Laryngeal papillomas: the epidemiology in a Danish subpopulation 1965-1984

The incidence rate of laryngeal papillomas in a Danish subpopulation (approximately 2.8 million inhabitants) was 3.84 x 10(-6) per year in the period 1968-1984. For juvenile papillomas the incidence rate was 3.62 x 10(-6), compared with 3.94 x 10(-6) for laryngeal papillomas of adult onset. When comparing different time periods a significantly low incidence was found in the time 1965-1968, while the incidence remained constant in 1969-1984. The low incidence rate in the early period may be real, but selectional bias may have played a part. It is general anticipated that maternal genital HPV-infections may serve as an HPV-reservoir, and that juvenile laryngeal papillomas is a result of HPV transmission from the mother to the child during birth. In the period in question cervical HPV-infections have been recorded with increasing frequency in younger women, indicating that the prevalence is rising. However, this is not reflected in the incidence of laryngeal papillomas.     

Laryngeal papillomas with adult onset. An epidemiological study from the Copenhagen region

All patients treated for laryngeal papillomas with adult onset in the Copenhagen region during a 4-year period were identified for this epidemiological study. The incidence was 0.8/100,000 among the population at risk and the prevalence was 2.3/100,000. It is concluded that papillomas with juvenile and adult onset are one and the same disease and that single papillomas versus multiple papillomas cannot be considered different entities. As is the case with juvenile laryngeal papillomas, the prognosis is good and the morbidity low in most cases of adult onset papillomas, but malignant degeneration must be considered a risk factor.     

原位杂交在成年和幼年型喉乳头状瘤HPV病因学的对比研究

探讨成年和幼年型喉乳头状瘤ＨＰＶ感染发病差异及其影响因素。方法：用地高辛配基（Ｄｉｇｏｘｉｇｅｎｉｎ）标记ＨＰＶ６和ＨＰＶ１１型作探针，原位核酸杂交方法在２９例成年型喉乳头状瘤（ＡＬＰ）和２１例幼年型喉乳头状瘤（ＪＬＰ）石蜡包埋标本检测ＨＰＶ同源序列。结果：ＡＬＰＨＰＶ６和ＨＰＶ１１阳性率分别为４１４％（１２／２９）和４８３％（１４／２９）；ＪＬＰＨＰＶ６及ＨＰＶ１１阳性率均为７６２％（１６／２１）。ｘ２统计示：两型喉乳头状瘤ＨＰＶ６及ＨＰＶ１１阳性率明显不同（ＨＰＶ６ｘ２＝５９９，ＨＰＶ１１ｘ２＝３９５，Ｐ均小于００５）。结论：１）ＡＬＰ和ＪＬＰＨＰＶ感染发病存在差异。２）ＡＬＰ除了ＨＰＶ感染外，其促发因素不可忽视，ＪＬＰ更倾向于依赖ＨＰＶ感染而发病。     

The course of laryngeal papillomatosis treated by endolaryngeal microsurgery

Surgical excision of papillomas remains the mainstay of the management of laryngeal papillomatosis, as causal therapy is not yet available. Eighty-nine patients – 32 with juvenile papillomatosis (JP) and 57 with adult papillomas (AP) – underwent endolaryngeal microsurgery (EM) in our department during the last 15 years. The ENT-department in Kaunas serves most of the patients with laryngeal papilloma among the 3.85 million inhabitants of Lithuania. Therapeutic outcome was assessed as both the recurrence rate and the length of time between recurrences of papillomas in the follow-up period lasting at least 2 years. The recurrence rate was 71.9% (23 patients) in the JP group and 22.8% (13 patients) in the AP group. The interval between recurrences of papillomas ranged from 1 month to 10 years (mean 1.9 years) in the JP group and from 6 months to 9 years (mean 3.2 years) in the AP group. The number of EMs per patient ranged from 1 to 18 (mean 3.2) in the JP group and from 1 to 5 (mean 1.35) in the AP group. EM is a minimally invasive and safe technique which provides accurate removal of papillomas, although recurrence is often unavoidable. Prognosis for the disease therefore remains rather unpredictable. Received: 31 December 1999 / Accepted: 30 May 2000     

A 585-nanometer pulsed dye laser treatment of laryngeal papillomas: Preliminary report

