Surgical treatment of 186 sinonasal inverted papillomas and analysis of the immunohistochemical and molecular features associated with recurrences.

INTRODUCTION: Inverted papillomas (IP) are benign epithelial tumors with a tendency to be locally invasive and with disposition to recur. The aim of our study is to present the results of IP treatment, considering pathological, immunohistochemical and molecular features of recurrence. MATERIAL AND METHODS: From 1978 to 2020, 186 sinonasal IPs surgeries corresponding to 152 patients were treated in our center. We performed a pathology evaluation of all the recurrent cases reviewing the histological diagnosis, the presence of mixed component other than IP, the koilocytic changes, the p16 over expression and HPV-DNA detection. RESULTS: Overall recurrence rate was 19 % (35/186). The 35 IP recurrences correspond to 22 patients, 9 of whom presented a single recurrence (single recurrence group) while 13 of them presented more than one recurrence (multi-recurrent group). Immunohistochemical analysis showed a higher percentage of p16 overexpression (54 % vs 33 % p = 0.415) and HPV-DNA presence (23 % vs 0 % p = 0.240) in the multi-recurrent group compared with single recurrence group. In addition, the revision showed more IP with exophytic papilloma focus (38 vs 22 % p = 0.648) and a higher proportion of IP with koilocytotic changes (61 % vs 22 % p = 0.099) in the multirecurrent group. There is no significant difference between groups in our results. CONCLUSION: The analysis of our patients may differentiate between two groups with recurrent papillomas. A single recurrence group where the cause of recurrence is probably an anatomical problem related to an incomplete resection, and a second pattern, the multi-recurrence group, where HPV infection may be the main cause of recurrence.

Modifications in the treatment of advanced laryngeal cancer throughout the last 30 years.

In the last decades, the treatment schemes for patients with locally advanced laryngeal cancer have changed significantly. These changes may have an impact in the survival of these patients. Our objective is to review the treatments administered to patients with locally advanced larynx tumors during a period of 30 years in our institution and to evaluate the prognostic impact of the changes in treatment protocols. Retrospective analysis of a cohort of 830 consecutive patients with T3 or T4 laryngeal carcinomas diagnosed and treated between 1985 and 2014 with a minimum follow-up of 1.5 years. During the study period, we witnessed a reduction in surgery as the initial treatment, as well as a substitution of induction chemotherapy by chemoradiotherapy as an organ preservation strategy. For patients with T3 tumors, there were no differences in cancer-specific survival by type of treatment, while patients with T4 tumors treated surgically showed significantly better survival than those treated with preservation strategies. Patients treated in the last decade (2005-2014) showed worse cancer-specific survival than those treated in the previous decade (1995-2004). The multivariate analysis showed significant differences in cancer-specific survival for larger tumors, positive nodal extension, and treatment with radiotherapy alone. The main changes in the management of advanced laryngeal carcinomas are the implementation of organ preservation strategies that reduce the use of surgery and the progressive of chemoradiotherapy as a standard treatment. These changes may have had a negative impact in survival of these patients.

Descending necrotizing mediastinitis: key points to reduce the high associated mortality in a consecutive case series.

Background: Descending necrotizing mediastinitis (DNM) is an acute life-threatening infection that originates in the oropharyngeal region. It is an uncommon disease with a mortality rate of about 20-40%. This high mortality is mainly attributed to delays in diagnosis and treatment and poor drainage of the mediastinum. We highlight key points that may help reduce mortality. Case Description: We analyze a retrospective case series of seven patients diagnosed with DNM between March 2019 and July 2022 at Hospital de la Santa Creu i Sant Pau. The primary oropharyngeal infection was peritonsillar abscess in three cases and odontogenic abscess in four. All patients showed symptoms of severe cervical infection and symptoms suggestive of mediastinitis. A cervicothoracic computed tomography (CT) scan confirmed the presence of cervical and mediastinal collections and emphysema in all cases. All patients were simultaneously evaluated by the otorhinolaryngology and thoracic surgery teams. Broad-spectrum antibiotic therapy was instituted pending culture. All the patients underwent urgent surgery, consisting of cervicotomy to control the cervical focus and unilateral or bilateral video-assisted thoracoscopic debridement and drain of the pleural cavities and mediastinum. Regarding the outcomes, no patients died, one patient (14.2%) underwent transcervical mediastino-thoracoscopy drainage only. In six patients (85.8%) we performed a combined transcervical and transthoracic approach. Reoperation was required in 3 (43%) cases. The parameter that indicated a poor clinical evolution in these patients was an increase in C-reactive protein and the infection extension on the cervicothoracic CT scan. The follow-up was 30 days from last surgery; there were no losses. Conclusions: Based on our experience, the key points that can help reduce the high mortality associated with DNM are a rapid multidisciplinary assessment and a combined surgical procedure, considering the minimally invasive approach as the first option to drain the pleural cavities and mediastinum.

