Papillomatosis

Recurrent respiratory papillomatosis (RRP) is a disease in which pappillomas (small soft tissue masses) grow in the air passages. They are also referred to as juvenile-onset recurrent respiratory pappillomatosis (JORRP) as they are frequented in young adolescent males. They can form right from the nose and mouth upto the lungs (respiratory tract). Although these masses can grow anywhere in the respiratory tract, their presence in the larynx (voice box) causes the most frequent problems. The pappillomas can be very aggressive in their growth and have high recurrence rates even when removed.

RRP is caused by the human pappilloma virus HPV 6 or 11 and often affects the upper airway. The incidence of laryngeal papillomatosis in Europe is 3-4 out of 2,000 children under 12 years of age. The spread of the virus is through a sexual contact or during birth when an infected mother with genital warts passes it on to the baby.

The patient presentation depends on the site affected by the pappillomas. Patients with laryngeal papillomas commonly present with voice changes, and have the papillomas growing on the vibratory edge of the vocal cords. Difficulty in breathing is present when the papillomas are voluminous and extend down from the larynx involving the the trachea and in severe cases, even the bronchi. Extensive papillomas involving the larynx may cause severe breathing problems necessitating a tracheostomy.

It is possible for spontaneous regression of the papillomas, though the exact mechanism is unclear. Thus, the treatment goal for recurrent respiratory papillomatosis is in maintaining an adequate airway until the papillomas regress spontaneously, with minimal sequelae due to the treatment modalities.

The main aim of surgery is to debulk the papillomas thereby preventing severe repiratory obstruction. Whatever the form of surgical debulking, it must not create any or have the least collateral damage to the surrounding laryngeal structures. Lasers (CO2) can be used to do a subepithelial excision or vaporization of the papilloma tissue. The laser is precise but with a possibility of heat dispersion through the larynx. Mechanical shavers (Microdebriders) are long and well adapted for its use in the larynx. The papillomas are suctioned into a device and cut free from the surrounding tissue with great precision. The collateral tissue damage is thus minimised.

Several complemetary medical treatments have been explored in the treatment of JORRP and have shown encouraging results. Vaccinating young individuals with the quadrivalent HPV vaccine against the subtypes 6,11,16,18 has shown promise, and is presently advised for all young adults affected by the virus.