PMC6747856_01
A, Preoperative external photograph of a 58-year-old man from Liberia who presented with a progressively enlarging mass below his left medial canthus for 2 years. B, Postoperative external photograph after an inverted papilloma was removed in a combined endoscopic and external approach.
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A 58-year-old African male from Liberia initially presented to the Wills Eye Emergency Room with a 2-year history of a progressively enlarging mass inferior to the left MCT (Figure 1(A)). The patient healed well postoperatively (Figure 1(B)).
A, Axial CT scan demonstrating a mass centered in the left lacrimal sac with erosion of the lacrimal fossa and nasal bones. B, Axial CT scan demonstrating a widened NLD secondary to tumor extension. C, Coronal CT scan demonstrating a left lacrimal sac mass eroding the lacrimal fossa and extending down the NLD causing its expansion. D, Axial T1 postcontrast MRI redemonstrating a large well circumscribed mass at the medial canthus with anterior extension and compression of the medial orbit. E, Axial T1 postcontrast MRI redemonstrating extension of tumor inferiorly within a widened NLD. F, Coronal T1 postcontrast MRI redemonstrating a mass at the lacrimal fossa extending into the NLD.
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The patient underwent computed tomography (CT) of the orbits which demonstrated a 3.4 cm (transverse) x 3.1 cm (anteroposterior) x 3.4 cm (craniocaudal) enhancing mass centered in the medial canthus and lacrimal sac of the medial left orbit (Figure 2(A)). The mass extended along the osseous canal of the NLD causing its bony expansion (Figure 2(B) and (C)) and was most consistent with a lacrimal sac tumor. MRI redemonstrated a T1 and T2 isointense mass measuring 4.0 cm x 2.6 cm in axial dimension centered in the left medial canthus (Figure 2(D)), extending inferiorly through the NLD, and exiting the inferior meatus into the inferior nasal cavity (Figure 2(E) and (F)).
Pathologic findings, endoscopic biopsy. A, Nonkeratinizing stratified squamous epithelium growing inward toward the stroma consistent with inverted papilloma. B, Lobules of polarized epithelium composed of cells with elongated nuclei and cytoplasm reminiscent of transitional epithelium with few foci of neutrophils. No nuclear atypia or mitotic figures are present, consistent with a diagnosis of inverted papilloma without dysplasia.
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Endoscopic, endonasal biopsy was performed in the office with histopathology revealing an IP (Figure 3(A) and (B)).
Intraoperative photograph during combined endoscopic and external resection of an inverted papilloma of the lacrimal sac demonstrating severe dilation of the NLD system superiorly secondary to tumor growth (solid arrow) and a large defect in the lateral nasal side wall (dotted arrow).
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The NLD was noted to be severely widened secondary to tumor growth (Figure 4).