmAN 1964) to 78% (Calcaterra et al. 1980). We concur with other authors (HYAms 1971; Lund 2000) that most of these "recurrences" were probably "residual" lesions, since the exposure offered by a transnasal approach did not guarantee an adequate radicality of the resection and "recurrent" lesions prevalently occurred at the same site of the primary (LuNd 2000). By using external medial maxillectomy or microen-doscopic dissection the occurrence of recurrences has dropped down to a prevalence ranging from 0% (Weissler et al. 1986) to 29% (BiELAmowicz et al. 1993), and from 0% (KAmEL 1995) to 33% (Stankiewicz and Girgis 1993), respectively. Even though most recurrent inverted papillomas present within 2 years following treatment, late recurrences may also occur. Therefore, it is mandatory to prospectively follow patients with endoscopic controls every 4 months during the first postoperative year and subsequently every 6 months for at least

4 years. In contrast to other benign diseases such as juvenile angiofibroma, which requires radiologic evaluation for early detection of recurrent submucosal lesions (Nicolai et al. 2003), imaging should be obtained only in patients with clear endoscopic evidence of disease or with a complete stenosis of sinus ostium/a precluding a full endoscopic sinus inspection. In the latter situation, imaging evaluation is aimed not only at detecting recurrent lesions, but also to diagnose possible sequelae such as mucocele.

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