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Papilloma Options: Endoscopy Part of a Stepwise Approach to Treatment

Diagnosis and Management of Sinonasal Papillomas
1:15 – 2:15 pm
Room N137

The management of sinonasal papillomas has changed dramatically in recent years. What was once the gold standard in removing these benign neoplasms—a lateral rhinotomy and medial maxillectomy—has been replaced with a stepwise approach that relies heavily on endoscopy.

Marilene B. Wang, MD

“Many of the smaller, simpler papillomas can be managed endoscopically with simpler procedures,” said Marilene B. Wang, MD, professor of head and neck surgery at the University of California, Los Angeles, David Geffen School of Medicine. “Larger papillomas, or those in locations such as the frontal sinus, will require more extensive approaches, but many can still be accessed endoscopically using more expanded approaches that have been described recently.”

Dr. Wang and colleagues will explore the latest surgical and nonsurgical options for managing these lesions during “Diagnosis and Management of Sinonasal Papillomas.” They will discuss stepwise approaches to treatment, including the surgical procedures and technologies in development and potential nonsurgical treatments.

“There is a clear, stepwise progression of approaches that will give you the best chance of clearing the papilloma surgically,” she said. “Considering and using these more appropriate approaches can give you a better chance of removing the papilloma completely, drilling down to the attachment site, and allowing more effective post-op surveillance. Because papillomas tend to burrow into the crevices of the bone, drilling the attachment site can help remove the last remnants of the lesion and prevent recurrence.”

Smaller papillomas on the lateral nasal wall can usually be accessed with simple endoscopic procedures, such as a middle meatal antrostomy. As papillomas become larger, more extensive approaches may be needed.

Techniques such as the mega maxillary antrostomy and the modified medial maxillectomy are still performed endoscopically, but require the removal of progressively more sinus tissue to allow access to the papilloma.

More recently developed techniques, such as the endoscopic Denker’s approach, allow access to the anteroinferior and lateral aspects of the maxillary sinus, which can be difficult to access through the nose. This approach, which resembles a modified Caldwell-Luc procedure, allows the surgeon to take down the anterior maxillary sinus wall, providing a better angle to approach the anterioinferior and lateral walls of the maxillary sinus.

Some lesions still require an open approach, Dr. Wang said, but most sinonasal papillomas can be managed with a purely endoscopic approach.

“Techniques such as the endoscopic Denker’s approach allow access to the anteroinferior and lateral walls of the maxillary sinus without having to do an incision in the sublabial region or a lateral rhinotomy,” she said. “These approaches have been described more recently and can be extremely useful tools.”

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