Laryngeal distribution of recurrent respiratory papillomatosis in a previously untreated cohort

Distribution Characteristics of Juvenile-Onset Recurrent Respiratory Papillomatosis at First-Time Surgery

OBJECTIVES

The lesion distribution of juvenile-onset recurrent respiratory papillomatosis (JORRP) during first-time surgery has been rarely reported. The purpose of this study was to describe the anatomical distribution of papilloma across 25 Derkay sites during initial surgery and to assess the impact of the lesion distribution on disease severity.

METHODS

Surgical videos and medical records of 106 patients with JORRP (27 aggressive and 79 nonaggressive cases) were retrospectively reviewed. Lesion locations were recorded using Derkay anatomical sites. Logistic regression was used to analyze the effect of the lesion distribution on disease severity.

RESULTS

Among the 106 patients, the true vocal cords (90.6% left, 84.0% right) were the most frequently involved site, followed by the false vocal cords (39.6% left, 35.8% right) and the anterior commissure (26.4%). Two patients (1.9%) had tracheal involvement. Patients with false vocal cord involvement (odds ratio [OR] = 3.425, 95% confidence interval [CI] [1.285, 9.132], P = .014) and a younger age at diagnosis (OR = .698, 95% CI [.539, .905], P = .007) were more likely to require more than 4 procedures in the year following first-time surgery.

CONCLUSIONS

Lesions were most common on the true vocal cords. False vocal cord involvement and a younger age at diagnosis were risk factors for disease severity.

Prospective, Multi-Center Study of the Anatomic Distribution of Recurrent Respiratory Papillomatosis

OBJECTIVES/HYPOTHESIS

To create a model of the anatomic distribution, recurrence, and growth patterns of recurrent respiratory papillomatosis (RRP).

STUDY DESIGN

Prospective, multi-institutional cohort study.

METHODS

Adult patients with a diagnosis of RRP evaluated between August 1, 2018 and February 1, 2021 at six participating centers were invited to enroll. At each office or operating room encounter, laryngologists recorded the location and size of RRP lesions using a 22-region schematic. A generalized linear mixed effects model was used to compare region variations in lesion prevalence and recurrence.

RESULTS

The cohort comprised 121 patients: 74% were male, 81% had been diagnosed with adult-onset RRP, and a plurality (34%) had undergone 0 to 3 RRP interventions prior to enrollment. Across the study period, the odds of a lesion occurring in the glottis was significantly higher (odds ratio [OR]: 26.51; 95% confidence interval [CI]: 11.76-59.75, P < .001) compared with all other areas of the larynx and trachea. Within the true vocal folds, the membranous vocal folds had significantly higher odds (OR: 6.16; 95% CI: 2.66-14.30, P < .001) of lesion occurrence compared to the cartilaginous vocal folds. Despite these strong trends in lesion distribution, there were no differences in the odds of lesion recurrence, growth, or in the time to recurrence, between anatomic subsites.

CONCLUSIONS

RRP lesions are most likely to occur in the glottis, particularly the membranous vocal folds, compared with other regions of the larynx or trachea. However, all lesions demonstrate similar behavior with respect to recurrence, growth, and time to recurrence regardless of anatomic location.

LEVEL OF EVIDENCE

3 Laryngoscope, 132:2403-2411, 2022.

NBI and Laryngeal Papillomatosis: A Diagnostic Challenge: A Systematic Review

Highlights

Abstract

Narrow-band imaging (NBI) represents a valid aid in laryngeal squamous cell carcinoma (LSCC) diagnosis for detecting vascular changes. However, LSCC and laryngeal papillomatosis (LP) show similar vascular patterns that may lead to misdiagnosis and improper treatment. This review aims to deepen this NBI limit in order to stress a careful preoperative evaluation of laryngeal lesions. The research was carried out on PubMed, Web of Science and Scopus databases using specific keywords. The topic of research was assessed by these parameters: accuracy, sensitivity, specificity, and positive and negative predictive values. This review included only five articles: they demonstrated that NBI is better than white-light endoscopy in detecting LSCC and LP. They also reported that LP is frequently mistaken for LSCC, resulting in high rates of false positives using NBI. This is the first review that emphasized this NBI limitation in distinguishing between LP and LSCC in cases of a type V pattern of intraepithelial papillary capillary loop. Although NBI application increased the rate of early cancer detection, LP reduces NBI accuracy. This drawback may lead to misdiagnosis and improper treatment. Our advice is to be careful in cases of type V pattern on NBI and to research LP epithelial and clinical features because it could be a pitfall.

