This article is on Laryngeal Papilloma. It is intended to help inform patients, relatives of patients and health professionals. The information in the grey boxes is more technical and intended more for Health professionals that are reading this article.

 

What is a Laryngeal Papilloma?

Laryngeal papillomatosis is a rare disease caused by the human papilloma virus (HPV). There are more than 200 subtypes of HPVs that exist. There are some that are much more frequent than others. Laryngeal papillomatosis causes the growth of tumors inside the voice box (larynx), vocal cords, or anywhere the air passage from the nose to the lungs.

Recurrent Respiratory Papillomatosis (RRP)
(Figure 1)
Recurrent Respiratory Papillomatosis (RRP)
(Figure 2)

Human papilloma virus is a small double stranded DNA virus with approximately 200 subtypes [1.11]. It belongs to the papova family of virus. The subtypes 6, 11, cause approximately 90% of laryngeal papilloma.

The other 10% is attributed to HPV Type 16, 18. The Type 11 is the clinically aggressive type while Type 16 and 18 have more malignant transformation potential. HPV Types 6, 11, 16 and 18 together cause most cervical cancers

 

Who gets Laryngeal Papillomas?

HPV infection in children is most commonly transmitted vertically at birth from HPV infected mothers. Transplacental transmission of HPV to the foetus happens in about 12% of cases. A vast numbers of adults with high-risk HPV infections can remain asymptomatic and go unnoticed, thereby adding risk of spread to the population [1.11].

The incidence is 4.3 per 100,000 populations in children and 1.8 per 100,000 in adults [1.10]

 

What are the causes?

This disease is caused by the human papilloma virus (HPV). Presence of anal /genital papilloma in the mother can increase the risk of development of laryngeal papilloma by 231 times in the newborn.

In adults, HPV virus is transmitted through sexual interactions. It is estimated that over 80% of us will pick up HPV during our lifetime [1.10].

 

What are the symptoms?

They are usually quick growing and can vary in size, causing breathing and swallowing problems. Symptoms depends on the site and size of the papillomas,

  • Persistent hoarseness of voice
  • Shortness of breath at rest or during exertion
  • Cough
  • Stridor (is a high-pitched, wheezing sound caused by disrupted airflow)

Involvement of the anterior commissure, anterior two thirds of the vocal cord or bulky disease preventing vocal cord adduction during voice generation tend to present early. Supraglottic involvement may go unnoticed (Fig 1).

 

How is it diagnosed?

Diagnosis is made through a combination of symptoms, examination of the nose and scans of the sinuses. In some, but not all CRS cases, “polyps” are seen inside the nose.

Diagnostic Criteria:
– 2 or more of the 4 main symptoms for >12 weeks AND
– Evidence of mucosal inflammation
– Direct visualisation (Nasal enodoscopy)

 

How is it diagnosed?

The doctor will usually use a combination of techniques to make a diagnosis;

Physical examination: usually performed in the clinical setting. A medical history and your risk factors will be asked. The doctor will look in the mouth and feel for any lumps on the neck.

EndoscopyThis allows the doctor to see the back of the mouth and throat. Typically, a thin, flexible tube with an attached light and view lens, called an endoscope, is inserted through the nose to examine the back of the nose and neck areas. An anaesthetic spray to the nose can be used to make the patient more comfortable, although the risks of the spray need to be balanced with the benefit in each case.

Laryngo-Tracheo-Bronchoscopy & Biopsy. This is performed under general anaesthetic (patient is put to sleep), metal tubes (laryngoscopes) are used to gain a view of the voice box and a fibreoptic camera is introduced through the mouth to locate the papillomas. A small amount of tissue is removed for examination under a microscope and this can make a definite diagnosis, and also give information on what subtype (strain) of virus may be responsible. If bulky disease is present, it may be removed taking care to prevent damage to the normal surrounding tissue.

 

What are the Treatment/ Management options?

