Recurrent Respiratory

Papillomatosis

Warty

growths in aerodigestive tract

Natural history unknown
Caused by human papillomavirus
Can lead to airway obstruction
Treatment essentially palliative

Overview

Icosahedral,

naked, supercoiled DNA

Papovavirus family

PApillomavirus
POlyoma

(HPV)

JC virus -- progressive multifocal leukencephalopathy

BK virus -- isolated from urine of renal transplant patients

siman

VAculolating virus

Basic Science

Basic Science, cont.

Over

90 subtypes
Subtypes arranged in families by DNA
homology
RRP usually HPV 6,11
HPV 16, 18 implicated in cervical cancer

Bimodal

juvenile, 75% by age 5

incidence: 4.3/100,000

adult, usually young adulthood

incidence: 1.8/100,000

Epidemiology

Clinical

Triad:

firstborn
teenage mother
vaginal delivery
Cost

$151 million annually

Epidemiology, cont

Acquired

during vaginal birth

10-25% childbearing-age women with HPV in

cervical swabs
Hematogenous
Ascending
Contact

with anogenital lesions

Transmission

Shah:

109 children with RRP, only 1 born

by C-section
No consensus
Literature does not generally endorse in
absence of other indications

Cesarean?

Symptoms

Hoarseness
Weak cry
Chronic cough
Stridor

Visualize

lesions

Biopsy

Diagnosis

Epithelial

projection with fibrovascular

core
Viral histological findings
parakeratosis
acanthosis
koilocytosis
Virus

demonstrated in normal epithelium

Histology

Limen

vestibuli
Nasopharyngeal surface soft palate
Midzone, laryngeal surface of epiglottis
Upper and lower margins of ventricle
Undersurface of ventricles
Carina and bronchial spurs

Location (Squamocolumnar
junction)

Variable

by patient
Frequent debulking mainstay of Rx
Avoid damage to normal tissue
May

require tracheotomy

?predisposes to distal spread

Course

Spontaneous

remission

1/3 by age 40
Distal

disease -- bad
Malignant degeneration

Course, cont.

Apnea
Laser

tube
Jet ventilation
Spontaneous ventilation

Anesthesia

Cold

steel, less common

CO2 Laser
protect airway from fire
protect health care personnel
laser masks
adequate suction

Treatment, Surgical

Interferon
I3C
Acyclovir
Retinoids
Photodynamic

therapy

Methotrexate
Cidofovir
Ribavirin

Treatment, Medical

Derived

from leukocytes, now

recombinant
Dose 3MU per m2 BSA
Bad side effects
Healy:

Initial benefit seen at 6 mo. not

sustained at one year
Neutralizing antibodies may play a role

Alfa-Interferon

Derived

from cruciferous vegetables

Over-the-counter
Dose 200-400 mg adults, 100-200 mg
kids
well-tolerated
Affects

estrogen metabolism

Indole-3-carbinol

Thought

that Herpesvirus coinfects many

cases
Limited studies

Acyclovir

Vitamin

A derivative
Alters epithelial differentiation
May synergize with interferon

Retinoids

Patient

is given IV photosensitizing agent

Concentrated in proliferating tissues
Ablated with argon dye laser
Photosensitivity limits usefulness, lasts
weeks/months

Photodynamic Therapy

Morbid

disease we still do not understand

Treatment is debulking, airway protection
Future therapies are under investigation

Conclusion