Expanded Basal Compartment and Disrupted Barrier in Vocal Fold Epithelium Infected with Mouse Papillomavirus MmuPV1

Laryngeal infection with low-risk human papillomaviruses can cause recurrent respiratory papillomatosis (RRP), a disease with severe effects on vocal fold epithelium resulting in impaired voice function and communication. RRP research has been stymied by limited preclinical models. We recently reported a murine model of laryngeal MmuPV1 infection and disease in immunodeficient mice. In the current study, we compare quantitative and qualitative measures of epithelial proliferation, apoptosis, differentiation, and barrier between mice with MmuPV1-induced disease of the larynx and surrounding tissues and equal numbers of uninfected controls. Findings supported our hypothesis that laryngeal MmuPV1 infection recapitulates many features of RRP. Like RRP, MmuPV1 increased proliferation in infected vocal fold epithelium, expanded the basal compartment of cells, decreased differentiated cells, and altered cell–cell junctions and basement membrane. Effects of MmuPV1 on apoptosis were equivocal, as with RRP. Barrier markers resembled human neoplastic disease in severe MmuPV1-induced disease. We conclude that MmuPV1 infection of the mouse larynx provides a useful, if imperfect, preclinical model for RRP that will facilitate further study and treatment development for this intractable and devastating disease.

A Novel In Vivo Model of Laryngeal Papillomavirus-Associated Disease Using Mus musculus Papillomavirus

Recurrent respiratory papillomatosis (RRP), caused by laryngeal infection with low-risk human papillomaviruses, has devastating effects on vocal communication and quality of life. Factors in RRP onset, other than viral presence in the airway, are poorly understood. RRP research has been stalled by limited preclinical models. The only known papillomavirus able to infect laboratory mice, Mus musculus papillomavirus (MmuPV1), induces disease in a variety of tissues. We hypothesized that MmuPV1 could infect the larynx as a foundation for a preclinical model of RRP. We further hypothesized that epithelial injury would enhance the ability of MmuPV1 to cause laryngeal disease, because injury is a potential factor in RRP and promotes MmuPV1 infection in other tissues. In this report, we infected larynges of NOD scid gamma mice with MmuPV1 with and without vocal fold abrasion and measured infection and disease pathogenesis over 12 weeks. Laryngeal disease incidence and severity increased earlier in mice that underwent injury in addition to infection. However, laryngeal disease emerged in all infected mice by week 12, with or without injury. Secondary laryngeal infections and disease arose in nude mice after MmuPV1 skin infections, confirming that experimentally induced injury is dispensable for laryngeal MmuPV1 infection and disease in immunocompromised mice. Unlike RRP, lesions were relatively flat dysplasias and they could progress to cancer. Similar to RRP, MmuPV1 transcript was detected in all laryngeal disease and in clinically normal larynges. MmuPV1 capsid protein was largely absent from the larynx, but productive infection arose in a case of squamous metaplasia at the level of the cricoid cartilage. Similar to RRP, disease spread beyond the larynx to the trachea and bronchi. This first report of laryngeal MmuPV1 infection provides a foundation for a preclinical model of RRP.

Evaluating the Effect of Recurrent Respiratory Papillomatosis on Work Productivity

OBJECTIVE

Patients with recurrent respiratory papillomatosis (RRP) have significant vocal dysfunction which affects their performance at work. This study aimed to evaluate voice-related work productivity before and after ablative treatment for RRP.

METHODS

This is a prospective case series conducted at 2 academic laryngology outpatient clinics. Adult employed patients with RRP completed the Work Productivity & Activity Impairment instrument (WPAI), Voice Handicap Index (VHI-10), WorkHoarse, Hospital Anxiety and Depression Scale (HADS), and a demographics questionnaire immediately before and 1 month after ablative treatment of papilloma. The primary outcome measure was the change in work productivity impairment domain of the WPAI, and changes in ratings before and after ablation were compared using a Wilcoxon Signed-Rank test.

RESULTS

The 32 participants (mean age 45, 84% male) had a median (interquartile range) voice-related work productivity impairment score of 48.8% (30.0) at baseline which was improved to 5.0% (10.0) at 1 month after surgical ablation of papillomata (difference 30.0% (30.0) improvement). For the secondary outcome measures, there were significant improvements in VHI-10 (P < .001), self-reported voice quality (P = .002), and Workhoarse (P = .001), but no significant change in HADS.

CONCLUSION

Patients with RRP experience significant voice-related work productivity impairment, and ablation of papillomata significantly improves work productivity.

