Laryngeal Papillomatosis Analysis of 20 Cases SATISH MEHTA, ASHOK VERMA, NARESH K. PANDA, S. B. S. MANN & Y. N. MEHRA

A s tudy o f 20 pa t i en t s o f laryngeal pap i l l o ma to s i s is presented w i th an ana lys i s o f e p i d e m i o l o g l c a l factors , resu l t s o f s u r g e r y and sy s t emic use o f l evamlso le . The y o u n g e s t pat i ent w a s 6 m o n t h s old. 9 o u t o f 20 pat ients p r e s e n t e d w i t h stridor. Invo lvement o f b r o n c h u s and lung p a r e n c h y m a w a s not s e en in any o f the cases . Repeated surg ica l exc i s ion (14 on average) were needed in ma jo r i ty o f pat ients to achieve cure. Ro le o f l e v a m i s o l e needs further evaluat ion.

In troduct ion

Marcellus Donalus first recognised laryngeal papi l lomata as Warts in the throat in seventeenth century. Morell Mackenzie (1871) first des- cribed the condition of papillomato- sis of larynx in children. Ul lman (1923) was able to grow papil lomata by implantat ion from Child's larynx on to skin of his a rm and vagina of a bitch. Dedo and Jackler (1982) noted that 50% of juvenile laryngeal papil lomata contained papova virus particles. Presently laryngeal papil- lomatosis is considered a lesion origi- nating as an exophytic proliferation of squamous epithel ium and stroma. The epithelium is usually well differ- entiated but some amount of dys- keratosis may be observed. The typical clinical course is of extensive growth and rapid recurrence after excision, necessitating frequent sur- gery.

O b s e r v a t i o n s

The salient features noted in 20 cases of juvenile laryngeal papillo- matosis treated at Nchru Hospital, Postgraduate Institute of Medical Education & Research, Chandigarh, during the period of 1976-1986 arc as follows :

Age of onset (Fig. 1)

Majori ty of patients presented during the first three years of life. Two patients were under one year of age and one presented as late as 6 years o f life.

Satish Mehta and Naresh K. Panda, Senior Resident, Ashok Vcrraa, Lecturer, S. B. S. Mann, Associate Professor, Y. N. Mehra, Professor & Head, Department of Otolaryngology, Postgraduate Institute of Medical Education & Research, Chandigarh, India-160 012.

Address fo~ reprint : Dr. S. B. S. Mann, Associate Professor, Deptt. of Otolaryngology, PGIMER, Chandigarh-160 012.

AGE AND SEX WISE DISTRIBUTION 0F" LARYNGEAl., PAPILLOMATOSIS PATIENTS.

Male- Femate-EZZ]

6

S

4

Z 4 S $ 7 Years ~" l i f t

Fig. 1. Shows age and sex wise distribution of laryngeal papillomatosis patients.

Sex (Fig. 1)

There were 12 males (60%) and 8 females (40%).

Symptoms (Table I)

The commonest symptom was change in voice and patients usually manifested with a weak or hoarse voice. 9 patients (45%) presented with stridor. 10 patients (50%) had multiple symptoms.

Site of presentation (Table II)

In all cases, the site of lesion at the initial was carefully examined and recorded. 9 patients (45%) had papil lomata on the true cords and in 2 of these, anterior commissure was also involved. None presented with subglottic or tracheal lesion.

Spread of Papillomata

During the treatment period spread of disease from larynx to tracheostome was noted in 2 cases (10%) and from glottis to supraglot- tis in another 3 cases (15%).

Traeheostomy (Fig. 2)

Tracheostomy was performed in 14 patients (70%). 10 of these

patients required tracheostomy at the time of first admission. These patients revealed extensive involve- ment of glottis and supraglottis.

TABLE I

Present ing S y m p t o m s

No. Percentage

Voice change 18 90

Stridor 09 45

Acute obstruction 02 l0

Cyanosis -- - -

Recurrent U R I 04 20

Cough 06 30

Weight loss 01 05

Multiple symptoms 10 50

T A B L E II

No. Percentage

Glottis

Supraglottis

Subglottis

Glottis + Supraglottis

Glottis d- Subglottis

T rachea + Bronchi

09 45

01 05

I0 50

Indian Journal of Otolaryngology, Volume 42, No. 1, March, 1990 11

Laryngeal Papillomatosis--Analysis 0f20 Cases--Mehta et al.

