Rhinosinusal Polyposis and Inverted Papilloma: A Morphometric Comparative Study

THIEME 196 Original Research Rhinosinusal Polyposis and Inverted Papilloma: A Morphometric Comparative Study Gabriel Costa Andrade1 Luciana Harumi Fujise1 Atílio Maximino Fernandes1 1 Faculadade de Medicina de São José do Rio Preto, São José do Rio Preto, São Paulo, Brazil Reinaldo Azoubel1 Address for correspondence Gabriel Costa Andrade, MD, Alameda Barros, 66 - Santa Cecília, São Paulo, São Paulo, 01232-000, Brazil (e-mail: ). Int Arch Otorhinolaryngol 2015;19:196–199. Abstract Keywords ► nasal polyps ► papilloma ► inverted ► nasal cavity ► otorhinolaryngologic neoplasms Introduction Nasal obstruction is one of the main rhinologic complaints, and two diseases must be investigated as differential diagnosis: rhinosinusal polyposis and inverted papilloma. Using traditional methods, the differential diagnosis between these diseases may be difficult. The morphometric study may be a useful tool for differential diagnosis and to define prognosis. Objective Calculate the morphometric values of rhinosinusal polyposis and inverted papilloma and compare the average of variables obtained between the groups. Methods The nasal mucus of 10 patients who had surgery in the Department of Otorhinolaryngology and Surgery of Head and Neck was studied; 5 had rhinosinusal polyposis and 5 had inverted papilloma. After the capture and print of corresponding data of each slide, the largest and smallest diameters of the nuclei were measured and the morphometric variables were calculated: average diameter, perimeter, ratio between largest and smallest diameter, volume, area, ratio of volume to area, form coefficient, contour index, and eccentricity. Results We found a significant difference (p < 0.05) between the two groups in the following morphometric variables: largest diameter, smallest diameter, average diameter, volume, area, perimeter, and ratio of volume to area, indicating that these parameters can be useful in diagnostic differentiation between these diseases. Conclusion We founded morphometric variables higher in patients with inverted papilloma, which can be related to the neoplastic origin of the inverted papilloma. The analysis of nuclear parameters is an instrument of great value in the differential diagnosis between rhinosinusal polyposis and inverted papilloma. Introduction Nasal obstruction is one of the main rhinologic complaints, and rhinosinusal polyposis is an important cause. Among inflammatory nasal polyps, rhinosinusal polyposis is a chronic disease of the nasal mucosa and paranasal sinuses, with formation of polyps due to degeneration of the mucosa.1 This disease affects between 1 and 4% of the population and is slightly more prevalent in men, with an incidence peaking in the fifth decade of life.2 received September 8, 2014 accepted January 21, 2015 published online March 12, 2015 DOI http://dx.doi.org/ 10.1055/s-0035-1547521. ISSN 1809-9777. This disease has a multifactorial origin and is frequently associated with salicylates intolerance (such as acetylsalicylic acid, AAS), asthma, and cystic fibrosis.1–4 It presents macroscopically with a smooth surface and bright, jellylike appearance. It is pliable and light-colored gray or pink, with body and pedicle covered by nonkeratinized pseudostratified epithelium. It is usually located in the middle meatus, shell, and meatus superior. The clinical presentation is widely variable, and it can manifest by the appearance of polypoid formations (usually Copyright © 2015 by Thieme Publicações Ltda, Rio de Janeiro, Brazil Rhinosinusal Polyposis and Inverted Papilloma bilateral), painless, and without bleeding, leading to partial or total nasal obstruction, rhinorrhea (usually serious), hyposmia or anosmia, and chronic rhinosinusitis.1,3,4 Although the diagnosis is clinical, computed tomography is the best image test used, showing the extent of disease in paranasal sinuses.5 In cases of unilateral polypoid mass, the histopathology is not reliable and polyp antrochoanal and inverted papilloma may be considered as differential diagnoses. The inverted papilloma is a benign epithelial tumor with hyperplastic epithelium. Inverted papilloma occurs predominantly in males in the fifth and sixth decades of life. It represents 0.5 to 4% of all nasal tumors, with potential for malignancy ranging from 5 to 13% and with frequent recurrence and a variant rate of 0 to 78%.6–8 Inverted papilloma is usually located on the nose sidewall in the inferior shell and rarely implants in the nasal septum or paranasal sinuses. Macroscopically, it is a unilateral mass, rounded, with irregular surface and color that varies from pink to gray.1 Despite the usually unilateral location, studies have shown that inverted papilloma may appear bilaterally (0.92% of cases) and has been previously diagnosed as nasal polyps. Surgical interventions for exeresis of recurrent nasosinusal polyps showed 0.26% incidence of inverted papilloma.7 The etiology of inverted papilloma is not well defined, and there are several theories that attribute its onset to chronic inflammation, allergy, smoking, and infection by the EpsteinBarr virus and the human papillomavirus.8 The clinical presentation is a unilateral nasal obstruction, rhinorrhea, epistaxis, and anosmia. Depending on the tumor’s extension and the invasion of nearby tissue, visual and central nervous system manifestations can be found. The diagnoses should include detailed clinical and physical examination, with radiologic study and anatomopathological study.1 Due to the difficult differential diagnosis between rhinosinusal polyposis and inverted papilloma based on often unspecific signs and symptoms, investigation of microscopic morphological characteristics is necessary through karyometric or morphometric study, corroborating findings for an accurate diagnosis and appropriate treatment. Morphometry is a direct method of evaluating the morphology of an injury. Karyometry is, basically, nuclear morphometric study that evaluates possible nuclear changes, such as in shape and volume.9 In recent publications, morphometric study has been commonly used, primarily because it is statistically accurate and due to the extreme degree of objectivity, economy, accuracy, and the reduction of the usual bias inherent in subjective assessing.10,11 The benefits of morphometric study in relation to qualitative study are numeric results, which make them easily reproducible and confirmable by different laboratories. Moreover, the fact that they are composed of nonsubjective mathematical elements makes them very well accepted among researchers.10 Karyometry can be studied through the use of a microscope coupled with a clear chamber. With this method, the nucleus is drawn manually, the measurements are made with millimetric paper, and, finally, statisti- Andrade et al. cal calculations are made. A computerized system can also be used in which the nucleus is automatically analyzed.9 The karyometric variables are largest diameter, smal (...truncated)