Recurrent respiratory papillomatosis: clinical characteristics and viral genotyping in a Brazilian population

This study presents 25 cases of recurrent respiratory papillomatosis (RRP) that occurred in Sao Luis, Maranhao State, Northeast region, Brazil, between January 2007 and December 2018. Sociodemographic and clinical profile of patients as well as human papillomavirus (HPV) infection status were evaluated. Clinical and histopathological data were collected from the patients' medical records. For the HPV infection analysis, DNA was extracted and subjected to amplification by a nested polymerase chain reaction. Viral genotyping was performed by automated sequencing. The median age of patients was 12.40 ± 12.6. years, and the juvenile form of the disease (68%) was the predominant form of disease. Female participants were predominant (60%), and they were from cities located in the interior of the State (60%). The most common clinical manifestation was dysphonia; recurrence was observed in most cases (56%), and tracheostomy was necessary in seven patients (26.9%). When comparing the RRP forms, patients in the juvenile-RRP group had higher recurrence rates and need of tracheostomy than those in the adult-RRP group. The viral genotyping analysis revealed that 47.8% of patients had low-risk HPVs, whereas 13.1% had high-risk HPVs, and in 39.1% of patients the viral genotype was not obtained. HPV-6 was the most prevalent type and Juvenile-RRP was more prevalent in our population. HPV was present at a high rate, and HPV-6 was the predominant genotype. This study serves as the basis for further studies to be conducted in the Brazilian population. Our findings aid the better understanding of RRP, possibly suggesting some prognostic factors associated with the disease aggressiveness.

The Impact of Laryngopharyngeal Reflux on Occurrence and Clinical Course of Recurrent Respiratory Papillomatosis

OBJECTIVES/HYPOTHESIS

Laryngopharyngeal reflux (LPR) has been proposed both as a trigger for recurrent respiratory papillomatosis (RRP) onset and as a factor favoring an aggressive clinical course.

STUDY DESIGN

In this prospective study, 106 participants were recruited within a period of 24 months at the Department of Otorhinolaryngology and Cervicofacial Surgery, University Medical Centre Ljubljana.

METHODS

This study compared a group of RRP patients (N = 36) with a group of LPR patients (N = 28) and a group of healthy participants (N = 42) based on Reflux Symptom Index (RSI), Reflux Finding Scores (RFS), and saliva analyses (pH, pepsin concentration, bile acid concentration, and pepsin enzymatic activity).

RESULTS

The RRP group compared to the LPR group showed a statistically significant difference only in RSI and RFS scores, while the RRP group compared to healthy controls showed significantly higher values in all tested parameters (RSI score, RFS, saliva pH, pepsin concentration, bile acids concentration, pepsin enzymatic activity).

CONCLUSIONS

LPR is common in RRP patients and significantly more prevalent compared to healthy controls. Our results show that saliva analyses are a better office-based tool than RSI questionnaires and RFS scores for diagnosing LPR in RRP patients.

LEVEL OF EVIDENCE

Level 3 Laryngoscope, 2021.

Recurrent respiratory papillomatosis: A 2020 perspective

OBJECTIVE

Despite recent advancement recurrent respiratory papillomatosis (RRP) remains a rare but challenging benign airway neoplasm. In recent years there has been significant shifts in incidence of this disease due to changes in vaccination and prevention for human papilloma virus (HPV) and its related pathology. This review will highlight the epidemiology, prevention and treatment of RRP.

METHODS

The PubMed database was searched using relevant MeSH terms including "recurrent respiratory papillomatosis." The titles and abstracts were reviewed to assess relevance and unrelated articles were excluded. A full-text review for select articles was performed, the data and discussions were interpreted and synthesized to create a concise update on the management of RRP.

RESULTS

With the increasing utilization of the 9-valent and quadrivalent HPV vaccine in Australia, we have seen a significant decrease in the incidence of RRP. Preliminary data in the US shows a similar trend of decreased incidence after implementation of vaccination. Single dose Gardasil in developing countries has shown sustained immunization for at least 7 years. Preliminary clinical trials and retrospective studies have shown the HPV vaccine may have benefit as a treatment method in addition to prevention for HPV related diseases. Bevacizumab (Avastin), a VEGF monoclonal antibody, has shown promise as a systemic treatment for RRP. The Corona Virus Disease 2019 (COVID-19) pandemic has affected perioperative management of RRP.

CONCLUSION

RRP continues to decline in incidence since the implementation of HPV vaccination. Advancement in the medical management including Bevacizumab show promise as an additional option for the management of RRP.

