Recurrent Laryngeal Papillomatosis

RECURRENT LARYNGEAL PAPILLOMATOSIS/RECURRENT RESPIRATORY PAPILLOMATOSIS
  • RRP has a bimodal age distribution and manifests most commonly in children younger than 5 years (juvenile-onset RRP [JORRP]) or in persons in the fourth decade of life (adult-onset RRP [AORRP]).
  • JORRP is more common and more severe than AORRP.
CAUSE OF RECURRENT LARYNGEAL PAPILLOMATOSIS
  • JORRP is caused by exposure to HPV during the peripartum period.
  1. Multiple Paillomatosis is the most common manifestation of HPV infection in children.
  2. The disease associated with HPV-11 is more severe than with HPV-6.
  3. Vaginal delivery is a risk factor, but cesarean delivery is not completely protective.
  4. The classic triad for increased risk of JORRP includes being firstborn, vaginal delivery, and having a mother younger than 20 years.
  • The mode of infection in adults is still not known, but sexual transmission is likely.
CLINICAL FEATURES IN A CASE OF RECURRENT LAYNGEAL PAPILLOMATOSIS
  • Papillomas may develop anywhere in the respiratory tract, from the nose to the lung; however, >95% of cases involve the larynx.
  • JORRP affects males and females in equal numbers, whereas AORRP is more common in males.
  • Because the larynx is the most frequently affected site for both JORRP and AORRP, symptoms of upper airway obstruction predominate. Upper airway obstruction may be life threatening and may be the presenting symptom.
  • Hoarseness is the most common presenting symptom(as these lesions particularly affect the "true" and "false" vocal cords.)
  • Other symptoms include the following:
  1. Voice change(in patients with glottic lesions)
  2. Choking episodes
  3. Foreign body sensation in the throat
  4. Cough
  5. Dyspnea
  6. Inspiratory wheeze
  7. Stridor.
  • Inspiratory wheezing, stridor, or both may develop over the trachea or the upper thorax.
  1. Patients with JORRP commonly present with a weak cry, episodes of choking, hoarseness, or failure to thrive. 
  2. Patients with AORRP present with hoarseness, choking spells, voice change, dyspnea, or a foreign body sensation in the throat.
  3. Adult onset papilloma usually arise from the anterior half of the vocal cord or anterior commissure.
  • They are usually single, small in size, less aggressive and do not recur after surgical removal.
  • In 3-5% of patients, respiratory papillomas may undergo malignant degeneration to squamous cell carcinoma.
  • Malignant transformation in a case of papilloma occurs most commonly in distal bronchopulmonary tree and prognosis is univer­sally poor
INVESTIGATIONS IN A CASE OF RECURRENT LARYNGEAL PAPILLOMATOSIS
  • Laryngoscopy findings provide confirmation of the diagnosis of RRP
  • Reveals the characteristic multiple, friable, irregular warty,cauliflowerlike growths in the larynx. 
  • Obtaining a biopsy specimen of visualized lesions is essential for histologic confirmation of respiratory papillomatosis.
TREATMENT OF RECURRENT LARYNGEAL PAPILLOMATOSIS
  • The primary treatment involves repeated surgical debulking, usually by means of microdebridement, angiolytic laser, cryotherapy, or carbon dioxide laser. This may be followed by an injection of cidofovir into the resection site in patients with moderate-to-severe disease.
  • Interferon treatment appears to slow the rate of growth without curing the disease. 
  • Compared with microdebridement and laser procedures, surgical resection may be associated with a higher risk of complications (eg, tracheal stenosis). Tracheostomy may be needed if significant airway obstruction occurs.
  • A quadrivalent vaccine for prevention of genital HPV infection was approved in 2006. This vaccine protects against HPV types 6, 11, 16, and 18 and therefore has promise for decreasing the incidence of RRP.
Exam Question
  • Recurrent Laryngeal Papillomatosis is caused by Human Papilloma Virus (HPV).
  • HPV6 and HPV11 are most commonly implicated.
  • Transmission to neonate occurs through contact with mother during vaginal delivery.
  • The disease associated with HPV-11 is more severe than with HPV-6.
  • Multiple Paillomatosis is the most common manifestation of HPV infection in children.
  • Adult onset papilloma usually arise from the anterior half of the vocal cord or anterior commissure.
  • CO2 laser resection is done in a casr of multilpe laryngeal Papillomatosis.
Don't Forget to Solve all the previous Year Question asked on Recurrent Laryngeal Papillomatosis