Objectives/Hypothesis: Standard management of recurrent respiratory papillomatosis (RRP) currently consists of CO₂ laser microsurgical ablation of papillomas. Because of the recurrent nature of this viral disease, patients are often faced with significant cumulative risk of soft tissue complications. As a minimally traumatic alternative to management of RRP, we have investigated the use of the 585-nm pulsed dye laser (PDL) to cause regression of papillomas by selective eradication of the tumor microvasculature. Study Design: Nonrandomized prospective pilot study. Methods: Patients with laryngeal papillomas were treated with the PDL at fluences of 6 J/cm ² (double pulses per irradiated site), 8 J/cm ² (single pulses), and 10 J/cm ² (single pulses), at noncritical areas within the larynx, using a specially designed micromanipulator. Lesions on the true cords were treated with the CO₂ laser, using standard methodology. Results: Clinical examination of three patients treated to date showed that PDL treatment appeared to produce complete regression of papillomas. Unlike the sites of lesions treated by the CO₂ laser, the epithelial surface at the PDL treatment sites was preserved intact. Conclusions: These preliminary results suggest the PDL may eradicate respiratory papillomas with minimal damage to normal laryngeal tissue. Further analysis of the ongoing study is required to demonstrate potential benefits of the technique.     

HPV11对小儿喉乳头状瘤预后的影响

目的 :研究人乳头状瘤病毒 (HPV)型别对小儿喉乳头状瘤 (JLP)预后的影响。方法 :应用聚合酶链反应结合斑点杂交技术对 2 5例JLP的石蜡标本进行HPV定型分析 ,并统计HPV11、HPV6 感染组的气管切开率和术后复发率。结果 :HPV总检出率为 96.0 % ,其中HPV11为 5 6.0 % ,HPV6 为 4 0 .0 % ,HPV16、18、33无一例阳性。HPV11感染组的气管切开率为 71.4 % ,术后复发率为 85 .7% ;HPV6 感染组的气管切开率为 3 0 .0 % ,术后复发率为4 0 .0 %。两组分别比较 ,其差异均有显著性意义 (P <0 .0 5 )。结论 :HPV6、11与JLP发生密切相关 ,HPV11感染与JLP的喉梗阻和术后复发率相关 ,HPV11感染可作为JLP预后评判的重要依据。     

Laryngeal papillomas: clinical aspects in a series of 231 patients

The records of 231 patients with laryngeal papillomas were reviewed. Considering age at onset and sex distribution, the patients were divided into four groups: juvenile solitary, juvenile multiple, adult solitary, and adult multiple papillomas. The main conclusions are (1) it is in general impossible to predict the course in individual cases, but solitary papillomas in adults follow a less severe course than do juvenile and adult multiple cases; (2) late recurrences (up to 42 years) makes it impossible to declare a patient cured; (3) there is no linkage between puberty and the disappearance of laryngeal papillomas; (4) a latent infection, acquired at or before birth, is unlikely to be responsible for adult papillomas.     

Laryngeal papillomas: classification and course

Seventy-one cases of laryngeal papillomas have been reviewed. Based on differences in age at presentation, female: male ratio and multiple versus solitary papillomas, the cases were classified into 4 groups: multiple juvenile papillomas, solitary juvenile papillomas, multiple and solitary adult papillomas. The clinical course in the groups is described. The authors do not support the common opinion that juvenile papillomas are influenced by puberty.     

Laryngopharyngeal reflux and laryngeal web formation in patients with pediatric recurrent respiratory papillomas

OBJECTIVE: To determine whether treatment of laryngopharyngeal reflux reduces the laryngeal soft tissue complications encountered in surgery for recurrent respiratory papillomas. STUDY DESIGN: Retrospective chart review. METHODS: Retrospective chart review of all pediatric patients treated for laryngeal recurrent respiratory papillomas between 1984 and 1999 was performed. Thirty-one such patients were identified. Twenty-four were at "high risk" for developing complications based on the number of operating suite visits and the presence of disease at the anterior commissure. Twelve patients underwent 24-hour double pH probe testing. RESULTS: Overall, 13 of 31 patients (42%) developed laryngeal webs. No other soft tissue complications were encountered. Of the patients who had pH probe testing, 12 of 12 (100%) had at least one pharyngeal episode of acid exposure. Of the "high-risk" patients, 10 were treated for reflux and only 2 of 10 (20%) developed webs. Eleven of 14 (79%) of the "high-risk" patients who were not treated for reflux developed webs. The difference in rate of web formation between patients treated for reflux and those not treated for reflux was statistically significant (P =.011). CONCLUSIONS: Antireflux treatments for patients undergoing surgery for laryngeal recurrent respiratory papillomas may reduce the soft tissue complications, especially scarring and web formation. Prophylactic antireflux therapy may be warranted in any patient undergoing surgery during which laryngeal mucosal disruption is anticipated.     