At present there is no curative treatment for laryngeal papillomatosis. Removal of superficial tissue infected with HPV, which is the visible swellings on the voice box (Fig 2), without causing further damage to the voice box is the frequent practice.

Some additional treatments have been used at the time of surgery but with variable success including antiviral agent cidofovir and a growth preventing agent called bevacizumab.

 

Can you prevent Laryngeal Papillomas?

HPV infection is almost non-existent in people who have never had sexual intercourse. Sexual encounter at an early age and having multiple sexual partners are the two most important determinants of HPV infections in adults.

However you cannot absolutely prevent viral infections from occurring, but one can optimally reduce the probability of developing these diseases by vaccinating against the HPV strains available. In New Zealand the HPV vaccination is recommended for all children aged 11-12 years and is free for everyone aged 9-26 years.

 

What is the prognosis?

This can be a difficult condition to deal with considering it is incurable, the management is often different in each case. Some patients will have papillomas recurring sooner than others making it difficult to give a definitive prognosis.

Most commonly patients will have a high frequency of surgeries soon after diagnosis that diminishes over time and with increasing age (1.12). The papillomas can grow aggressively, spread to lungs and rarely may transform into a cancer.

 

Further reading:

1) The patient Resource.com

 

References:
1.1. Oral and Oropharyngeal Cancer: Statistics
Statistics adapted from the American Cancer Society’s (ACS) publication, Cancer Facts & Figures 2020, and the ACS website (January 2020).
1.2 Sociodemographic differences in the incidence of oropharyngeal and oral cavity squamous cell cancers in New Zealand
Australian and New Zealand journal of Public Health
First published: 31 March 2015
1.3 National institute of Dental and craniofacial Research
Source: Surveillance, Epidemiology, and End Results (SEER) Program, National Cancer Institute
Surveillance Research Program, based on previous submissions of SEER data (1977-2003)
1.4 Thoeny HC. Imaging of salivary gland tumours. Cancer Imaging. 2007;7 : 52-62. doi:10.1102/1470-7330.2007.0008 – Free text at pubmed – Pubmed citation
1.5 Moonis G, Patel P, Koshkareva Y et-al. Imaging characteristics of recurrent pleomorphic adenoma of the parotid gland. AJNR Am J Neuroradiol. 2007;28 (8): 1532-6. doi:10.3174/ajnr.A0598 – Pubmed citation
1.6 Maria R. Bokhari, Joshua Greene. Pleomorphic Adenoma. (2019) Pubmed
https://radiopaedia.org/articles/pleomorphic-adenoma-of-the-salivary-glands
1.7 Gündüz AK, Yeşiltaş YS, Shields CL. Overview of benign and malignant lacrimal gland tumors. (2018) Current opinion in ophthalmology. 29 (5): 458-468. doi:10.1097/ICU.0000000000000515 – Pubmed
1.8 Karcioğlu ZA. Orbital tumors, diagnosis and treatment. Springer Verlag. (2005) ISBN:038721321X. Read it at Google Books – Find it at Amazon
1.9 Arch Pathol Lab Med 2008;132:1445 [http://www.pathologyoutlines.com/topic/salivaryglandspleomorphicadenoma.html. Accessed June 29th, 2020.]
1.10 Stanford healthcare
https://stanfordhealthcare.org/medical-conditions/ear-nose-and-throat/vocal-cord-disorders/types/laryngeal-papillomatosis.html
1.11 Fortes HR, von Ranke FM, Escuissato DL, et al. Recurrent Respiratory Papillomatosis:
A State-of-the-Art Review. Respiratory Medicine 2017;126:116-21
1.12 Silverberg MJ, Thorsen P, Lindeberg H at al. Clinical course of recurrent respiratory papillomatosis in danish children. Arch Otolaryngol Head Neck Surg. 2004;130(6):711-716

 

 

Author + Affiliation:
1. Dr Tonye Onyemelukwe, Department of Otolaryngology, Waikato Hospital.
2. Reviewed by Dr James Sanders, Otolaryngology, Waikato Hospital.

Date of Publication +/- Review:
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