Semaphorin-3F/Neuropilin-2 Transcriptional Expression as a Predictive Biomarker of Occult Lymph Node Metastases in HNSCC.

The expression of the semaphorin-3F (SEMA3F) and neuropilin-2 (NRP2) is involved in the regulation of lymphangiogenesis. The present study analyzes the relationship between the transcriptional expression of the SEMA3F-NRP2 genes and the presence of occult lymph node metastases in patients with cN0 head and neck squamous cell carcinomas. We analyzed the transcriptional expression of SEMA3F and NRP2 in a cohort of 53 patients with cN0 squamous cell carcinoma treated with an elective neck dissection. Occult lymph node metastases were found in 37.7% of the patients. Patients with occult lymph node metastases (cN0/pN+) had significantly lower SEMA3F expression values than patients without lymph node involvement (cN0/pN0). Considering the expression of the SEMA3F-NRP2 genes, patients were classified into two groups according to the risk of occult nodal metastasis: Group 1 (n = 34), high SEMA3F/low NRP2 expression, with a low risk of occult nodal involvement (14.7% cN0/pN+); Group 2 (n = 19), low SEMA3F or high SEMA3F/high NRP2 expression, with a high risk of occult nodal involvement (78.9% cN0/pN+). Multivariate analysis showed that patients in Group 2 had a 26.2 higher risk of lymph node involvement than patients in Group 1. There was a significant relationship between the transcriptional expression values of the SEMA3F-NRP2 genes and the risk of occult nodal metastases.

Concordance of p16INK4a and E6*I mRNA among HPV-DNA-Positive Oropharyngeal, Laryngeal, and Oral Cavity Carcinomas from the ICO International Study.

Background: Tests or test algorithms for diagnosing HPV-driven oral cavity and laryngeal head and neck carcinomas (HNC) have not been yet validated, and the differences among oral cavity and laryngeal sites have not been comprehensively evaluated. We aimed to assess the utility of a diagnostic algorithm for the detection of HPV-driven oral cavity (OCC), oropharyngeal (OPC) and laryngeal (LC) carcinomas using HPV-DNA testing followed by p16INK4a immunohistochemistry, taking E6*I mRNA detection as the reference standard. Methods: Formalin-fixed paraffin-embedded OCC, OPC, and LC carcinomas were collected from pathology archives in 29 countries. All samples were subjected to histopathological evaluation, DNA quality control, and HPV-DNA detection. All HPV-DNA-positive samples (including 78 OCC, 257 OPC, and 51 LC out of 3680 HNC with valid HPV-DNA results) were also tested for p16INK4a immunohistochemistry and E6*I mRNA. Three different cutoffs of nuclear and cytoplasmic staining were evaluated for p16INK4a: (a) >25%, (b) >50%, and (c) ≥70%. The concordance of p16INK4a and E6*I mRNA among HPV-DNA-positive OCC, OPC, and LC cases was assessed. Results: A total of 78 OCC, 257 OPC, and 51 LC were HPV-DNA-positive and further tested for p16INK4a and E6*I mRNA. The percentage of concordance between p16INK4a (cutoff ≥ 70%) and E6*I mRNA among HPV-DNA-positive OCC, OPC, and LC cases was 79.5% (95% CI 69.9−89.1%), 82.1% (95% CI 77.2−87.0%), and 56.9% (95% CI 42.3−71.4%), respectively. A p16INK4a cutoff of >50% improved the concordance although the improvement was not statistically significant. For most anatomical locations and p16INK4a cutoffs, the percentage of discordant cases was higher for HPV16- than HPV-non16-positive cases. Conclusions: The diagnostic algorithm of HPV-DNA testing followed by p16INK4a immunohistochemistry might be helpful in the diagnosis of HPV-driven OCC and OPC, but not LC. A different p16INK4a expression pattern was observed in those cases HPV-DNA-positive for types other than HPV16, as compared to HPV16-positive cases. Our study provides new insights into the use HPV-DNA, p16INK4a, and HPV-E6*I mRNA for diagnosing an HPV-driven HNC, including the optimal HPV test or p16INK4a cutoffs to be used. More studies are warranted to clarify the role of p16INK4a and HPV status in both OPC and non-OPC HNC.

