Laryngeal papillomatosis

Laryngeal papillomatosis
Classification and external resources
Specialty otolaryngology
ICD-10 D14.1
ICD-9-CM 212.1

Laryngeal papillomatosis, also known as recurrent respiratory papillomatosis or glottal papillomatosis or associated with condyloma acuminata, is a rare medical condition (2 per 100,000 adults and 4.5 per 100,000 children),[1]:411 caused by a human papillomavirus (HPV) infection of the throat.[2]:411 Laryngeal papillomatosis causes assorted tumors or papillomas to develop over a period of time. Without treatment it is potentially fatal as uncontrolled growths could obstruct the airway. Laryngeal papillomatosis is caused by HPV types 6 and 11, in which benign tumors form on the larynx or other areas of the respiratory tract. These tumors can recur frequently, may require repetitive surgery, and may interfere with breathing. The disease can be treated with surgery and antivirals. In addition antiangiogenic therapy shows promising results.

Transmission

In general, physicians are not sure what causes certain people to develop laryngeal papillomatosis while others who have been exposed to HPV types 6 and 11 do not develop the disease. Since the disease is most commonly found in children, the disease may be caused by an infant contracting HPV from the mother during vaginal child birth.[3][4]:411 There is no evidence that it is transmitted through oral sex, and it is not considered a sexually transmitted disease.[5] While laryngeal papillomatosis itself is not thought to be due to sexual transmission, maternal genital infections with either HPV types 6 or 11 result from sexual transmission. Infections with these HPV types can cause genital warts and can be prevented by HPV vaccines that include HPV 6 and 11 antigens (e.g., quadrivalent or nonavalent HPV vaccines).[6] Routine vaccination of pre-adolescent girls with these vaccines is expected to prevent persistent HPV 6 or HPV 11 genital infections among expectant mothers and thus prevent secondary laryngeal infections to their newborns that can lead to laryngeal papillomatosis.

Signs and symptoms

Adults

In adults, the symptoms of laryngeal papillomatosis are hoarseness, or a strained or breathy voice. Size and placement of the tumors dictate the change in the person's voice. Breathing difficulties may occur but more commonly are found in children.[4]

Children

In babies and small children, the signs and symptoms include a weak cry, trouble swallowing, noisy breathing, and chronic cough. Noisy breathing may be a stridor, which can sound like a whistle or a snore, and is a sign that the laryngeal or tracheal parts of the airway are narrowing.[4]

Diagnosis

A physician may diagnose laryngeal papillomatosis by placing a mirror into a patient's mouth to reflect light onto the vocal cords and examining the larynx. More often, a doctor or a trained speech-language pathologist diagnoses laryngeal papillomatosis by an indirect laryngoscopy in the office. This procedure involves the placement of a flexible, fiber optic camera through the patient's nose to view the vocal folds in the throat or the use of a straight, rigid camera placed through the mouth to view the vocal folds.[7]

The most accurate way to diagnose laryngeal papillomatosis is for a biopsy to be conducted and for the lesion to be tested for HPV. This procedure takes place in an operating room with the patient under general anesthesia. This is sometimes the best option for small children. This disease is most often misdiagnosed as asthma, croup, or chronic bronchitis.[5] The consequences may be serious, as papillomas are at least partially obstructing the airway to cause these symptoms and should be removed immediately.[7]

Treatment

Traditional surgery and carbon dioxide laser surgery, a "no touch" removal of affected tissue, are forms of treatment for laryngeal papillomatosis. Carbon dioxide laser removal is the most common removal method.[5] The carbon dioxide laser must be used precisely to prevent scarring, fibrosis, and laryngeal web malformation. In children, carbon dioxide laser is effective for removing papillomas on the larynx. Photodynamic therapy controls tumors by using targeted dyes and bright light to illuminate tumors.[1] In this procedure, a physician injects a light-sensitive dye that is only absorbed by the tumors. Then the physician activates the dye using a bright light, and the tumors are eliminated. This procedure has also been able to decrease the number of tumors that reoccur.[1]

Another method is tracheotomy, which reroutes air around the affected area. An incision is made in the front of the patient's neck, and a breathing tube is inserted through a hole (stoma) into the windpipe. The patient is then able to breathe through the tube. Although this is usually temporary, some patients must use the tube indefinitely.[1] This method should be avoided if at all possible, since insertion of a breathing tube may cause the tumors to form as far down as the lungs.[5]

