Baylor University Medical Center Proceedings October 2017 - 457

Multifocal sinonasal inverted papilloma with middle ear
involvement
E. Burke Haywood, MD, Colin Fuller, MD, MS, Gerhard W. Hill III, MD, Felix Olobatuyi, MD, JS, and David W. Clark, MD

Inverted papilloma of the nasal cavity is a benign neoplasm, although it
can be locally invasive and has the potential for malignant degeneration.
Inverted papilloma of the temporal bone is extremely rare. We describe a
case of a 44-year-old woman who was treated for nasal inverted papilloma and was later found to have inverted papilloma of her temporal
bone. The patient required several procedures to remove the inverted
papilloma from the nasal cavity and temporal bone, and she is currently
free of recurrence.

nverted papilloma (IP) is the second most common benign
neoplasm of the nasal cavity, though it is relatively rare
with a reported frequency of 0.6 to 1.5 per 100,000 per
year. It is more common in men than women, and it usually occurs in the ﬁfth to sixth decades of life (1). Nasal IP
originates from the Schneiderian mucosa of the sinonasal tract
and is most commonly attached on the lateral nasal wall (2).
At the temporal bone, IP is exceedingly rare and much less
is known about this entity than nasal IP. Only 32 cases of IP
involvement of the temporal bone have been reported in the
literature (3-6).
CASE DESCRIPTION
A 44-year-old woman presented with nasal obstruction,
and a right nasal mass consistent with IP was found on exam.
The patient underwent endoscopic resection of this lesion in
2009 and was found to have multifocal IP located on the right
middle turbinate, the right posterior nasal septum, and the
left torus tubarius. The patient was reported to have persistent
disease on the left torus tubarius; she was subsequently lost to
follow-up. She presented 21 months later with new right-sided
conductive hearing loss and underwent myringotomy with tympanostomy tube placement. At the time of surgery, a ﬂeshy mass
was biopsied from the middle ear that was consistent with IP
with severe dysplasia. Nasal endoscopy at that time indicated
recurrent disease on the right side, without involvement of the
eustachian tube oriﬁce intranasally.
The patient underwent right middle ear exploration and
was found to have tumor encroaching into the eustachian tube
oriﬁce. She also underwent directed biopsies endoscopically of
suspicious nasal lesions. Specimens from the middle ear and

Proc (Bayl Univ Med Cent) 2017;30(4):457-458

Figure 1. T1 MRI post-contrast demonstrating mild enhancement of the lesion in
the right middle ear encroaching on the eustachian tube (white arrow) adjacent
to the carotid artery (black arrowhead).

nasal cavity revealed IP and no malignancy. Deﬁnitive endoscopic resection was performed on the patient's nasal lesions,
at which point the margins were clear of papilloma by ﬁnal
pathology. Four months after this resection, additional middle
ear exploration was performed, and disease extending into the
eustachian tube oriﬁce with focal high-grade dysplasia was
found (Figures 1 and 2). The IP in the middle ear was completely
grossly removed with forceps and potassium titanyl phosphate
laser. The patient had a 30 pack-year history of smoking, and
at this time, she stopped smoking and switched to electronic
cigarettes. She currently has an anterior tympanic membrane
perforation allowing for oﬃce surveillance. Genotyping for
human papillomavirus (HPV) was negative in the nasal tissue
but positive for HPV 11 in the middle ear space.
From the Division of Otolaryngology, Department of Surgery (Haywood, Hill, Clark)
and the Department of Pathology (Olobatuyi), Baylor Scott and White Health
and Texas A&M Health Science Center, Temple, Texas; and the Department of
Otolaryngology, Augusta University, Augusta, Georgia (Fuller).
Corresponding author: David Clark, MD, Division of Otolaryngology, Department
of Surgery, Baylor Scott and White Health, 2401 South 31st Street, Temple, TX
76508 (e-mail: dwclark@sw.org).
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