What is Laryngeal Papillomas?
Laryngeal papillomatosis, also known as recurrent respiratory papillomatosis, is a common non-cancerous growth that appears in the voice box of children. It is characterized by the excessive growth of benign (non-cancerous) warts in the upper part of the throat and airway. This condition can start in childhood or adulthood. It’s particularly challenging to treat because it tends to come back and can spread to nearby parts of the respiratory tract.
This summary will briefly cover the causes of the condition, signs and symptoms, methods for diagnosing it, treatment options – both surgical and non-surgical, and recent measures to prevent it. Understanding this information helps identify and manage the condition more effectively.
What Causes Laryngeal Papillomas?
Laryngeal papillomatosis is a condition caused by a virus, specifically the human papilloma virus (HPV). This is a small virus that commonly infects the cells of the skin. While there are many types of HPV, the ones most closely associated with this condition are HPV 6 and HPV 11.
HPV are usually passed on during childbirth, particularly when the mother is having her first child or has recently had genital warts. Because the first birth typically includes a longer labor, there is a higher chance for the newborn to contract the virus. Contrarily, genital warts are especially fragile, making them easier to spread. In adults, laryngeal papillomatosis could be transmitted through oral sex. However, just having the virus present on the skin doesn’t necessarily mean someone will get this condition; there seem to be additional factors at work.
An interesting finding is that surgeons who remove these warts using lasers may become exposed to the virus. A study observed that surgical materials soaked in the area where these warts were removed contained high levels of HPV 6 and HPV 11. Fortunately, the amount of virus present was too small to transmit the virus, however, precautions are still suggested in these situations to prevent potential infection.
Risk Factors and Frequency for Laryngeal Papillomas
Laryngeal papillomatosis is a condition that shows up more frequently in children than adults. On average, it affects 4.3 in 100,000 children compared to 1.8 in 100,000 adults. It’s actually the second most common non-cancerous growth in the voice box among kids, and it’s often a reason why a child might have a hoarse voice.
This disease comes in two types, each with a different level of severity. The type that begins in childhood tends to be more serious. It can block the airway, spread to multiple locations in the airway, come back quicker after treatment, and usually requires more surgery.
The adult-onset form is generally less severe. However, some cases in adults can be more severe, most likely due to the specific type of HPV causing the disease.
Signs and Symptoms of Laryngeal Papillomas
When evaluating a patient, asking about respiratory symptoms and patient stability is crucial. It’s important to ask questions about previous cases of intubation, the patient’s birthing history, when the symptoms started and how they’ve developed, any injuries, and changes in voice. Additional symptoms like difficulties with eating, allergies affecting the nose, misuse of the voice, and irritation due to acid reflux can help distinguish this condition from others. All the while, doctors should observe if the patient has a fast breathing rate, a harsh vibrating noise when breathing, is using extra muscles for breathing, or has changes in speech or cry.
The use of a flexible fiberoptic nasopharyngoscope, a device used to view the inside of the nose and throat, helps with accurate diagnosis before surgery, and can eliminate other possible diagnoses. Laryngeal papilloma shows up as small pink to white growths, resembling grapes, that can be flat or on a stalk, having a visible central blood vessel. It looks like a transparent grape with a visible seed. Modern technology called narrow-band imaging (NBI) is very beneficial when a stroboscope, a device for viewing vocal cord movement, is available. NBI uses short wavelength blue light that is mostly absorbed by hemoglobin – a protein in red blood cells that carries oxygen. Since laryngeal papilloma is rich in blood vessels, it’ll appear as soft tissue with blue spots around it.
This condition usually affects areas of the respiratory tract where the tissue type changes. The true vocal cords are a common place for papilloma lesions because they have a transition from one type of skin cell to another – from cells stacked in multiple layers with hair-like structures to cells stacked in multiple layers without these structures. Nonetheless, laryngeal papilloma may be found in other parts of the respiratory tract as well.
Testing for Laryngeal Papillomas
The most reliable way to determine if someone has laryngeal papilloma, a non-cancerous growth in the throat, is to perform a biopsy, which means removing a small piece of the growth for examination. This biopsy also undergoes a process known as HPV typing, to identify the type of human papillomavirus (HPV) that may be causing the papilloma.
In certain cases, ranging between 1% to 4%, the laryngeal papilloma can transform into a cancerous condition known as squamous cell carcinoma. This risk largely depends on the type of HPV identified. While low-risk types – HPV 6 and 11 – are often associated with this condition, high-risk types like HPV 16 and 18 can also be present and pose a bigger risk.
Generally, imaging tests are not necessary because laryngeal papilloma is typically non-cancerous and doesn’t cause serious complications. However, in preparation for surgery, or if there’s suspicion of papilloma in the lungs (pulmonary papillomatosis), a CT (computed tomography) scan might be used. This type of scan can help the doctor assess the extent of the condition and plan the treatment effectively.
