Laryngeal Papillomas - Clinical Features, Diagnosis, and Treatment

What Are Laryngeal Papillomas?

Neoplasms or cancers of the larynx, that is, the voice box in children, are complex, challenging, and have high recurrence rates. Amongst these neoplasms, the benign (non-malignant) tumors of the larynx called laryngeal papillomas are quite common. The peak incidence of laryngeal papilloma occurs in infants or children between two and five years. There is no sex predilection as both genders may be equally affected. However, the infant often presents with a hoarse tone cry that may be the first clinical symptom of laryngeal papilloma. Because they occur in children commonly and are not malignant, these authentic and benign neoplasms are also called juvenile laryngeal papillomatosis in medical terminology. Recurrent respiratory papillomatosis (RRP) is when these neoplasms recur in a lifetime and is characterized primarily by over-proliferation of benign squamous papillomas, especially within the aerodigestive tract. Recurrent respiratory papillomatosis is one of the most common yet benign mesenchymal origin neoplasms of the larynx in children. This condition may either have a childhood-onset type or would be again an adult-onset type.

What Are the Clinical Features of Laryngeal Papillomas?

The clinical features of laryngeal papillomas include:

• Breathing difficulty would be the most common clinical feature in the child. Severe and advanced cases will have the child gasping for breath due to the mechanical blockage or obstruction at the larynx region.

• Laryngeal papilloma in infants and children appears as pale white and translucent masses that are friable in consistency and involve either the true cords, the false cords, or the anterior commissure (a joint or junction between two anatomical parts) in the larynx region or even the epiglottis.

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• These papillomas can also extend into the subglottic region.

How Does Tracheostomy Impact Papillomas?

History needs to be elicited by the pediatrician or the health care professional about the previous record of the child regarding any tracheostomy procedure performed. Children with neuromuscular disorders and respiratory diseases who have difficulty breathing may require a surgical procedure known as tracheostomy to facilitate breathing. Tracheostomy opens up the airway into the trachea or windpipe. In tracheostomized children, these papillomas may occur within the bronchi or in the tracheal stroma or implant at the tracheostomy site. Research also suggests that genital warts in the mother during pregnancy may also be transmitted to the infant at the time of birth, causing laryngeal masses or papillomas.

What Are the Diagnostic Challenges and Differential Diagnosis in Laryngeal Papillomas?

Juvenile laryngeal papillomas also need to be differentiated from vocal nodules, polyps (small clumps of tissue growth), and laryngeal granulomas, which occur more often due to trauma or inflammatory causes in the child and are non-neoplastic. In contrast, laryngeal papillomas remain a benign form of cancer.

Laryngeal papillomas are also diagnostically challenging, considering the need to use mechanical devices such as laryngoscopes. The procedure can be performed better in older children as they tend to cooperate and withstand the procedure reasonably; however, it tends to be difficult in infants as they may not permit examination. Hence differential diagnosis plays a significant role in determining the accurate diagnosis based upon the child's age. These papillomas peak only in age groups between two to five years. Also, they should be differentiated from common viral infections, allergies, asthma, vocal nodules, or chest infections that are more common in the developing infant or child and are environmentally induced. In infants, certain conditions like laryngeal paralysis, laryngeal webs, subglottic haemangiomas, and laryngomalacia cause hoarseness of voice and stridor. Hence differential diagnosis is all-important for confirming the diagnosis as a laryngeal papilloma.

How Is Laryngeal Papillomas Managed?

The aim of treatment strategies for treating this condition is not just to establish the airway, to eliminate the hoarseness of voice and stridor, but also to preserve the voice of the infant or child and to prevent recurrent lesions of this tumor. Also, the surgeon should aim to cause minimal trauma during the surgery while operating on the laryngeal tissues. The laryngeal papillomas can be managed using the following surgical methods:

• Microlaryngoscopy (MLS) - This technique coupled with CO2 (carbon dioxide) laser vaporization is the fundamental surgical treatment for removing and preventing the recurrence of laryngeal papillomas. The advantage of the laser during the technique enables the operator or surgeon to avoid injury to the laryngeal tissues like the ligament and muscle areas and also helps prevent local scarring of the region. Laser vaporization with KTP (photoselective potassium titanyl phosphate), argon, or flash dye lasers is commonly used by surgeons to avoid postoperative edema and to maintain good surgical hemostasis or bleeding control. When the operator does not use laser vaporization, MLS can be performed by laryngeal cup forceps to remove the tumor's bulk.

• Microdebrider - These are used to shave the papilloma off using laryngeal blades.

• Coblators - They are used to remove papillomas, provide hemostasis, and work at temperatures between 40 to 70 degrees Celsius.

• Adjuvant Treatment Options - Surgical removal may not alone suffice to completely establish the airway, protect the voice, and prevent lesion recurrence. Hence other modalities like alpha interferon therapy are used alongside recombinant deoxyribonucleic acid (DNA) technology, intralesional systemic injections of Acyclovir and Ribavirin, or immunomodulatory antireflux therapy in the cases of respiratory papillomatosis are essential adjuvants for complete elimination and recurrence prevention of the benign tumor.

Conclusion:

To conclude, laryngeal papillomas are benign yet challenging neoplasm to treat due to their high recurrence rates and spread to the adjacent respiratory tract as recurrent respiratory papillomas. However, specific surgical procedures and medications can help prevent the recurrence of laryngeal papillomas. In addition, early diagnosis and prompt treatment can help reduce this condition's risks.