The presence of human papillomavirus (HPV) in solitary adult laryngeal papillomas demonstrated by in-situ DNA hybridization with sulphonated probes

Human papilloma virus (HPV) types 6 and 11 have been repeatedly demonstrated in multiple laryngeal papillomas, and there is little doubt that these lesions are caused by HPV. It has been clearly demonstrated in recent reports that the clinical course of solitary adult onset laryngeal papillomas is entirely different from that of multiple papillomas of juvenile as well as of adult onset. We here report the presence of HPV types 6 and 11 in 19 out of 20 solitary papillomas from 16 patients, while HPV types 16 and 18 were totally absent. We conclude that the milder clinical course in such patients is most likely to be due to host factors, rather than to viral factors.     

Investigations in exaggerated juvenile laryngeal papillomas

In the period between 1983 and 1986, 11 cases of juvenile laryngeal papillomas (JLP) were treated because of recurrences which were removed many times. One special group of 4 cases was isolated from these 11 cases in which papillomas grew very rapidly and were resistant to all management. Histological, biochemical and immunological investigations were made and the data are given.     

Transoral robotic excision of laryngeal papillomas with Flex® Robotic System — A novel surgical approach

Introduction

Recurrent respiratory papillomatosis results in hoarseness, stridor and airway obstruction. Management is surgical, with most surgeons using microdebrider or laser. Transoral robotic surgery (TORS) has been successfully utilised for the excision of oropharyngeal malignancies and paediatric airway surgery. This is the first case report of TORS being used for the excision of laryngeal papillomas.

Interferon therapy for laryngeal papillomatosis in adults

Eight patients with recurrent laryngeal papillomatosis were treated with exogenous leukocyte interferon alpha, 1 to 4 X 10(6) IU daily or every second day for 150 days. During an initial three-week period of low-dose treatment, tumor size was reduced in five patients. After three weeks of treatment, microsurgical removal was performed, followed by increased dosage of interferon. At the end of the five-month treatment, recurrence of small papillomas was found in one of the patients. During the posttreatment period (seven to 11 months), recurrences occurred in four patients. We conclude from this pilot study that exogenous leukocyte interferon changes the pattern of recurrences of laryngeal papillomas in adults and may supplement surgical treatment.     

Juvenile laryngeal papillomatosis. An epidemiological study from the Copenhagen region

All 23 patients treated for juvenile laryngeal papillomatosis (JLP) in the Copenhagen region during a 4-year-period were identified for this epidemiological study. The incidence of JLP was 0.6/100,000 among the population at risk, children aged 0-14 years, and the prevalence was 0.8/100,000. It is concluded that the condition in most cases has a good prognosis, i.e., short duration and low morbidity. Only in a few cases JLP will take a long-lasting course. Regression before or during puberty does not in all cases ensure complete recovery. Thus, 7 of 12 adult patients experienced a quiescent period of 21 years (median). Spread of papillomas to the bronchogenic system seems to be a serious prognostic sign.     

Treatment of Juvenile Laryngeal Papillomatosis with Two Types of Interferon

The successful application of fibroblast and leucocyte interferon in the treatment of juvenile laryngeal papillomatosis in two patients with papillomas extending down into the lower airways is reported. The papillomas recurred during interruption of interferon ad ministration. This indicates that the regression of papillomas is a genuine effect of interferon and not merely a reflection of the capricious natural course of the disease.     

Human papilloma virus vaccination in patients with an aggressive course of recurrent respiratory papillomatosis

In the case of an aggressive course of recurrent respiratory papillomatosis (RRP), adjuvant therapy can be used besides surgery. The aim of the study was to investigate the influence of vaccination with a quadrivalent vaccine against human papilloma viruses (HPV) types 6, 11, 16 and 18 on the course of RRP. Eleven subjects aged 13–46 years with a rapid growth of laryngeal papillomas were included in the study. They were vaccinated with three doses of the quadrivalent prophylactic HPV vaccine (Silgard^®, MSD) and followed up for 12–52 months. The intervals between the successive surgical procedures, the extension of the disease (Derkay score) at each surgery, and the number of surgical procedures per year before vaccination and after its completion were compared. The mean interval between the surgical procedures was 271.2 days before the vaccination and 537.4 days after it (p = 0.034). The mean number of surgeries per year was 2.16 before the vaccination and 0.93 after it (p = 0.022). The Derkay score did not change significantly after vaccination. Complete remission of the disease was observed in one patient, partial response to the vaccination was observed in seven patients and no response was observed in three patients. In conclusion, vaccination with the quadrivalent HPV vaccine can favorably influence the course of RRP in patients with the rapid growth of the papillomas. It significantly prolongs the intervals between the surgical procedures and reduces the number of procedures needed in the majority of patients. The present investigation can serve as a pilot study for further research. For a final conclusion a longer follow-up and studies on more patients are necessary.     

