Inverted papillomas and benign nonneoplastic lesions of the nasal cavity

Abstract

Background: Benign lesions of the nasal cavity represent a diverse group of pathologies. Furthermore, each of these disorders may present differently in any given patient as pain and discomfort, epistaxis, headaches, vision changes, or nasal obstruction. Although these nasal masses are benign, many of them have a significant capacity for local tissue destruction and symptomatology secondary to this destruction. Advances in office-based endoscopic nasendoscopy have equipped the otolaryngologist with a safe, inexpensive, and rapid means of directly visualizing lesions within the nasal cavity and the initiation of appropriate treatment.

Methods: The purpose of this study is to review the diagnosis, management, and controversies of many of the most common benign lesions of the nasal cavity encountered by the primary care physician or otolaryngologist.

Results: This includes discussion of inverted papilloma (IP), juvenile angiofibroma, squamous papilloma, pyogenic granuloma, hereditary hemorrhagic telangiectasia, schwannoma, benign fibro-osseous lesions, and other benign lesions of the nasal cavity, with particular emphasis on IP and juvenile angiofibroma.

Conclusion: A diverse array of benign lesions occur within the nasal cavity and paranasal cavities. Despite their inability to metastasize, many of these lesions have significant capability for local tissue destruction and recurrence.

Figure 1.

Inverted papilloma characteristically arises from the lateral nasal wall and has a typical granular mulberry-like appearance. Only a small aspect of the mass is evident prior to dissection as the majority of the mass has invaginated into the surrounding structures.

Figure 2.

Inverted papillomas are characterized by epithelial proliferation which grows down into preexisting mucosal glands, displacing and replacing normal epithelium. The characteristic fungiform pattern results from this invagination of mucosal epithelium into the underlying stroma.

Figure 3.

Despite the nonmalignant histopathology of IP, it has a significant capacity for local invasion and destruction as seen in this preoperative MRI. (A) A large mass is seen arising from the left with invasion of the lamina papyracea and cribriform with extension to the dura mater. Transnasal endoscopic resection required a medial maxillectomy, partial superior septectomy, total ethmoidectomy and resection of the left anterior hemi-skull base. (B) MRI was obtained one month postoperatively demonstrating complete resection of the mass.

Figure 4.

(A and B) Classic granular mulberry-like appearance of an IP seen arising high on the lateral nasal sidewall.

Figure 5.

Endoscopic view of a telangiectasia on the middle turbinate of a patient with HHT. Telangiectasias and arteriovenous malformations with convoluted venules extending through the dermis arise because the vascular walls have excessive smooth muscle without appropriate elastic fiber production.