Whats your diagnosis? A 72-year-old female with a diffuse mass in the right tonsillar region.

A 72-year-old female presented with progressively increasing difficulty in swallowing for the past 1 year and occasional bleeding from the mouth for the past 15 days. On examination, a pinkish diffuse mass was seen in the right tonsillar region (Figure 1), which reached the base of the tongue, extending to the posterior wall of the oropharynx and superiorly into the nasopharynx. Inferiorly it involved the lateral and posterior walls of the hypopharynx. The neck examination was normal. Computed tomography showed an enhancing mass with extensive involvement of the nasopharynx, oropharynx, and hypopharynx (Figure 2a and 2b). Punch biopsy under local anesthesia revealed pseudostratified epithelium growing endophytically into the underlying stroma (Figure 3).

Figure 1

Pinkish diffuse mass seen in the right tonsillar region on examination of the patient.

Figure 2

Sagittal and coronal sections on computed tomography showed an enhancing mass with the extensive involvement of nasopharynx, oropharynx, and hypopharynx.

Figure 3

Pseudostratified epithelium growing endophytically into the underlying stroma was seen on histopathological examination after punch biopsy of the lesion.

What is your diagnosis?

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Inverted papilloma is a benign epithelial tumor with locally invasive nature commonly seen in the nasal cavity. It is named after its characteristic histological feature, that is, inversion of columnar or ciliated epithelium into the underlying stroma.1 It is an uncommon tumor comprising 0.5%–4% of primary tumors of the nasal cavity.1 It is significant due to its tendency to recur and due to synchronous as well as metachronous malignancies.2 It arises from the Schneiderian membrane of ectodermal origin, which is different from the endodermally derived mucosa of the respiratory tract.2

The etiology is not well established; however, human papillomavirus DNA has been implicated.3 The commonest site of origin is the lateral wall of the nasal cavity.2 The usual presentation is with unilateral nasal discharge (occasionally blood stained) with progressive nasal obstruction. The growths are usually pinkish and polypoidal in the lateral wall of the nasal cavity. Contrast-enhanced computed tomography revealed focal hyperostosis at the site of origin in the nasal cavity.2,3 A nasal mass with convoluted cerebriform pattern on the enhanced T1-weighted image on the magnetic resonance imaging scan usually suggests inverted papilloma.4 The diagnosis is confirmed on biopsy. The treatment of choice is wide excision, preventing recurrence. Radiation therapy is used in nonresectable tumors, residual tumors, and inverted papilloma associated with squamous cell carcinoma.5