High incidence of malignant transformation of laryngeal papilloma in Taiwan

OBJECTIVES: Papillomas of the larynx include solitary laryngeal papilloma and recurrent respiratory papillomatosis. This study investigated the incidence of malignant transformation and assessed possible risk factors for laryngeal papillomas. STUDY DESIGN: A prospective, longitudinal study. METHODS: Twenty-six consecutive laryngeal papilloma patients were prospectively studied for 5 or more years, and each patient was periodically examined at 3 to 6 month intervals. A detailed epidemiologic questionnaire was administered at the initial visit. After enrollment, tissue obtained during each laryngeal surgery was examined by polymerase chain reaction assay for human papilloma virus (HPV) and typing. RESULTS: During 237 person-years of follow-up, six new, pathologically confirmed cases of laryngeal carcinoma were ascertained (incidence 2.5/100 person-years), and all were associated with HPV-6 or HPV-11. Malignant transformation revealed no correlation with the following: age less than 3 years at diagnosis, sex, history of tobacco use, history of alcohol consumption, family history of laryngeal cancer, or type of laryngeal papilloma. Laryngeal papilloma without demonstrable HPV DNA was the only significant risk factor for malignant transformation (P < .05). The cumulative risk of malignant transformation in subjects without demonstrable HPV DNA was significantly higher than that in HPV-positive patients (relative risk, 8.0; 95% confidence interval, 1.1-60.3; P = .05). CONCLUSIONS: A relatively high incidence of malignant transformation of laryngeal papilloma was noted in Taiwanese patients. Patients without demonstrable HPV DNA require more frequent follow-up and may benefit from anti-HPV vaccinations.     

Anesthesia management in pediatric patients with laryngeal papillomatosis undergoing suspension laryngoscopic surgery and a review of the literature

Objective

The excision of laryngeal papillomas poses a great challenge for both the anesthesiologist and the surgeon. The narrowness of the airways and the great variability of the pathological lesions necessitate close collaboration between the surgical and anesthesia teams to provide optimal operating conditions and ensure adequate ventilation and oxygenation. Our aim was to explore perioperative anesthesia management in pediatric patients during the excision of laryngeal papillomas with a suspension laryngoscope.

Methods

Fifty-eight pediatric patients suffering from laryngeal papillomas were included in this retrospective study. These patients had degrees of laryngeal obstruction from I to III and underwent suspension laryngoscopic surgery to excise laryngeal papillomas between January 2007 and December 2010. The American Society of Anesthesiologists (ASA) physical status of the patients ranged from I to III. Anesthesia was induced by intravenous administration. Once the child was unconscious, a 2% lidocaine aerosol solution was sprayed over the laryngeal area directly under the laryngoscope. For patients to tolerate suspension laryngoscopy, it is necessary to maintain spontaneous breathing and ensure adequate anesthesia depth. The airway was secured, and sufficient ventilation was established throughout a tracheal tube (ID 2.5 or 3.0) which was placed close to glottis and connected to Jackson Rees system. Hemodynamic parameters and pulse oxygen saturation (SpO₂) were closely monitored, and adverse events were recorded.

Results

Most of the patients 89% (52/58) were hemodynamically stable during the perioperative period. Laryngospasm and laryngeal edema occurred in several children during emergence from the anesthesia. Tracheal intubations were performed in six patients (10.3%). Tracheotomies were performed in two patients. One patient had to be sent to the ICU for comprehensive therapy.

Conclusion

The most important consideration for anesthesia during suspension laryngoscopy is (1) the maintenance of adequate ventilation, (2) to permit surgical exposure, and (3) to maintain suitable depth of anesthesia which relaxes the vocal band, avoids laryngeal spasms (reflex closure), reduces cardiovascular reaction and wakes up quickly after operation. Any factors that aggravate laryngeal obstruction and dyspnea should be avoided.     

Analysis of archived newborn dried blood spots (DBS) identifies congenital cytomegalovirus as a major cause of unexplained pediatric sensorineural hearing loss

Purpose

Congenital cytomegalovirus (cCMV) infection is the most common non-genetic cause of sensorineural hearing loss (SNHL). However, accurate diagnosis of cCMV as the etiology of SNHL is problematic beyond the neonatal period. This study therefore examined whether cCMV infection could be identified retrospectively in children presenting with unexplained SNHL to a multidisciplinary diagnostic outpatient otolaryngology clinic at an academic medical center in Minnesota.