Exophytic sinonasal papilloma

Last revised by Ciléin Kearns on 27 May 2024

Exophytic sinonasal papillomas (ESP) or fungiform sinonasal papillomas are a benign sinonasal tumor arising from the nasal septum, and one of the three main histological forms a Schneiderian papilloma can take.

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.

Exophytic sinonasal papilloma arise from the Schneiderian epithelium of the nasal septum.

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 anteriorly in the nasal septum 1-4. Rarely, they can 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 usually arise from the nasal septum 5.

They may appear as an isodense, unilateral mass in the nasal cavity or sinus without calcification, but cannot be readily differentiated from retained mucous or inflamed mucosa. Sometimes they may thin or destroy the adjacent bone 7.

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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