Recurrent Respiratory Papillomatosis
 |
Examples of papillomas on the vocal cords. These can be removed using a number of techniques. These particular lesions were removed using a CO2 laser. |
 |
Recurrent respiratory papillomatosis (RRP) is a disorder that results in the recurrent growth of a certain type of lesion in the respiratory tract (air passages and lungs). These lesions are referred to as papillomas (or commonly as warts). They are caused by the human papillomas virus (HPPV). HPPV also causes venereal warts, but the strains that cause in this problem are typically different than those that cause RRP. RRP occurs most commonly in children and is, in fact, most aggressive in this group. Adults in general tend to have milder disease. The reasons for this remain unknown.
Although the cause of RRP is known, there is less certainty as to how a given individual acquires this problem. Some have speculated that children are exposed to the virus during birth, but there are frequent examples of children who have affected mothers that never develop the disease. Infection through close contact with affected individuals is unlikely as it is uncommon to have several members of the same family affected with this disease.
Though papillomas may occur anywhere along the respiratory tract, they are typically found in the larynx, most commonly on the vocal cords themselves. It is interesting to note that although patients with this disorder may tend to develop papillomas in a certain places, the papilloma virus has been found in tissues of other, non-affected areas of the respiratory tract in these same individuals. This has led investigators to surmise that there must be a secondary factor that triggers the development of papillomas. Many believe this factor to be inflammation. Inflammation may be due to several different causes. One of the most common causes is laryngopharyngeal reflux (LPR). Another common cause is smoking. Additionally, trauma to the lining of the respiratory tract may trigger papillomas growth.
The elimination of factors that may exacerbate the condition is also essential in preventing recurrence and limiting papillomas growth. In this regard, patients are strongly encouraged to stop smoking and are started on an anti-reflux regimen. This regimen typically includes dietary and lifestyle modifications as well as medications.
Treatment for RRP had traditionally consisted of surgical removal of the papillomas. Patients typically require a multiple procedures, as the disease is recurrent. There are many different techniques for removal of papillomas, none of which has been proven to be superior. In removing papillomas, however, it is essential to cause minimal damage to surrounding structures to prevent scarring that may lead to breathing difficulties or hoarseness.
In addition to surgical treatment of papillomas, certain medications have been used to treat this disorder. Interferon has been used with some success in severely affected patients. More recently, anti-viral medications have been shown to be of benefit, most notably Cidofovir. This drug has been shown in early studies to slow or eliminate regrowth of papillomas when injected into the tissues of the respiratory tract.
A recent addition to our treatment armamentarium is in-office laser treatment. An example of this is the Pulsed Dye Laser (PDL), which can treat papillomas after adequate diagnosis is made by biopsy. The laser has several advantages, including safety and the ability to avoid general anesthesia.
Overall, patients with milder forms of RRP do well. Eventually the disease process goes into remission. The rare patients with severe disease may need lifelong frequent therapy.