Treatment Options for Laryngeal Papillomas
At this time, there is no established cure for laryngeal papillomatosis (LP), a condition characterized by the growth of benign tumors, called papillomas, on the larynx or voice box. The standard treatment approach is the surgical removal of these papillomas while ensuring that normal tissues are preserved. When performing this surgery, doctors aim to balance the removal of visible papillomas and the protection of healthy tissue, as invisible viral infection may exist in surrounding areas.
The most commonly used surgical technique involves the use of laser removal during a procedure called “suspension microlaryngoscopy.” Different types of lasers can be employed, including a CO2 laser, a potassium titanium phosphate (KTP) laser, a pulsed-dye laser, or an argon laser. Other surgical techniques, such as the use of microdebriders, cold instruments, and phonomicrosurgery, can also be employed. These procedures are typically carried out in an operating room, but some advancements have now allowed for office-based laser surgeries.
Control of the disease has been greatly improved with the development of these office-based surgeries, and this has in turn decreased the need for general anesthesia. However, it’s crucial that surgeons avoid potential damage to healthy tissue, as this can lead to the development of new areas of papillomatous growth.
When large or hard-to-reach clumps of laryngeal papilloma are present, there could be a severe risk of airway obstruction. In such situations, the first method attempted should be endotracheal intubation – a process that involves inserting a tube through the mouth and then into the airway. This process is typically carried out with the help of a flexible bronchoscope or a video laryngoscope. Most laryngeal papillomas can be moved and managed easily since they don’t infiltrate deep tissues. Tracheostomy, a surgical procedure to create an opening in the neck for direct access to the trachea or windpipe, is usually only performed as a last resort, as it can create a condition conducive to the further spread of the disease.
Even though surgical removal remains the gold-standard treatment, additional therapies may be considered for certain cases, such as when there have been over four surgeries within a year, rapid regrowth of the disease, airway obstruction, or when the disease has spread to multiple sites. These additional treatment options may include medications like cidofovir, a drug that can be toxic to the virus and has shown some excellent responses, although no clinical trial has yet been developed to evaluate the efficacy of cidofovir for this specific disease.
The use of the human papillomavirus (HPV) vaccine is another additional therapy. Even though it is primarily a preventive treatment, it has been studied for its potential to aid in managing existing laryngeal papilloma cases. A retrospective study reported that patients with existing laryngeal papilloma experienced a significant decrease in the frequency of surgeries and in the severity of the disease when the vaccine was used.
In addition to these treatment methods, preventive measures like the use of proton pump inhibitors can be beneficial. These medications control the chronic exposure of the epithelium to gastric acid, which in turn can prevent the transformation of the epithelium that could lead to the growth of further papillomas.
What else can Laryngeal Papillomas be?
Laryngeal papilloma, a condition that can potentially develop into cancer, can often be mistaken for other issues affecting the voice box. Although it carries a risk of turning malignant, it’s important to differentiate it from other conditions like vocal cord leukoplakia, squamous cell carcinoma, and verrucous carcinoma. These similar conditions can usually be distinguished through a biopsy, which is a small sample of tissue from the lesion for examination.
Moreover, laryngeal papilloma can also be confused with non-cancerous issues such as vocal cord granulomas, vocal cord nodules, and a condition known as polypoid corditis or Reinke’s edema. Unlike the cancerous lesions, these benign issues can usually be identified with a detailed stroboscopic examination, a specialized examination of the voice box and vocal cords.
What to expect with Laryngeal Papillomas
Patients with laryngeal papilloma generally have a very good prognosis because it’s a non-cancerous (or benign) lesion. However, it can be dangerous if it causes a blockage in the airway. There’s also a small risk that it can turn into a cancerous lesion.
The issue with this condition is that it often comes back. As a result, patients usually need to have several treatments, which increases the risk of complications after surgery.
Possible Complications When Diagnosed with Laryngeal Papillomas
There is a significant risk of complications associated with laryngeal airway surgery. The most common issue is the recurrence of the initial problem or the disease spreading to nearby tissues because of unintentional changes triggered during surgery. Additionally, aggressive removal could result in scarring of the vocal cords or the formation of webs in the glottic space. These complications may impact the sound-producing properties of the vocal cords. One more risk linked with laser-assisted surgery is airway fire.
Possible Complications:
- Recurrence or spread of the disease to nearby tissues
- Vocal cord scarring
- Formation of glottic webs
- Changes in voice
- Airway fire during laser surgery
Preventing Laryngeal Papillomas
Laryngeal papilloma is a condition that patients and their family should understand as it’s a long-term condition without a cure. This means that patients need to know they will likely need several surgeries throughout their lifetime to manage the disease. It’s also important to mention that while there are extra treatments available, they don’t work for everyone, and most aren’t officially approved by the FDA, the U.S. Food and Drug Administration. Nonetheless, researchers continually study these treatments.
Preventive steps are also crucial and must be discussed. One of these steps is the 9-valent HPV vaccine, which can help with treating or slowing down the spread of laryngeal papilloma.