The Effect of Perioperative Blood Transfusions on Microvascular Anastomoses.

INTRODUCTION: Perioperative transfusions are associated with complications of free flaps. The purpose of the present study was to find out whether there is a significant relationship between the risk of developing complications in vascular anastomoses and the history of transfusions. METHODS: We studied 372 patients retrospectively with microsurgical reconstruction between 2009 and 2017 with regards to the number of red blood cell concentrates transfused. Complications were analyzed relative to flap loss and complications in microvascular anastomoses. RESULTS: 130 patients (34.9%) received blood transfusions. Some 55% of them were transfused between the day of the intervention and the first postoperative day. Ninety-six patients were reoperated on (25.7%). Of those, thirty-six patients (37.5%) corresponded to anastomosis failure. The percentage of patients transfused among those who required reoperation was 55.2%. The percentage of patients transfused among those who were reoperated on within the first 72 h due to an alteration in the anastomosis was 60.6%, while it was 25.6% (Chi square P = 0.0001) for the rest of the patients. CONCLUSIONS: Although there is a strong association between transfusion and vascular anastomosis failure, it is not possible to establish the causation between the two.

[Pectoralis major flaps. Evolution of their use in the age of microvascularized flaps]. / Colgajo de pectoral mayor: evolución de su uso en la era de los colgajos microanastomosados.

INTRODUCTION: Oncological head and neck surgery has progressed with the possibility of adapting reconstruction to the surgery effected. In the last 30 years, two basic techniques have been developed: the pectoralis major myocutaneous flaps (PMMF) and microvascularized flaps. PMMF had a leading role in reconstruction surgery during the 1980s, but this has subsequently diminished in favour of microvascularized flaps. MATERIAL AND METHOD: A review was conducted on 351 reconstructive surgeries in 317 patients, of which 275 were PMMF and 76 free flaps. We analyzed age, gender, flap type, indication, and year of the surgery in all cases. RESULTS: 34 % of the revised flaps were used for reconstruction of the hypopharynx, 33 % for the oropharynx, 21 % for soft tissues, and 12 % for the repair of pharyngocutaneous fistulae. At our hospital, the introduction of the free flap technique from 2001 on has led to an increase in the use of reconstructive procedures as well as the replacement of PMMF by microvascularized flaps in a number of indications. CONCLUSIONS: In this age of microvascularized flaps, we believe that PMMF still has a privileged role in the repair of hypopharynx and cervical lesions. However, in such locations as the oral cavity or oropharynx and in facial soft- tissue reconstruction we prefer the use of microvascularized flaps.

HSP-90 expression as a predictor of response to radiotherapy in head and neck cancer patients. / Expresión de Heat Shock Protein-90 (HSP-90) como factor predictor de la respuesta a radioterapia en pacientes con tumores de cabeza y cuello.

INTRODUCTION AND OBJECTIVES: HSP-90 is an intracellular protein that protects the cell from environmental stress situations. The overexpression of HSP-90 isoforms could serve as a mechanism of resistance to radiotherapy for tumour cells. We studied this effect in a sample of head and neck tumours. METHODS: We included 87 patients diagnosed with oral cavity, oropharynx, larynx and hypopharynx tumours. We studied the expression of the HSP-90 isoforms by real-time PCR on pre-treatment biopsy samples. We analysed the relationship between HSP-90 expression levels and local relapse of the tumour with CRT decision trees. RESULTS: The expression levels of the inducible citosolic isoform (HSP90AA) allowed the definition of 2 groups of patients with different rates of local relapse. The group with a low expression level showed a 2.9% local relapse rate, while the group with a high expression level showed a 38.2% rate. Survival curves showed differences in time to local relapse for both groups of patients. These differences did not reach statistical significance. CONCLUSIONS: Radiotherapy response was related to expression levels of HSP-90 in a sample of head and neck cancer patients. This result could prove useful in the selection of treatments for this group of patients.

[Surgical treatment of head and neck squamous cell carcinomas in Spain during the 2006-2011 period]. / Tratamiento quirúrgico de los carcinomas escamosos de cabeza y cuello en España durante el periodo 2006-2011.

