This case reports a 28 year old male who presented with left sided nasal obstruction and rhinorrhoea. He had undergone two previous endonasal surgeries for removal of left inverted papilloma at a different hospital. Clinical and radiological findings were suspicious of disease recurrence, for which an endoscopic clearance was performed, confirming the diagnosis. He however developed further aggressive recurrences, with areas of severe dysplasia involving the orbit and disease in nasal septum, frontal sinuses and sphenoid bilaterally, necessitating five further endoscopic procedures – two combined with external approach and one assisted by image guidance.

The multiple bilateral recurrences in this young patient are an unusual presentation. It compels us to draw a comparison with laryngeal papillomatosis, HPV being a known aetiopathological factor for this and also reported with recurrences of disease in the nose. We also wonder about the possible benefits of an HPV vaccination in a case like ours. The role of image guidance in revision endoscopic surgery with loss of most anatomic allandmarks is well borne out with this case.