Frontal sinus inverted papilloma: surgical strategy based on the site of attachment

The surgical management of inverted papilloma (IP) involving the frontal sinus (FS) remains a challenge given the narrow confines of the frontal recess and the close proximity to critical structures. The objective of this study was to elucidate a surgical strategy for management of frontal sinus IP based on the site of attachment.

A retrospective chart review was performed on 18 patients with FS IP treated at the Pusan National University Hospital and the Cleveland Clinic Foundation between 1998 and 2008.

The mean age was 53.8 years with a male/female ratio of 13:5. The sites of tumor attachment included the medial wall (MW; six cases), posterior wall (PW; five cases), diffuse (all walls involved; five cases), intersinus septal cell (three cases), lateral wall (two cases), and anterior wall (two cases). IP involvement was unifocal in 10 cases and multifocal in 8 cases. Unifocal IP attached to the MW or PW was managed strictly by endoscopic frontal sinusotomy (EFS) in five of six cases (83%). Multifocal IP required endoscopic modified Lothrop (EML) and/or open approaches (endoscopic frontal trephination [EFT], four, osteoplastic flap [OPF], one) in seven of eight cases (88%). One additional patient with bilateral anterior table involvement required OPF. Four (22%) patients developed recurrences. Two were managed by EML, one was managed by EFS, and one was managed by EFT and EFS. Two patients developed cerebrospinal fluid leaks that were managed endoscopically without untoward effects. All patients were free of disease at the time of last evaluation with a mean follow-up of 36.6 months.

Frontal sinus IP with MW or PW involvement can generally be managed by standard EFS. Tumors with multifocal involvement often require EML, along with adjunct EFT in selected cases. OPF can be avoided as the primary surgical approach in most patients with sinonasal papilloma of FS.