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
