Respiratory Papillomatosis

Viral papillomas are the most common benign laryngeal tumors in the pediatric population. The disease tends to be more aggressive in children, usually presenting with symptoms of airway obstruction and a higher number of recurrences, whereas in adults it tends to be milder, with hoarseness as the main complaint.

The disease is associated with the human papillomavirus types 6,11, and occasionally 16.32 These lesions tend to affect areas of junction between squamous and respiratory epithelium, with the vocal cords being the most commonly affected site.33 However, these lesions can also occur in the subglottic and tracheal airway. There is no cure for recurrent respiratory papillomatosis, and treatment is directed to the control of its symptoms. CO2 laser has become the standard treatment since first introduced by Strong and Jako in 1972.1

The CO2 laser treatment of laryngeal papillomas is best delivered with a microspot micromanipulator. Tracheal papillomas, in which the CO2 laser can not be precisely delivered with a micromanipulator, are best treated with a KTP laser in pediatric cases and a Nd:YAG laser in the adult patient.34,35 Treatment of airway papillomas often combines laser resection with the use of systemic drugs and nutritional supplements such as interferon and indole-3-carbinol (I3C).36 I3C, found in cruciferous vegetables, has the ability to arrest the proliferative effect of estrogen in laryngeal papillomas by altering its metabolic pathway in the cytochrome P450. However, unlike interferon, I3C can not induce regression of papillomas that are already developed.

Our experience with laryngeal papillomas has been chiefly in adult patients. These patients tend to have more sessile lesions, which are well suited for treatment with the CO2 laser using a "laser painting technique" (Figure 37-3 [Color Plate 9]). This technique relies on delicately ablating the papilloma 50 microns at a time, using the laser in a sweeping fashion, at longer exposure settings such as 0.5 to 1 sec at 2 to 3 W of power. Gentle suctioning and cleaning of the treated area, with a small cottonoid moistened in a 1/1,000 adrenaline solution, is performed to remove char and control bleeding after each laser sweep. As the papilloma base is approached, the laser is intermittently applied using 2 W at 0.5 sec, at 25x magnification in the operating microscope. We recommend using a micro-whistle-tip suction close to the laser site of impact to remove hot steam of vaporization, which can be injurious to the normal epithelium. Papillomas involving the anterior commissure should be managed with special care, leaving at least 1 mm of mucosa untreated to avoid web formation during healing. Interferon-a at 10 units/mL can be injected intralesionally in the anterior commissure, to better control scarring from the laser.

When treating tracheal papillomas, the YAG laser photocoagulates the tumors, using 30 to 40 W for protuberant and partially obstructing lesions, which are then mechanically debrided with the ventilating bronchoscope and optical forceps. If the lesions are sessile and nonobstructing, then low powers of 20 to 30 W are used intermittently to photocoagulate and allow spontaneous sloughing to occur.

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