Exophytic sinonasal papilloma

Last revised by Dr Joachim Feger on 06 Jan 2022

Exophytic sinonasal papillomas (ESP) or fungiform sinonasal papillomas are a form of Schneiderian papillomas and benign sinonasal tumors arising from the Schneiderian epithelium of the nasal septum.

Exophytic sinonasal papillomas are the second most common form of sinonasal papillomas and can occur at any age range with a peak in the third to fifth decade 1,2. They have a strong male predilection 1.

The diagnosis of exophytic sinonasal papillomas is made by its septal location, endoscopic appearance and histological features 3.

Clinical symptoms are similar to the other variants and include nasal obstruction, rhinorrhea, epistaxis and the presence of a mass lesion. They might be also found incidentally on imaging studies 3.

Low-risk human papillomavirus, in particular, type 6 and 11 are considered to have a role in their etiology 1,2.

Exophytic sinonasal papillomas are typically located in the nasal septum in particular anteriorly 1-4. Rarely do they arise from the middle turbinate or the nasal vestibule 3.

Subtypes of exophytic sinonasal papillomas include:

  • transitional cell papilloma
  • fungiform papilloma
  • squamous papilloma
  • Ringertz tumor
  • everted papilloma

Macroscopically exophytic sinonasal papillomas display the following features 1-4:

  • exophytic, papillary or verrucoid, cauliflower-like growth
  • fleshy, pink to a tannish color
  • firm consistency
  • stalk

Histologically primary exophytic sinonasal papillomas resemble squamous papillomas of other organs 1-4:

  • papillary or exophytic frond-like growth pattern around fibrovascular cores
  • most often well-differentiated squamous epithelium
  • variably transitional or columnar epithelium
  • hyperchromasia
  • some keratinization
  • fewer mucocytes and intraepithelial mucous cysts
  • variable koilocytic changes

Exophytic sinonasal papillomas are characterized by a rather nonspecific appearance and are usually seen arising from the nasal septum 5.

On CT they appear isointense and do not have any calcifications.

Exophytic sinonasal papillomas might show striations within the mass 3.

  • T1: iso to hyperintense
  • T2: hyperintense
  • T1 C+(Gd): homogeneous enhancement (less than surrounding mucosa)

The radiological report should include a description of the following features:

  • location and size of the lesion
  • presence of a stalk
  • associated focal hyperostosis

Treatment includes resection with clear margins. If there is no evidence of carcinoma long term prognosis is even better than with the other two variants 1,3. Recurrences can happen in cases of incomplete excisions but are less common than with the other two variants 3,4.

The first histological-based classification of sinonasal papillomas into inverted, cylindrical cell 'fungiform papillomas' was undertaken by VJ Hyams in 1971 1,6.

The differential diagnosis of exophytic sinonasal papillomas include the following 6:

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Cases and figures

  • Case 1: exophytic papilloma - squamous subtype
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