Laryngeal papillomatosis

Laryngeal papillomatosis (papilloma) is a benign tumor that develops from a flat or transitional epithelium and protrudes above its surface in the form of a papilla. Papillomatosis is a pathological process characterized by the formation of multiple papillomas in any part of the skin or mucosa. Throat papillomas are found almost as often as laryngeal polyps. They are the result of a proliferative process that develops in the epithelium and connective tissue elements of the laryngeal mucosa.

Solitary papillomas are very rare, in the overwhelming majority of cases there are multiple formations that can occur not only in the larynx, but also simultaneously on the soft palate, palatine tonsils, lips, skin, tracheal mucosa. Probably, due to the special predisposition of the epithelium of papilloma recur very often, because of what this disease has received the name of papillomatosis.

Papillomas occur most often in early childhood and rarely in adults. Cases of congenital papillomas are described.

In most cases, papillomas have viral etiology, which was proved by a number of authors who managed to reproduce this tumor by auto-inoculation of its filtrate. Papillomatosis is also believed to be a kind of diathesis, which manifests itself only in some individuals with an individual predisposition to it. It is impossible to exclude in the occurrence of this disease and the role of androgenic hormones, which probably can explain its occurrence only in boys. A number of authors in the pathogenesis of papillomatosis see the uneven age-related development of various tissues that constitute the morphological basis of papilloma.

Structurally, papillomas are structures consisting of two layers - papillary of connective tissue and epithelial. In multiple children papillomas, connective tissue is abundantly vascularized, while elements of the epithelium predominate in the “older” papillomas in boys and adults, and the connective tissue layer is less vascularized. Such papillomas, unlike the first pink or red color, have a whitish-gray color.

ICD-10 code

D14.1 Papilloma of the larynx.

[1]

Epidemiology of laryngeal papillomatosis

In the structure of benign tumors, papillomas make up 15.9-57.5%, according to different authors. The disease can begin both in childhood and in adulthood. More common is juvenile papillomatosis (87%), whose symptoms appear in the first five years of life.

[2], [3], [4], [5], [6],

Causes of laryngeal papillomatosis

The causative agent is a DNA-containing human papillomavirus of the 6th and 10th types of papovaviruses. To date, about 100 types of this virus have been identified.

[7], [8], [9]

Pathogenesis of laryngeal papillomatosis

The disease is characterized by a rapid course, a tendency to relapse is often accompanied by stenosis of the laryngeal lumen. In adults, papilloma develops in 20-30 years or in old age. Frequent development of relapses forces to perform repeated surgical interventions, in connection with which in most cases cicatricial deformities of the larynx develop in patients, sometimes leading to a narrowing of its lumen and deterioration of the vocal function. Children may develop bronchopneumonia, with the spread of papillomas in the trachea they are diagnosed in 17-26%, in the bronchi and lungs - in 5% of cases. The latter is considered an unfavorable prognostic sign for malignancy.

The disease is accompanied by a decrease in general and local immunity, a violation of its humoral link, and changes in the hormonal and metabolic status.

[10], [11], [12], [13]

Symptoms of papillomatosis of the larynx

The main clinical sign of laryngeal papillomatosis is hoarseness of the voice and respiratory disorders. The severity of the disease is due to frequent relapses, which can lead to stenosis of the larynx, the possibility of papillomas spreading to the trachea and bronchi, followed by the development of pulmonary insufficiency and malignancy.

Symptoms of laryngeal papillomatosis are determined by the patient's age, localization and prevalence of tumors. Young children are more likely to have diffuse forms, while older children have papillomas with more limited localization (papillomatosis circumscripta). In adults, papillomas are more common on the vocal folds characterized by hyperkeratosis.

The main symptom in both children and adults is the growing hoarseness of the voice, reaching a full aphonia. In children, respiratory disturbances, shortness of breath during physical exertion and other hypoxic hypoxia also increase at the same time. The phenomena of dyspnea are growing, there are spasms of the larynx, stridor and suffocation syndrome, in which, if not to take emergency measures, the child may die.

In some cases, attacks of asphyxia occur suddenly during a banal intercurrent inflammatory disease of the larynx, which develops with its concomitant edema. The smaller the child, the more dangerous these attacks are, due to the significant development of loose connective tissue in the sub-storage space, the small size of the respiratory tract and the fact that in young children papillomatosis is diffuse and develops very quickly. All of these risk factors for asphyxiation should be kept in mind when observing such children. In adults, asthma attacks are not observed, and the only symptom indicating the presence of a lesion in the glottis is hoarseness.