INTRODUCTION AND OBJECTIVES: Surgery is one of the basic pillars in the treatment of patients with head and neck squamous cell carcinoma (HNSCC). The objective of the present study was to analyse the current state of the use of surgery in patients with HNSCC in Spain. METHODS: Retrospective review of the hospital discharge reports of the patients with HNSCC treated surgically during the 2006-2011 period in Spain. We obtained the data from the Minimum Basic Data Set during the hospital discharge. RESULTS: We obtained information on 26,629 hospital discharges, with a total of 27,937 surgical procedures. Overall, in our country about half of the patients with HNSCC receive surgical treatment of the primary tumour location. There were no significant changes in the number of surgical procedures throughout the study period. There was a smooth downward trend in the number and percentage of surgeries carried out in male patients, and a significant increase in those carried out in female patients throughout the study period. Among the total of surgical procedures, 15.7% were carried out in hospitals with a low level of complexity, 32.2% in hospitals with an intermediate complexity and 52.1% in centres of high complexity. CONCLUSIONS: Surgery is one essential pillar in the treatment of patients with HNSCC. In Spain about half of the patients with HNSCC receive surgical treatment for the primary location of the tumour.

Management of sinonasal mucosal melanomas and comparison of classification staging systems.

OBJECTIVE: The aim of this study was to describe treatment results in patients with sinonasal mucosal melanomas (SMMs) and to compare three different classification staging systems. MATERIALS AND METHODS: From 1988 to 2013, we performed a retrospective study of 20 patients with primary sinonasal melanomas. The median age at diagnosis was 71 years. There were 10 males and 10 females. RESULTS: Nine SMMs (45%) were originated in the ethmoidal sinus complex, four (20%) in the inferior turbinate, three (15%) in the nasal septum, two (10%) in the maxillary sinus, and two (10%) in the nasal vestibule. Local recurrence was diagnosed in eight patients (40%), and six out of 20 patients (30%) developed distant metastasis during the course of their disease. The adjusted survival rates at three and five years were 47% and 34%, respectively. The adjusted three-year survival rate according to the sinonasal staging system 7th edition for SMM (TNM-SMM) was 60% in T3 stage, 50% in T4a stage, and 34% in T4b stage (p = 0.05). According to Thompson's staging system, survival was 33% for group one, 58% for group two, and 0% for group three (p = 0.006). With the sinonasal staging system 7th edition for carcinoma (TNM-CAR) survival was 33% in T1, 100% in T2 and T3, 0% in T4a, and 34% in T4b (p = 0.006). CONCLUSIONS: Our experience confirms the distribution of patients according to survival rates was better with the TNM-SMM than with Thompson's or the TNM-CAR systems.

Traqueotomía en pacientes COVID-19: un procedimiento necesario de alto riesgo. Experiencia de dos centros / Tracheotomy in patients COVID-19: A necessary high risk procedure. Two center experience

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Infección parotídea por Mycobacterium malmoense / Mycobacterium malmoense parotid gland infection

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Chronic adherence to heat and moisture exchanger use in laryngectomized patients.

INTRODUCTION AND OBJECTIVE: Total laryngectomy leads to pulmonary problems such as excessive sputum production, forced expectoration and increased coughing. The use of a heat and moisture exchanger (Provox(®) HME) reduces these symptoms. The aim of this study was to quantify chronic adherence to HME use in laryngectomized patients. METHODS: A prospective study of 115 patients laryngectomized at our centre during 2005-2011 was performed. RESULTS: Of the 115 patients, 90 (78.2%) used the HME consistently and 25 (21.8%) abandoned its use. The most common causes of desertion were adhesion problems due to mucus and skin irritation. Of the 30 patients with voice prostheses, 90% of them used the HME system regularly. Voice prosthesis use (P=.05) and early indication in postoperative laryngectomy (P=.001) were factors significantly associated with chronic HME use. CONCLUSIONS: There is high adherence (78.2%) to heat and moisture exchanger (Provox(®) HME) use in laryngectomized patients. Chronic HME use was higher in patients with voice prosthesis and the ones with early indication in postoperative period. The major causes of abandonment were related to problems with the adhesive.

Endonasal endoscopic scalpel-forceps dacryocystorhinostomy vs endocanalicular diode laser dacryocystorhinostomy.