An estimate of the incidence and prevalence of laryngeal papillomatosis in São Paulo State (Brasil)

SUMMARY BACKGROUND: Recurrent laryngeal papillomatosis, caused by the Human Papilloma Virus, has a significant economic impact worldwide and there are no epidemiological data of this disease in Brasil. OBJECTIVE: The objective of the study was to estimate the incidence and prevalence of laryngeal papillomatosis of some otorhinolaryngology centers in São Paulo State (Brasil). METHODS: A questionnaire containing data on the number of new and follow-up cases diagnosed with laryngeal papillomatosis was sent to the Otorhinolaryngology services (n=35) of São Paulo State (Brasil). RESULTS: A total of 20 otorhinolaryngology centers answered the questionnaire. Of these, the five largest regional health centers were selected as follows: Campinas (42 cities – 4,536,657 inhabitants), Sao Jose do Rio Preto (102 cities – 1,602,845 inhabitants), Ribeirão Preto (26 cities – 1,483,715 inhabitants), Bauru (68 cities – 1,770,427 inhabitants), and Sorocaba (47 cities – 2,478,208 inhabitants). The incidence and prevalence of each regional health centers were, respectively: Campinas (5.51;7.27), Sorocaba (2.02;6.86), São José do Rio Preto (1.87;7.49), Ribeirão Preto (11.46;22.92), and Bauru (3.95;7.91). CONCLUSION: The incidence and prevalence of the laryngeal papillomatosis of the five largest regional health centers of the interior of São Paulo State (Brasil) varied between 1.87 to 11.46 and 6.86 to 22.92 per 1,000,000 inhabitants, respectively for a total population of 11,871,852 inhabitants.

Update on Recurrent Respiratory Papillomatosis

Recurrent respiratory papillomatosis (RRP) remains a challenging disease afflicting children and adults, resulting in an estimated $120 million per year in United States healthcare-related costs, with annual costs per patient approaching $60,000. Although the prevalence of RRP has declined, RRP remains the most common benign laryngeal neoplasm in children. RRP is unique in its high rate of multisite recurrence, its high burden on patient quality of life, and its high associated healthcare costs. This article summarizes current understanding of the natural history and quality of life burden of RRP, and basic science advancements in prevention and treatment.

Laryngeal distribution of adult-onset recurrent respiratory papillomatosis: A longitudinal study

OBJECTIVES/HYPOTHESIS

To describe recurrence patterns in patients with recurrent respiratory papillomatosis (RRP) following surgical intervention.

STUDY DESIGN

Single-center, retrospective, longitudinal case series.

METHODS

Initial and follow-up laryngoscopic examinations of seven previously untreated adult-onset RRP patients were reviewed. Patients were followed longitudinally for periods ranging from 3 months to 7 years. Lesion locations were recorded using a twenty-one region laryngeal schematic, and maps were generated to illustrate the distribution of disease before and after cold-knife or potassium-titanyl-phosphate laser intervention. Univariate and multivariate analyses were employed to examine variables affecting recurrence patterns.

RESULTS

Across all patients, a statistically significant correlation between initial distribution and primary recurrence was observed. Seventy-five percent of new lesions were adjacent to regions with preexisting disease; 83% of new glottic lesions were adjacent to preexisting glottic lesions, and 66% of supraglottic lesions were adjacent to preexisting supraglottic regions. No statistically significant differences in recurrence rate were observed across sites.

CONCLUSIONS

In previously untreated patients with adult-onset recurrent respiratory papillomatosis, lesions tended to recur either in the same regions or regions adjacent to those affected at the time of initial surgery.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:1993-1997, 2019.

Voice Outcomes Following Multiple Surgeries for Recurrent Respiratory Papillomatosis

OBJECTIVES

Recurrent Respiratory Papillomatosis (RRP) is a rare disease caused by the human papilloma virus that presents as warty, exophytic growths in the upper airway. RRP in the larynx can lead to severe airway obstruction and voice changes. It is clinically known that patients with RRP frequently experience dysphonia. The purpose of this study was to assess the impact of multiple surgical treatments on RRP patients' voice outcomes, and to determine whether a higher number of repeated surgeries lead to decreased voice quality.

METHODS

A retrospective cohort study was conducted of adult RRP patients (n = 23) who underwent multiple surgeries. Group 1 included patients (n = 11) who had <5 surgeries (range 2-4 surgeries) and Group 2 included patients (n = 12) who had ≥5 surgeries (range 5-50+ surgeries). Voice recordings were selected from the following clinic visits: initial office visit (initial presurgery), first postsurgery, and the last clinic encounter(s) with no immediate planned surgery. Blinded auditory-perceptual ratings along with cepstral and spectral acoustic measures assessed voice severity.

RESULTS

There was significant improvement from the initial presurgery visit compared to each postoperative visit over time for all voice outcome measures for both Group 1 and Group 2. The results of the study indicated that the number of surgeries did not significantly affect mean postoperative voice outcomes, and there were no significant differences between patient groups for voice quality over time.

CONCLUSIONS

The results of this study suggest that RRP patients' voice quality may not suffer cumulative negative effects when using modern tissue-sparing surgical techniques.