Classification of laryngeal papillomatosis

There are several histological and clinical classifications of papillomatosis. By the time of occurrence of the disease are distinguished:

• juvenile, originated in childhood;
• recurrent respiratory.

According to the prevalence of the process, according to the classification of DG Chireshkin (1971), the following forms of papillomatosis are distinguished:

• limited (papillomas are localized on one side or are located in the anterior commissure with the closure of the glottis no more than 1/3);
• common (papillomas are localized on one or two sides and extend beyond the inner ring of the larynx, or the areas of the anterior commissure are located with the glottis closed 2/3);
• obliterating.

The course of papillomatosis is divided into:

• rarely recurrent (no more than once every 2 years);
• often recurrent (1-3 times a year or more).

[14], [15], [16], [17], [18]

Screening

All patients with hoarseness and stridor must undergo laryngoscopy and fibrofolaryngotracheoscopy.

[19], [20], [21], [22], [23], [24],

Diagnosis of papillomatosis of the larynx

Laryngoscopic picture can be very varied.

In more rare cases, isolated small formations in size from millet grain to pea, located on one of the vocal folds or in the anterior commissure, are reddish in color. In other cases, papillomas have the appearance of cockscombs located on the upper and lower surfaces of the vocal folds; such forms are more common in adults. In young children, in which laryngeal papillomatosis occurs most often, diffuse forms of this formation are observed, in which papillomas have the appearance of conical formations that dot not only the walls of the respiratory slit, but also the adjacent surfaces of the larynx, even beyond the limits of the trachea and pharynx. These forms of papillomatosis are well vascularized and are characterized by rapid development and recurrence. With significant sizes, parts of papillomas can come off and cough off with sputum, slightly tinged with blood during coughing shocks.

The evolution of the disease is characterized by the progression of the proliferative process with penetration into all free cavities of the larynx and, in untreated cases, ends with attacks of acute suffocation requiring emergency tracheotomy.

Diagnosis in children does not cause difficulties, the diagnosis is made using direct laryngoscopy according to the characteristic external signs of the tumor. For differential diagnosis produce a mandatory biopsy. In children, papillomatosis of the larynx is differentiated from diphtheria, false croup, foreign body, congenital malignant tumors. In laryngeal papillomas in persons of mature age, oncological vigilance should be observed, since such papillomas, especially the so-called hard whitish-gray papillomas, have a tendency to malignancy.

When collecting the history should pay attention to the frequency of recurrence of the disease.

[25], [26], [27]

Laboratory research

General clinical studies are carried out in accordance with the plan of preparing the patient for surgical intervention, assessing the immune status.

[28], [29]

Instrumental studies

All patients should undergo endofibrolaryngotracheobronchoscopy in order to identify trachea and / or bronchial papillomatosis, as well as x-ray and tomographic examination of the lungs.

[30], [31], [32], [33], [34], [35], [36], [37]

Differential diagnostics

With microlaryngoscopy, the picture of papillomatosis is very characteristic - the formation has the appearance of limited, often multiple papillary growths with a fine-grained surface and resembles a mulberry berry in appearance. Its color depends on the presence of blood vessels, layer thickness and keratinization of the epithelium, so the papilloma can change color at different periods of its development from red, pale pink to white. Differential diagnosis is carried out with tuberculosis and laryngeal cancer. Signs of malignancy - ulceration of papillomas, changes in vascular pattern, a sharp restriction of the mobility of the vocal fold in the absence of cicatricial process, immersion growth, keratosis. Difficulties of differential diagnosis are papillomas in elderly patients and patients with a large number of surgical interventions in history. The final diagnosis is established by histological examination.

[38], [39], [40], [41], [42], [43], [44]

Indications for consulting other specialists

An immunologist consultation is indicated.

[45], [46], [47], [48]

Treatment of laryngeal papillomatosis

Treatment goals

• Elimination of airway stenosis.
• Reducing the number of recurrences of the disease.
• Prevent the spread of the process
• Restore voice function.

Indications for hospitalization

Hospitalization is carried out with the purpose of surgical treatment.

[49], [50], [51], [52], [53], [54]

Non-drug treatment of laryngeal papillomatosis

Recently, photodynamic therapy has become very common.

[55], [56], [57], [58]

Drug treatment of laryngeal papillomatosis

An important role is played by the treatment of postoperative laryngitis - antibiotic therapy, local and general anti-inflammatory therapy. Local application of cytostatics, antiviral drugs and drugs affecting the level of estrogen metabolites, etc., is acceptable. Based on a study of the immune status, immunocorrection is performed.