Many antiviral drugs like cidofovir have been used to treat laryngeal papillomatosis, but none completely stops the tumors from growing. Most antivirals are injected to control the frequency of tumor growth. The efficacy of the same is debated and subject to research. Some side effects of antivirals include dizziness, headaches, and body aches. Adjuvant chemotherapy with interferon may be used in very severe cases.[8] Regardless of the treatment used, the tumors will recur. In severe cases, tumors may occur once or twice a month. In less severe cases, tumors may occur once or twice a year. In addition, speech therapy may be beneficial to assist with vocal hygiene and retraining of voice.

Antiangiogenic therapy: A strong mRNA expression of VEGF-A and its receptors, VEGFR-1 and -2 has been observed in tissue samples of RRP patients.[9] The most promising adjuvant treatment approach seems to be the topical or systemic treatment with the anti-vascular endothelial growth factor (VEGF) antibody bevacizumab. In a small series of RRP patients the systemic antiangiogenic treatment showed rapid response and a significant reduction in the number of needed interventions.[10][11][12]

See also

References

  1. 1 2 3 4 "National Institute of Deafness and other Communication Disorders". Archived from the original on 2009-09-23. Retrieved 2009-09-19.
  2. ↑ James, William D.; Berger, Timothy G.; et al. (2006). Andrews' Diseases of the Skin: clinical Dermatology. Saunders Elsevier. ISBN 0-7216-2921-0.
  3. ↑ "Recurrent Respiratory Papillomatosis or Laryngeal Papillomatosis". National Institute on Deafness and Other Communication Disorders. 2011. Retrieved 9 August 2013.
  4. 1 2 3 "VoiceProblems.org". Retrieved 2009-09-19.
  5. 1 2 3 4 McClay MD, John E (2008-10-29). "Recurrent Respiratory Papillomatosis". Retrieved 2009-09-22.
  6. ↑ Joura EA, Pils S (2016). "Vaccines against human papillomavirus infections: protection against cancer, genital warts or both?". Clin Microbiol Infect. 22 Suppl 5: S125–S127. PMID 28034371. doi:10.1016/j.cmi.2016.12.017.
  7. 1 2 "Recurrent Respiratory Papillomatosis Foundation". Archived from the original on 2009-09-23. Retrieved 2009-09-26.
  8. ↑ Color Atlas of ENT Diagnosis, 4th ed (Thieme 2003)
  9. ↑ Rahbar R, Vargas SO, Folkman J, McGill TJ, Healy GB, Tan X, Brown LF (2005). "Role of vascular endothelial growth factor-A in recurrent respiratory papillomatosis". The Annals of Otology, Rhinology, and Laryngology. 114 (4): 289–95. PMID 15895784. doi:10.1177/000348940511400407.
  10. ↑ Ahn, Julie; Best, Simon R. A. (2016). "Adjuvant and Novel Treatment of Recurrent Respiratory Papillomatosis". Current Otorhinolaryngology Reports. 4 (2): 67–75. doi:10.1007/s40136-016-0111-7.
  11. ↑ Mohr, Michael; Schliemann, Christoph; Biermann, Christoph; Schmidt, Lars‑Henning; Kessler, Torsten; Schmidt, Joachim; Wiebe, Karsten; Müller, Klaus‑Michael; Hoffmann, Thomas; Groll, Andreas; Werner, Claudius; Kessler, Christina; Wiewrodt, Rainer; Rudack, Claudia; Berdel, Wolfgang (2014). "Rapid response to systemic bevacizumab therapy in recurrent respiratory papillomatosis". Oncology Letters. 8 (5): 1912–1918. PMC 4186578 Freely accessible. PMID 25289079. doi:10.3892/ol.2014.2486.
  12. ↑ Zeitels SM, Barbu AM, Landau-Zemer T, Lopez-Guerra G, Burns JA, Friedman AD, Freeman MW, Halvorsen YD, Hillman RE (2011). "Local injection of bevacizumab (Avastin) and angiolytic KTP laser treatment of recurrent respiratory papillomatosis of the vocal folds: a prospective study". The Annals of Otology, Rhinology, and Laryngology. 120 (10): 627–34. PMID 22097147. doi:10.1177/000348941112001001.
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