|Year : 2014 | Volume
| Issue : 1 | Page : 30-32
Proptosis because of nasal inverted papilloma masquerading as cholesterol granuloma
Shivcharan Lal Chandravanshi, Malay Verma, Nirmala Subramanian
Department of Orbit and Oculoplasty, Medical and Vision Research Foundation, Sankara Nethralaya, 18, College Road, Nungambakkam, India
|Date of Web Publication||16-Aug-2014|
Shivcharan Lal Chandravanshi
E-15, Old Doctors Colony, Rewa, Madhya Pradesh - 486 001
Inverted papilloma is a relatively uncommon neoplasia of the nasal cavity and paranasal sinuses. We report a case of a 52-year-old patient having sinonasal inverted papilloma masquerading as orbital cholesterol granuloma. The cholesterol granuloma was removed by combined superior orbitotomy approach and nasal endoscopic route under general anesthesia. The diagnosis was confirmed by histopathological examination. Postoperative nasal endoscopic examination and CT scan revealed no residual tumor, with no recurrence over twelve months.
Keywords: Cholesterol granuloma, inverted papilloma, orbit, proptosis
|How to cite this article:|
Chandravanshi SL, Verma M, Subramanian N. Proptosis because of nasal inverted papilloma masquerading as cholesterol granuloma. Sudanese J Ophthalmol 2014;6:30-2
|How to cite this URL:|
Chandravanshi SL, Verma M, Subramanian N. Proptosis because of nasal inverted papilloma masquerading as cholesterol granuloma. Sudanese J Ophthalmol [serial online] 2014 [cited 2020 Jan 26];6:30-2. Available from: http://www.sjopthal.net/text.asp?2014/6/1/30/138849
| Introduction|| |
Inverted papillomas are relatively uncommon tumors of the nasal cavity, comprising 0.5-4% of all primary nasal tumors.  Men are affected four times more than women. Inverted papillomas are almost always unilateral. They are locally destructive lesions with a tendency for recurrence and occasional malignant transformation (8.9%).  The recurrence rate of these tumors is highly variable (0-78%), depending on the type of surgical approach and completeness of resection.  In ophthalmic literature, a few reports are published regarding the invasion of inverted papilloma directly into the orbit. , We hereby report a case where it caused proptosis secondarily by producing cholesterol granuloma of the fronto-ethmoid region due to obstruction of frontonasal duct and ethmoid sinus opening.
| Case report|| |
A 52-year-old gentleman presented to the orbit and oculoplasty services with complaints of painless, progressive protrusion of the right eyeball since four months. There was no diminution of vision, diplopia or tenderness of the eye and adnexa. No history of recent or remote facial trauma, sino-orbital surgery or episodes of sinusitis.
On examination, his unaided visual acuity was 6/6 in both the eyes. There was 3 mm proptosis on right side with 4 mm inferior displacement of globe with mild limitation of the elevation [Figure 1]a]. On palpation a soft to firm ill-defined, non-tender mass lesion was noted in the superonasal quadrant of the right orbit. Otherwise his anterior and posterior segment findings were unremarkable. There was no lymphadenopathy. Systemic examination was within normal limits. A computed tomographic (CT) scan of the orbit demonstrated homogenous soft tissue lesion in the right fronto-ethmoidal sinus eroding the roof of the orbit and extending into the orbit [Figure 1]b]. No evidence of intracranial extension was present. The radiological features were suggestive of a cholesterol granuloma. Ultrasound-guided fine needle aspiration cytology (FNAC) was done, which revealed the presence of cholesterol crystals and eosinophils correlating to cholesterol granuloma. A nasal endoscopy was done that revealed the presence of a smooth pale pinkish mass in the nasal cavity superior and posterior to the middle turbinate [Figure 1]c]. Its origin and extent could not be ascertained hence an incisional biopsy was done. The histopathological examination revealed the features of inverted papilloma [Figure 2]a and b]. Complete excision of the cholesterol granuloma was done by superior orbitotomy approach and endoscopic resection was done for the sinonasal mass at the same sitting. The postoperative period was uneventful and there was resolution of the proptosis. The postoperative CT scan of paranasal sinuses revealed the presence of mucosal thickening in the frontonasal duct but no mass lesion [Figure 2]c]. The subsequent CT scan of orbit and paranasal sinuses and nasal endoscopy till 1 year did not reveal any recurrence of the disease. Informed consent was obtained from patient for participation and publication of photographs and we adhered to the Declaration of Helsinki during period of study conduct.
|Figure 1: Clinical photographs of the patient. (a) Preoperative photograph showing downward displacement of the globe. (b) Preoperative CT scan (coronal cut) showing the cholesterol granuloma in the frontal sinus and|
the inverted papilloma extending into the nasal cavity (arrow). (c) Nasal endoscopic image showing the inverted papilloma marked as asterisk
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|Figure 2: Photomicrograph showing the inverted papilloma. (a) Lobules of squamous epithelial cells invading the stroma (H and E, 40×). (b) Inverted papilloma showing koilocytic changes (H and E,40×). (c) Postoperative CT scan (coronal cut) showing the resolution of the disease with mucosal thickening in the frontonasal duct|
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| Discussion|| |
Inverted papilloma was originally described by Ward in 1854 and is also known as Schneiderian papilloma and Ewing's papilloma. Inverted papilloma most often affects patients in 50-70 years of age (range 6-91 years).  Inverted papilloma most commonly arises from the lateral nasal wall, adjacent to the middle turbinate, posterior to the uncinate process.  Usually inverted papilloma of sinonasal cavity presents with unilateral nasal obstruction.  Epistaxis, rhinorrhea, sinusitis, anosmia, frontal headache, and otalgia have also been reported in patient with inverted papilloma.  proptosis, diplopia, medial canthal mass and epiphora are produced when it invades the orbit.
Inverted papilloma has propensity of the neoplasm to invert, proliferating into the underlying stroma rather than growing in an exophytic pattern. On CT scan, the mass appears homogenous, enhancing, well-defined and may contain calcium. The adjacent bone may be thinned, bowed or less commonly sclerotic. 
Management of inverted papilloma depends on the location of tumor. Conservative surgical excision is indicated for tumors limited to sinuses.  Radical surgery is reserved for more extensive lesions involving the lateral wall of the maxilla, nasolacrimal duct area, orbit and skull base.  Recurrence following surgery depends on tumor location, extent, multicentricity and method of removal of primary tumor versus secondary resection.  Lund found recurrence rate of 58% in conservative removal, 14% in radical removal and 18% in endoscopic removal. 
In our case, the proptosis was produced due to cholesterol granuloma formation in frontal and ethmoidal sinus, which in turn was due to the blockage of sinus drainage because of mucosal invasion of inverted papilloma. This is a hitherto unreported finding. In view of the sinus pathology we had performed nasal endoscopy that detected the papilloma. Hence we feel that it should be routinely performed in every case having proptosis due to any sinus pathology. Nasal endoscopy can also provide material for histopathological examination if any abnormality is detected. Possibility of a sinonasal pathology should be kept in mind in patient with cholesterol granuloma of the orbit.
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[Figure 1], [Figure 2]