Attachment-oriented endoscopic surgical approach for sinonasal inverted papilloma

Inverted papilloma has gained the reputation of a relentless tumor among otolaryngologists. Surgical treatment for inverted papilloma has evolved from limited transnasal removal to radical en bloc resection with transfacial approaches. With the rapid development of endoscopic surgical and advanced imaging techniques, many surgeons have begun to treat inverted papilloma endoscopically. The author believes that the advantages of an endoscopic approach in resecting sinonasal inverted papilloma are already established. This article describes a more refined, minimally invasive endoscopic technique that is aimed at achieving complete tumor resection and minimal morbidity. It is our experience that even advanced sinonasal inverted papillomas originate from a localized and clearly identified pedicle in most cases. Based on this observation, we show our attachment-oriented endoscopic approach for inverted papilloma. The stages of performing this technique are: (1) preoperative diagnosis, (2) tumor debulking, (3) precise identification of the tumor's mucosal attachment, (4) subperiosteal tumor dissection, (5) excision of the tumor pedicle and its surrounding normal mucosa, and (6) resection or drilling of the underlying bone. Different patterns of inverted papilloma radiographic appearances, the attachment sites as identified intraoperatively, and descriptions of the surgical technique are presented.