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  • Author: Ioan Alexandru Bulescu x
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Inverted papilloma is a rare benign sinonasal tumor with a still unclear etiology. In the last decades, HPV implication in inverted papilloma etiopathogeny has been studied and demonstrated in some scientific research papers, but with no causality proven. Imagistic investigations and the Krouse classification establish the surgical approach. Endoscopic surgery represents the golden standard treatment for most cases of inverted papilloma, while external or combined approaches present limited indications.

The authors present a case and therapeutic plan of an inverted papilloma located in the ethmoid sinus, with origin in the lamina papyracea and high-risk HPV implication.


The pterygopalatine fossa is an inverted pyramid-shaped space of the viscerocranium, protected by bony structures. Surgical access to this anatomical space is difficult, especially for tumor resection. There are numerous open surgical techniques for accessing this space, but nowadays, minimally-invasive endoscopic approaches are preferred in order to increase postoperative quality of life and reduce postoperative morbidities.

The tumors of the pterygopalatine fossa can be benign or malignant, and can occur primarily in the fossa or as secondary extensions from the surrounding regions through the multiple canals and foramina in its walls. Squamous cell carcinomas of this space have been described to appear as extensions from the nasopharynx, the paranasal sinuses or through perineural extension from the cutaneous branches of the maxillary nerve.

In this paper the authors present a rare case of squamous cell carcinoma of the pterygopalatine fossa, which was excised in an endoscopic transnasal approach after preoperative selective embolization.


Morphological variability of paranasal sinuses is well known for endoscopic surgeons and anatomists alike. The ethmoid sinus is the most complex and variable of all paranasal sinuses, due to the fact that its development is not yet well known and is influenced by many factors. Volumetric studies of the sinuses have been made using dried skulls, cadaver heads and imaging studies, but there are still not sufficient data in order to name a standard value for each sinus. Few data can be found especially regarding the ethmoid sinus. In this paper, we measured the volumes of ethmoid lateral masses, and for anterior and posterior groups of cells, using imaging studies and a volumetric feature of our imaging studies. Results showed an average volume between 7.34 cm3 and 8.39 cm3 for the ethmoid lateral mass, between 4.33 cm3 and 4.92 cm3 for the anterior ethmoid and between 3.01 cm3 and 3.47 cm3 for the posterior ethmoid groups. We also found that the average volume of the anterior ethmoid occupies between 58-59% of the whole volume, while the posterior ethmoid occupies only 41-42% of this volume.


The authors present a case of recurrent frontal rhinosinusitis, for which the drug therapy was ineffective. To avert the risk of complications, multiple classic and endoscopic surgical procedures were performed on the frontal sinus pathology.

The bacterium involved in this form of rhinosinusitis was represented by a Methicillin-resistant Staphylococcus aureus (MRSA) diagnosed during the first endoscopic approach (the second surgical procedure) for which the treatment corresponding to the antibiogram was followed. At the last hospitalization, the patient has underwent a frontal bilateral drainage surgery (modified Lothrop procedure) and started an adequate anti-MRSA treatment.

The authors wondered whether multiple recurrences of frontal rhinosinusitis are determined by an incomplete drainage, by a persistent infection with MRSA or by both.