Purpose. To compare the efficacy of endonasal endoscopic dacryocystorhinostomy and endocanalicular diode laser dacryocystorhinostomy. Materials and methods. A total of 126 dacryocystorhinostomies were performed in 111 patients with epiphora. In 55% of cases (69/126) we performed an endonasal endoscopic dacryocystorhinostomy and in 45% (57/126) we carried out an endocanalicular dacryocystorhinostomy using diode laser. The mean age at diagnosis was 63 years. The mean age was higher in the endocanalicular group than in the endonasal endoscopic group: 64 versus 62 years. There were 25 men (23%) and 86 women (77%). Results. Successful results were achieved in 73% of patients (92/126). In the endonasal endoscopic group, 83% of patients (57/69) were symptom free compared to 62% of patients (35/57) in the laser diode group. A bicanalicular nasal silicone tube was left in place for a mean of 2.32 months in the endoscopic endonasal group and for 2.82 months in the laser diode group (p=0.164). Median time of recurrence after removal of the tube was 3.56 months (range 0-9.6): 2.84 months in the laser diode group and 4.87 months in the endonasal endoscopic group (p=0.069). Conclusions. The endonasal endoscopic approach achieved better results for nasolacrimal obstruction than the endocanalicular laser diode technique.

Expresión de Heat Shock Protein-90 (HSP-90) como factor predictor de la respuesta a radioterapia en pacientes con tumores de cabeza y cuello / HSP-90 expression as a predictor of response to radiotherapy in head and neck cancer patients

Introducción y objetivos: La HSP-90 es una proteína intracelular que protege la célula en situaciones de estrés ambiental. El objetivo de este estudio es valorar si la sobreexpresión de alguna de las isoformas de HSP-90 confiere resistencia a la radioterapia en una muestra de tumores de cabeza y cuello. Métodos: Se incluyeron en el estudio 87 pacientes con tumores de cavidad oral, orofaringe, laringe e hipofaringe. En muestras de biopsia pretratamiento se analizaron mediante PCR en tiempo real la expresión de las isoformas de HSP-90. Se utilizaron árboles de decisión para estudiar la relación entre el nivel de expresión de HSP-90 y la recidiva local del tumor. Resultados: La expresión de la isoforma citosólica inducible (HSP90AA) permitió definir 2 grupos con diferentes índices de recidiva local. El grupo con expresión baja presentó un 21,9% de recidivas frente al 38,2% del grupo con expresión alta. Las curvas de supervivencia muestran diferencias en el tiempo libre de recidiva local entre ambos grupos, aunque estas diferencias no alcanzaron significación estadística. Conclusiones: La respuesta de los tumores de cabeza y cuello a la radioterapia parece relacionada con la expresión de HSP-90. Este resultado podría ser de utilidad en la selección de tratamientos en este grupo de pacientes (AU)

Introduction and objectives: HSP-90 is an intracellular protein that protects the cell from environmental stress situations. The overexpression of HSP-90 isoforms could serve as a mechanism of resistance to radiotherapy for tumour cells. We studied this effect in a sample of head and neck tumours. Methods: We included 87 patients diagnosed with oral cavity, oropharynx, larynx and hypopharynx tumours. We studied the expression of the HSP-90 isoforms by real-time PCR on pre-treatment biopsy samples. We analysed the relationship between HSP-90 expression levels and local relapse of the tumour with CRT decision trees. Results: The expression levels of the inducible citosolic isoform (HSP90AA) allowed the definition of 2 groups of patients with different rates of local relapse. The group with a low expression level showed a 2.9% local relapse rate, while the group with a high expression level showed a 38.2% rate. Survival curves showed differences in time to local relapse for both groups of patients. These differences did not reach statistical significance. Conclusions: Radiotherapy response was related to expression levels of HSP-90 in a sample of head and neck cancer patients. This result could prove useful in the selection of treatments for this group of patients (AU)

[Head and neck sarcomas. Our experience]. / Sarcomas de cabeza y cuello. Nuestra experiencia.

INTRODUCTION: Head and neck sarcomas are a heterogeneous group of malignant tumours that vary greatly in clinical presentation, with different histopathological and biological characteristics. MATERIAL AND METHODS: This was a retrospective study of patients with sarcoma located in the head and neck treated in our centre over a period of 25 years. RESULTS: During the study period, a total of 25 patients were diagnosed with sarcomas in the head and neck, accounting for 0.5% of all malignancies at this level. The most common treatments included surgical resection of the tumour, often supplemented with radiotherapy and/or adjuvant chemotherapy. The final local control, including the salvage, was 52%, with an adjusted survival of 51% at 5 years and 32% at 12 years. CONCLUSIONS: Surgical treatment of patients with head and neck sarcomas achieves acceptable results of local control and survival.

