Clinical outcomes of endoscopic and endoscopic-assisted resection of inverted papillomas: A 15-year experience Bradford A. Woodworth, M.D., Geeta A. Bhargave, B.S., James N. Palmer, M.D., Alexander G. Chiu, M.D., Noam A. Cohen, M.D., Ph.D., Donald C. Lanza, M.D., William E. Bolger, M.D., and David W. Kennedy, M.D. ABSTRACT Background: The endoscopic resection of sinonasal inverted papillomas (IPs) has been well described. However, the majority of published reports in the literature are small case series with limited clinical follow-up. The aim of this retrospective study was to review the experience with the endoscopic and endoscopic-assisted resection of IPs at a major academic tertiary care facility and assess long-term outcomes. Methods: A retrospective review of endoscopic and endoscopic-assisted resections of IP was performed. Charts were reviewed for standard demographic data, operative technique, adjuvant approaches, complications, and postoperative follow-up times. Results: One hundred fourteen patients (average age, 56 years) underwent endoscopic or endoscopic-assisted resection for IPs with a mean disease-free follow-up of 40 months (7–135 months). Seventeen patients developed disease after endoscopic or endoscopic-assisted resection for a recurrence rate of 15%. Average time to recurrence was 23 months. Combined approaches were used when indicated in 34% (39/114) of patients, including adjuvant osteoplastic flap, midface degloving, trephine, or Caldwell-Luc approaches. Four patients (4%) had cerebrospinal fluid leaks that were successfully repaired endoscopically. Conclusion: In this large series of endoscopically resected IPs with extensive clinical follow-up, recurrences occurred an average of 23 months after the procedure. This emphasizes the importance of long-term endoscopic follow-up to detect recurrences in all patients. Endoscopic or endoscopic-assisted resection of IPs is a valid technique in this series with recurrence rates comparable with open approaches. (Am J Rhinol 21, 591–600, 2007; doi: 10.2500/ajr.2007.21.3086) Key words: Endoscopic-assisted, endoscopic sinus surgery, image-guidance, intraoperative CT, inverted papilloma, inverting papilloma, recurrence, sinonasal tumor I nverted papilloma (IP) is a benign mucosal tumor of the nose and paranasal sinuses that is characterized by locally destructive and aggressive behavior. 1 Invagination of neo- plastic epithelium into the underlying stroma is characteristic of this tumor on histopathology. 2 Historically, IPs have been approached externally through partial or total maxillectomies using lateral rhinotomy or midface degloving procedures with surgical excision expanded depending on the tumor extent. The wide exposure obtained with these traditional techniques was frequently at the expense of a significant degree of facial dissection and/or brain retraction, which often resulted in undesirable perioperative morbidity. The cited reasons for these historically aggressive approaches were the potential for malignant degeneration into squamous cell carcinoma (5–21%) 3–8 and the strong propensity for recur- rence. However, our previous case series on IPs showed 22% sphenoid sinus involvement—an area that would not be sat- isfactorily approached with these aggressive standard tech- niques. Over the last 15 years, surgical management of IPs has changed dramatically in an attempt to decrease the morbidity from open surgical approaches. Technological advancements in the endoscopic management of paranasal sinus disease, including improved optics, angled suction irrigation drills, and computer-aided skull base and orbital wall navigation, have allowed a practical expansion into endoscopic and en- doscopic-assisted surgical removal of IPs. Angled endoscopes offer a panoramic perspective of the relevant surgical anat- omy and allow for thorough evaluation of the scope of dis- ease. Furthermore, the maneuverability of the endoscope al- lows positioning directly at the level of dissection, thereby effectively reducing viewing and operating distances. Although the advantages of endoscopic and endoscopic- assisted IP resection seem obvious, our current knowledge about endoscopic management is from a number of case series. Most of these series quote recurrence rates from 0 to 19%, which is comparable with older series using the more extensive lateral rhinotomy and medial maxillectomy. 9–25 Re- cently, Lawson et al. 26 described their operative experience and management of 160 patients with IP. Although the vast majority of these individuals had a lateral rhinotomy (112 of 160), they found that “conservative approaches” (defined as intranasal sphenoethmoidectomy, transantral sphenoeth- moidectomy, endoscopic sphenoethmoidectomy, septectomy, and the Caldwell-Luc procedure) had a lower recurrence rate of 12% when compared with 16% with the lateral rhinotomy approach. These outcomes are marred by an obvious selection bias, because endoscopic resections often were reserved for IPs without extension into the orbit, dura/brain, or frontal sinus. However, our institution has a long history of perform- ing aggressive endoscopic or endoscopic-assisted resections From the Department of Otorhinolaryngology–Head and Neck Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania Presented at the Combined Otolaryngological Spring Meeting, San Diego, California, April 26 –27, 2007 Bradford A. Woodworth, M.D., and Geeta A. Bhargave, B.S., contributed equally to this work Address correspondence and reprint requests to James N. Palmer, M.D., Division of Rhinology, Department of Otorhinolaryngology–Head and Neck Surgery, 3400 Spruce Street, Philadelphia, PA 19104 E-mail address: james.palmer@uphs.upenn.edu Copyright © 2007, OceanSide Publications, Inc., U.S.A. American Journal of Rhinology 591