CO-EXISTING OF SINONASAL INVERTED PAPILLOMA AND ANGIOFIBROMA: CASE REPORT AND REVIEW OF THE LITERATURE
Thirty seven years old male with no known chronic medical illness presented with history of four months left sided nasal blockage and discharge associated with left facial pain and two episodes of large amount of epistaxis from left nostril which stopped spontaneously. No history of ear symptoms, blurring of the vision and neck swelling noted.\nOn endoscopic examination, the left nasal cavity was occupied by the mass but did not extend to nasopharynx (Figure ). The mass was polypoidal and pinkish in appearance and bled minimally with touch and suction. Both fossa of Rosen Muller were clear. Moderate deviation of nasal septum to the right side noted but no mass seen in right nasal cavity.\nPunch biopsy from two different parts of the mass performed for histopathological examination and reported as inverted papilloma. Also CT scan done and reported as followings: heterogeneous soft tissue mass seen in left maxillary sinus and nasal cavity with no extension to nasopharynx (Figure ). Erosion of medial and posterolateral wall of left maxillary sinus noted. No intra cranial or orbital extension reported. Posterior extension to the left infratemporal space with intact pterygopalatine fossa was seen. The features were consistent with aggressive left maxillary soft tissue tumor such as inverted papilloma.\nOperation was decided and done as left open partial maxillectomy and complete excision of the tumor. After incision of the skin and raising the flap, osteotomy was performed as removal of frontal process of maxilla and medial wall of maxillary sinus. Then the lacrimal sac was exposed and distal end of lacrimal duct was cut. Intraoperatively, a big mass seen that occupied whole left nasal cavity and maxillary sinus. During the first step of resection of the tumor, bleeding occurred and was secured by packing for about half an hour. The tumor was removed from posterolateral wall of maxilla to the left infratemporal fossa and from posterior wall of maxilla until left pterygopalatine fossa. Inferiorly, the mass was resected from floor of the maxillary sinus and erosion of hard palate was noted. In addition, superior turbinate was removed and ethmoidectomy and sphenoidectomy conducted. There was no tumor seen inside the sphenoid sinus. The left frontal sinus was opened as well and clear antrum with polypoidal mucosa was noted.\nFinally, the bleeding secured. The amount of intraoperative blood loss was estimated as 700 ml. The cavity was packed by PIPP that was kept for one week duration. The patient was discharged 9 days after operation. Post-operative histopathology report was: co-existing of inverted papilloma and angiofibroma.\nCurrently, patient is asymptomatic with no sign of recurrence noted clinically (Figure ) and in post-operative CT scan. He is under regular three monthly follow up.