Laryngeal Papillomatosis is a viral infection of larynx caused by Human Papilloma Virus (HPV) types 6 and 11. Viruses usually infect vocal cords only. Macroscopically, there are widespread polypoid lesions (papillomata) upon which there are finger-like projections. The lesions resemble the warts seen on skin, because they are caused by the same virus. HPV is the most common infection among people in the world.
It has two clinical forms, called juvenile and adult forms. Juvenile form is seen in babies and children; it develops when the baby aspirates the virus while passing through birth canal of his mother during normal vaginal delivery. Papillomatosis causes cauliflower-like benign masses on vocal cords; they disturb phonation to cause hoarseness and they may enlarge enough to cause airway obstruction. Papillomata involve the larynx extensively and recur frequently when excised. Because papillomata cause hoarseness or airway obstruction, the child needs to be operated every several months or even weeks. Due to the multiple laryngeal surgeries these children develop permanent hoarseness due to scars on their vocal folds or web between vocal cords. At puberty papillomata tend to regress spontaneously. The reason for this regression is unknown; however, it may be related to immune maturation at puberty. However, some children continue to harbor this laryngeal infection throughout their life.
Laryngeal papillomatosis in a two-month-old baby
Adult form develops due to aspiration of virus to larynx during oral sex. Papillomata are more localized and less extensive than juvenile form. After excision, recurrence is less frequent than juvenile form; however, recurrence after surgery is always expected. Long periods of remission may be followed by repeated recurrences. However, there is no chance for spontaneous resolution; therefore, these adults continue to live with the virus in their vocal cords and harbor this laryngeal infection throughout their life.
Laryngeal papilloma in adult
Papillomata cause hoarseness; and when extensive, they may lead to dyspnea. It is reported that adult form may convert to laryngeal cancer; however, within our 56 year clinical experience we did not observe any patient developing laryngeal cancer after having laryngeal papillomatosis.
Diagnosis of laryngeal papillomatosis is performed by laryngeal examination using flexible and rigid scope and visualizing warty, exophytic, cauliflower-like masses on vocal cords; masses have finger-like projections on them. However, clinical diagnosis must be confirmed with histopathologic examination of biopsy material.
There is no curative treatment of laryngeal papillomatosis. For palliation, to correct voice and to solve dyspnea, papillomata are excised using cold instruments or CO2 laser under microlaryngoscopy. In USA and Europe, office KTP laser procedures are performed to evaporate papillomata through nose under topical anesthesia. After repeated surgeries for papilloma, the patient may develop acquired web, vocal fold scar and laryngeal stenosis due to scar tissue formation within larynx. These complications will result in permanent hoarseness and airway obstruction.
For treatment of laryngeal papilloma, podophyllin, estrogen, Mg, Zn, Ca, corticosteroids, 5-fluorouracil, antibiotics, vaccines, levamisole, transfer factor, alpha-interferon and cidofovir have been used with variable success in medical history.
In 80’s and 90’s interferon was very popular; however, treatment with interferon was very expensive, had many side effects and had to be continued for a very long time; when it was discontinued there was recurrence of papilloma. In the long run its cure rate was around 40 %, which is not superior to placebo.
In 2000’s intralesional injection of cidofovir using microlaryngoscopy under general anesthesia became very popular; this surgery was repeated every month; however, there are studies indicating both that it is successful and it is not. An experimental study showed that it caused cancer in laboratory animals; afterwards its use diminished; some clinical experiences are still reported about it.
Today’s available HPV vaccine may significantly decrease the incidence of laryngeal papillomatosis in the long run by increasing immunity in young girls and boys; however, this vaccine is not effective in already established disease. However, there are reports about the new coming HPV vaccine’s possible ability to cure already established disease. This new vaccine will lead to production of antibodies against intracellular antigens of the virus; thus it affords the possibility of cure of already established disease by destruction of cells infected with virus.
In tracheal, bronchial and pulmonary involvement systemic bevacizumab may be helpful.
Actually, surgery does not cure a viral infection. However, because there is no other medical solution for laryngeal papillomatosis, surgery is performed to correct voice and to solve airway obstruction.
Indole-3-carbinol, photodynamic therapy, cis-retinoic acid, acyclovir and ribavirin were other adjuvant treatments tried in the past without success.