A group of 87 patients with inverted papilloma, a locally aggressive benign sinonasal tumor, were treated over the past 15 years. Selection of therapy depends on an accurate radiographic assessment of the extent of tumor. The tumor's local aggressiveness, high rate of recurrence, associated malignancy, and multicentric tendency have led most workers to advocate radical surgical removal of the tumor by lateral rhinotomy and en bloc resection of the ethmoid labyrinth. Radiographic evaluation by computed tomography scanning and magnetic resonance imaging permits identification of a small group of patients who have limited lesions and may be candidates for conservative tumor resection by intranasal or transantral sphenoethmoidectomy. Among our ten patients treated with conservative surgery, there was recurrence in one case (10%). Seventy-five patients underwent rhinotomy and medial maxillectomy, with seven cases recurring (9%). The overall recurrence rate was 9% (8 of 87). Among the 87 cases, 5 patients had carcinoma (6%). The literature is reviewed and the principles of case selection and management are discussed.