DURATION OF DISEASE BEFORE TRACHEOSTOMY NEEDED

10

S

8

7

6

~s

~3 2

1

0 2 3 4 5 6 7 8 9

YEARS AFTER ONSET OF PAPILLOMATOSIS

Fig. 2. Shows the duration of disease before tracheostomy was required.

Diagnosis

Microlaryngoscopy revealed cha- racteristic appearance of papillomata. Histopathological examination was done to confirm the diagnosis in each case.

Treatment

All eases underwent surgery in the torm of scalping. The number of surgical excision required were 8 - 20 times (14 average). I n majori ty of the cases mean interval between scalping was 1--2 weeks initially and later on 8--12 weeks.

Out of 14 tracheostomised patients 10 were decannulated after 4 - - 6 years of treatment. 2 children deve- loped glottic web following surgical treatment. 4 patients developed minimal supraglottic scarring.

Levamisole was given to 3 patients but no marked reduction of papillo- mata was seen in these cases.

D i s c u s s i o n

75% of children in our series presented by the age of 3 years. Cohen et al. (1980) showed that maximum incidence is in the first six months, while other series de- monstrate a later overal presentation (Dedo and Jacklen, 1982; Majoros et al. 1964). I t is resonable to state that the condition is most likely to present under the age of five years.

Since the majority of papillomata begin on vocal cords, the voice is affected early. In our series, 90% of patients presented with hoarseness of voice. A similar figure is quoted by B.C. Irwin et al. (1986). 20% children had associated upper respiratory tract infection. I t is possible that by reducing the airflow the papil lomata does predispose to infection.

In our series 2 patients had anterior commissure involvement which is significant in the light of complication arising as a result o f surgery. Both of these patients de- veloped glottic web.

In our series no extralaryngeal lesions were present at the time of admission but other authors have reported papilloma in lips, gingiva, nasopharynx, pharynx, tracheobro- nchial tree and lungs (Strong et al., 1976; Cohen et al., 1980)

Tracheostomy may be inevitable in cases having sudden airway obstruction or stridor. 14 of our patients (70%) needed tracheostomy. 2 patients (10%) developed spread to trachea after tracheostomy. B.C. Irwin et al. (1986) noted papillo- mata spread to trachea in 18% and Majoros et al. (1964) in 56% of their cases. Weiss and Kashima, (1983) proposed that disruption of

tracheal mucosa following traeheos- tomy results in the spread of papillomata.

In conclusion, tracheostomy should be avoided as far as possible and during surgical removal it is always better to underdo so as to avoid injury to normal laryngeal structures.

References

I. Al-Saleen, T. Peale, A.R., Norris, C.M. (1968): Multiple papillomatosis of lower respiratory tract. Cancer, 22 : 1174-1184.

2. Birck, H.G., Manhart, H.E. (1963) : Ultrasound for juvenile laryngeal papil- lomatosis. Acta Otolao, ng 77 : 603-608.

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Dedo, H. I-I. and Jackler, R.K. (1982): Laryngeal papilloma results of treatment with CO s laser and podophyllum. Annal of Otology. Rhin. Laomg. 91 : 425--30,

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Holinger, D.H., Johnson, K.C. , Conner, G.H. (1962) :. Studies of Papil- lomaoflarynx. Ann. Otol.7 :443 117,

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Irwin, B. C., Hendnckse, W. A. et al. (April 1986) :Juvenile laryngeal papillo- matosis. 07ournal of La(yng. and Otol. Vol. 100, 435 n.45

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Majoras, M., Parkhill, E. M. R., Devine, K. D. (1964) : Papilloma of larynx in Children. Am. 07. of Surg. 108 : 470--75,

Meckenzie, M. (1871). : Essays on grow- ths in the larynx with reports and an analysis of one hundred consecutive case treated, Philadelphia, Lindsay and Blakis- ton.

Morcullus Donalus quoted by Me- ckenzie, M. (1871).

Singleton, G., Adkins, W. G. (1972) : Cryosurgical treatment of juvenile laryngeal papillomatosis, Ann. Otol. 81 : 784---790,

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