[59], [60]

Surgical treatment of laryngeal papillomatosis

The main method of treatment of laryngeal papillomatosis is surgical. Endolaryngeal removal of papillomas is possible under general anesthesia or local anesthesia with direct or indirect microlaryngoscopy, using a laser or ultrasound. Careful and gentle removal of papillomas is necessary. The number of surgical interventions should be minimized due to the risk of laryngeal scarring.

According to N.Costinescu (1964) and several other authors, since the etiology of the disease is mainly at the level of hypotheses, numerous suggestions for non-operational treatment of laryngeal papillomatosis were either ineffective or harmful. By the end of XX century. Not a single absolutely effective etiotropic treatment has been developed, the existing methods, most of which are effective only in the hands of the authors, with mass use, at best, only retard the development of papillomatosis, but do not eliminate it. Most of these methods can be attributed to auxiliary, used after the application of destructive methods aimed at the physical elimination of the tumor. However, the "bloody" extirpation of papillomas aims not to cure the disease, but only to create conditions for more or less satisfactory administration of the functions of the larynx and in particular to prevent the obstruction of the respiratory gap in children and asphyxia. Repeated surgical interventions are performed in relapses, which occur more frequently and more intensively than a younger child. In the middle of the XX century. Papillomas were removed using specially adapted forceps for indirect (in adults) and direct (in children) laryngoscopy. With the development of the method of microsurgical video technology, surgical interventions became more gentle and effective, however, this method does not prevent relapses. With the development of laser surgery, treatment of laryngeal papillomatosis has become much more effective, and relapses - more rare and not so intense.

As recommended by V. Steiner and J. Werner, before the procedure of laser surgery, the beam can be slightly defocused for a softer energy impact on the structures of the larynx. For this, a low-energy carbon dioxide laser is used. Surgery should be limited to the localization of the tumor, and the islands of the normal mucous membrane located between the individual papillomas removed should be maintained as centers of future epithelialization. Papillomas should be removed quite radically, but within the limits of their “fusion” with the underlying tissues in order to reduce the risk of recurrence. Bilateral papillomas located in the anterior commissure should be especially carefully operated, since it is here that adhesions that lead to fusion of the anterior parts of the vocal folds are possible. The authors recommend, especially when operating on children, to leave small patches of papilloma in this area to reduce the risk of an adhesive process. You can extubate a patient after anesthesia immediately after surgery, even after removing extensive papillomas. To prevent postoperative edema, the authors recommend a single injection of a specific dose of a corticosteroid, for example, 3 mg / kg of prednisolone.

Of the recommendations on adjuvant therapy in the postoperative period, broad-spectrum antibiotics, estrogens, and arsenic drugs deserve attention. It was also noted that the administration of methionine 0.5 g 3 times a day for 3-4 weeks after surgery prevents the occurrence of relapses. Some authors obtained satisfactory results with subcutaneous administration of an extract of the placenta, other authors used the method of tissue therapy according to the Filatov method, placing the graft in the sub-storage space with tracheal access. Many authors do not recommend radiation therapy because of possible radiation damage to the tissues of the larynx, as well as the risk of malignant papillomas.

[61], [62], [63], [64], [65]

Further management

Patients with papillomatosis are subject to mandatory medical examination, depending on the frequency of recurrence of the disease, but not less than once every three months.

In the surgical treatment of the disability period is 7-18 days. With the development of cicatricial deformity of the larynx and trachea possible disability

[66], [67], [68], [69]

Information for the patient

When detecting papillomatosis of the larynx, it is necessary to observe the terms of follow-up observation, avoid infections of the upper respiratory tract, voice loads, work in dusty, gassed rooms.

[70], [71],

Prevention of laryngeal papillomatosis

Preventive measures are reduced to dynamic observation of the patient, patient compliance with a gentle voice mode, elimination of occupational hazards, treatment of the accompanying pathology of the gastrointestinal tract (reflux esophagitis) and respiratory tract, inflammatory diseases of the ear, nose and throat.

[72], [73], [74], [75], [76], [77], [78],

Prognosis for laryngeal papillomatosis

The prognosis is usually favorable, even with repeated surgical treatment with the occurrence of postoperative relapses, since with the maturity of the patient, relapses become less frequent and not so intense, and then stop altogether. In adults, papilloma degeneration into cancer or sarcoma may occur, and then the prognosis depends not on the primary disease, but on its complication.

The prognosis of the disease depends on the prevalence and recurrence rate of the process. Fully restore voice function, as a rule, fails. The prognosis is worse after tracheostomy and radiotherapy. Laryngeal papillomatosis is considered a precancerous disease, malignization occurs in 15-20% of cases, but spontaneous remission is possible.

[79], [80],