Tratamiento quirúrgico de los carcinomas escamosos de cabeza y cuello en España durante el periodo 2006-2011 / Surgical treatment of head and neck squamous cell carcinomas in Spain during the 2006-2011 period

Introducción y objetivos: La cirugía es uno de los pilares básicos en el tratamiento de los pacientes con carcinomas escamosos de cabeza y cuello (CECC). El objetivo del presente estudio es analizar el estado actual del uso de la cirugía en este tipo de pacientes en España. Métodos: Revisión retrospectiva de las altas hospitalarias de los pacientes con CECC tratados quirúrgicamente durante el periodo 2006-2011 en España a partir de los datos obtenidos del Conjunto Mínimo Básico de Datos al Alta Hospitalaria (CMBD). Resultados: Se recogió información correspondiente a 26.629 altas hospitalarias, con un total de 27.937 procedimientos. Globalmente, en nuestro país la mitad de los pacientes con un CECC reciben un tratamiento quirúrgico sobre la localización primaria del tumor. No se produjeron modificaciones significativas en el número de procedimientos a lo largo del periodo de estudio. Apareció una suave tendencia hacia la disminución en el número y porcentaje de cirugías realizadas en pacientes del sexo masculino, y un elevado incremento para las pacientes del sexo femenino a lo largo del periodo de estudio. Del total de procedimientos realizados, un 15,7% se realizaron en centros hospitalarios de nivel de complejidad bajo, un 32,2% en los de complejidad intermedia, y un 52,1% en centros de alta complejidad. Conclusiones: La cirugía constituye un pilar fundamental en el tratamiento de los pacientes con un CECC. En España, aproximadamente la mitad de los pacientes con un CECC reciben un tratamiento quirúrgico sobre la localización primaria del tumor (AU)

Introduction and objectives: Surgery is one of the basic pillars in the treatment of patients with head and neck squamous cell carcinoma (HNSCC). The objective of the present study was to analyse the current state of the use of surgery in patients with HNSCC in Spain. Methods: Retrospective review of the hospital discharge reports of the patients with HNSCC treated surgically during the 2006-2011 period in Spain. We obtained the data from the Minimum Basic Data Set during the hospital discharge. Results: We obtained information on 26,629 hospital discharges, with a total of 27,937 surgical procedures. Overall, in our country about half of the patients with HNSCC receive surgical treatment of the primary tumour location. There were no significant changes in the number of surgical procedures throughout the study period. There was a smooth downward trend in the number and percentage of surgeries carried out in male patients, and a significant increase in those carried out in female patients throughout the study period. Among the total of surgical procedures, 15.7% were carried out in hospitals with a low level of complexity, 32.2% in hospitals with an intermediate complexity and 52.1% in centres of high complexity. Conclusions: Surgery is one essential pillar in the treatment of patients with HNSCC. In Spain about half of the patients with HNSCC receive surgical treatment for the primary location of the tumour (AU)

Management of sinonasal inverted papillomas and comparison of classification staging systems.

BACKGROUND: The aim of this study was to describe treatment results in patients with sinonasal inverted papilloma and to compare recent classification staging systems. METHODS: We performed a retrospective study of 79 patients with primary paranasal sinus inverted papilloma from 1978 to 2008. RESULTS: The median age at diagnosis was 59 years. There were 68 men (86%) and 11 women (14%). Sixty inverted papilloma (76%) were located in the ethmoidal sinus complex, 16 (20%) were in the maxillary sinus, 2 were in the sphenoid sinus (3%), and 1 was in the septum (1%). Malignancy was simultaneously associated in four cases (5%). Intracranial extension was found in five patients (6%) and we did not find orbital content involvement. The external approach was used in 22 cases (28%) and 57 patients were treated with endoscopic nasal resection (72%). The overall recurrence rate in the total population was 21%. Recurrences were observed in 7 cases (32%) in the group of patients who received external approach and in 10 (17%) patients in the endoscopic group. Recurrences according to the Krouse system were 0% in T1 stage, 16% in T2 stage, 25% in T3 stage, and 60% in T4 stage (p = 0.05). Recurrences for groups A, B, and C stages using the Cannady staging system were 12, 26, and 60%, respectively (p = 0.039). Recurrences according to Han's system were 19% in both T1 and T2, 20% in T3, and 60% in T4 (p > 0.05). CONCLUSION: Our results support the endoscopic approach as the treatment of choice when feasible in patients with inverted papilloma, combined in selected cases with external approaches. The Krouse and Cannady systems provided a good distribution of patients according to local control.