Sinonasal papilloma is an uncommon yet notable tumor that finds its origin in the nasal cavities and paranasal sinuses. Deriving its histological origin from the Schneiderian membrane, it emerges due to transitional metaplasia of the respiratory epithelium. Among the pantheon of sinonasal tumors, sinonasal papilloma is distinguished by three primary attributes: its proclivity for localized aggression, its notably high recurrence rates which can be both early and late in nature, and an association with carcinoma.

A nasal septal lesion’s occurrence makes the management more intricate for rhinologists. The recurrent propensity of the lesion combined with potential functional complications, such as septal perforation and saddle nose deformity, exacerbates the challenge. The primary approach to treatment typically encompasses surgical excision, with modalities ranging from cold knife excision to laser vaporization and others.

In this backdrop, our clinic recently encountered a particularly complicated case of saddle nose deformity, which followed the laser vaporization of a mucosal papilloma using a CO₂ laser. Through this report, we aim to elucidate the details of this case, hoping to shed light on potential complications and considerations for future treatment. A written informed consent was obtained from the patient for the publication of this case report.

A 48-year-old male with a complaint of nasal crusting and obstruction persisting for several months. Endoscopic examination revealed multiple septal and nasal papillomas within the nasal cavity (Fig. 1). Based on endoscopic findings and histological assessment, the patient was diagnosed with sinonasal papilloma.

Figure 1. Initial nasal endoscopic image of the patient.

The initial therapeutic approach was the removal of the septal papilloma. This was achieved through a nasal endoscope and CO₂ laser vaporization under general anesthesia (Fig. 2). Unfortunately, the patient’s condition relapsed three months post-procedure, necessitating a secondary laser vaporization, this time performed under local anesthesia (Fig. 3). There was a lapse in follow-up visits for about a year after this.

Figure 2. Immediate postoperative nasal endoscopic image of the patient.

Figure 3. After postoperative follow-up, papilloma of nasal septum has recurred.

Upon return four years post the initial procedure, the patient presented with a saddle nose deformity along with recurrent septal papillomatous lesions (Figs. 4, 5). To rectify the complications, an augmentation rhinoplasty using GORE-TEX was carried out, targeting the depressed region of the nasal dorsum. Concurrently, the septal papilloma was excised via cold knife dissection. Post-procedure, the patient’s saddle nose deformity was successfully corrected. Regular outpatient visits every 4 months have been maintained, with no significant complications reported to date.

Figure 4. Saddle nose deformity of the patient.

Figure 5. After postoperative follow-up, papilloma of nasal septum has recurred again.

Inverted papillomas, though infrequent, are a significant concern in otolaryngology due to their invasive potential. These neoplasms predominantly originate in the nasal cavity but can expand to invade the paranasal sinuses and, in severe cases, even adjacent structures like the lacrimal system, the orbit, or the intracranial cavity. Their growth can lead to considerable bone and soft tissue destruction. Importantly, there is a notable correlation between inverted papillomas and carcinomas.

Anatomically, inverted papillomas most frequently arise from the lateral nasal wall, with studies indicating this location in 68%-94% of cases. Following this, they emerge from the ethmoid and maxillary sinus (47%-71%). The nasal septum and the frontal and sphenoid sinuses are less frequent sites of origin [1].

The nasal septum, forming the midline division of the nasal cavity, has both cartilaginous and bony constituents. The anterior, cartilaginous portion of the septum is particularly susceptible to thermal injury. In the presented case, the patient underwent laser vaporization twice, which might have exposed the septal cartilage to detrimental high temperatures. A previous experimental study on rabbit cartilage demonstrated that a 1,460-nm diode laser at 1 W could impede the regenerative capability of chondrocytes, even when perichondria remained intact [2].

Given that temperatures can escalate to around 170°C in 1 W diode laser irradiation, it’s plausible to infer that the CO₂ laser in this case could have reached temperatures that compromised the cartilage, particularly the critical keystone area. Further complications arise if the perichondrium, which is crucial for regeneration, is inadvertently damaged during the procedure. Notably, while there’s a lack of literature on saddle nose deformities post-laser irradiation, a case was reported where the deformity arose after nasal septum electrocautery to control epistaxis [3]. Traditional electrocautery devices can achieve temperatures between 200°C and 350°C [4]. This temperature range has led some to speculate that such high heat levels might jeopardize the keystone area’s structural integrity, culminating in a saddle nose deformity.

Postoperatively, the four-year lapse in patient follow-up offers a window during which the saddle nose deformity could have gradually developed. During this healing period, the damaged cartilage might have been superseded by fibroblasts. Additionally, wound contracture could have expedited the deformity’s progression.

This case provides invaluable insights into the challenges and risks associated with using laser-based therapies, particularly in sensitive and structurally significant regions like the nasal septum. The potential complications emphasize the necessity for detailed patient counseling, precise operative techniques, and vigilant postoperative oversight when utilizing high-temperature instruments in nasal procedures.

In conclusion, sinonasal papillomas, though rare, can lead to significant functional and aesthetic complications. Careful monitoring, timely intervention, and consideration of the appropriate treatment modalities are crucial to prevent adverse outcomes. This case emphasizes the importance of regular follow-up and the potential pitfalls of laser interventions.

None.

None.

Conceptualization: JHM. Data curation: SHY. Formal analysis: SHY. Funding acquisition: all authors. Investigation: SHY. Methodology: JHM. Project administration: SHY. Software: JHM. Validation: SHY. Visualization: all authors. Writing–original draft: all authors. Writing–review & editing: all authors.

No potential conflict of interest relevant to this article was reported.

This research was supported by the Basic Science Research Program through the National Research Foundation of Korea (NRF), funded by the Ministry of Education [2021R1I1A1A01052298]. This research was supported by a grant of the Korea Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI), funded by the Ministry of Health & Welfare, Republic of Korea (grant number: HI22C0612).

This research was supported by the Bio&Medical Technology Development Program of the National Research Foundation (NRF) funded by the Korean government (MSIT) (RS-2023-00220408). This research was supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Science, ICT & Future Planning (2020R1A2C1012105). This research was supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education (NRF-2020R1A6A1A03043283).

None.