Recurrent Respiratory Papillomatosis: Researchers Advancing Toward Prevention

The traditional methods of therapy are standard-dissection with cold instrumentation, said Marvin Fried, MD, Professor of Otorhinolaryngology-Head and Neck Surgery at Albert Einstein College of Medicine in the Bronx, NY. It used to be just cup forceps. Then came the use of lasers, the first technology that brought kind of something new to laryngeal surgery and predated almost everything else we’ve done subsequently. Now we have the adjunct of cryosurgery, and the growing popularity of endoscopic resection.

Many physicians are currently using the latest laser devices to achieve resection, Dr. Fried noted, which allows improved precision, accuracy of visualization and quality of micromanipulation. With advances in technology, however, he cautions not to forget safety issues.

Many years ago I did a study to look at the risk of laser hazards in the operating room, particularly in patients with airway lesions, he said. It was surprising to find out that experience with the CO₂ laser did not make you safer; it actually lulled people into complacency. Airway catastrophes still can occur and a laser fire in the airway is probably one of the more frightening things that a surgeon can experience.

Putting the laser aside, Dr. Fried believes that, in many physicians’ hands, the microdebrider has superseded the use of the laser in the operating room.

I find it a much more elegant way to remove papilloma and I find it is as effective as the CO₂ laser, he said. One thing that I have noticed is that sometimes the angulation of the microdebrider makes it very difficult to get anterior commissure submucosal disease. The trick is to bend the distal end of the microdebrider and that seems to work fine to remove the disease there.

Antiviral Issues

The bottom line when it comes to the treatment of RRP is that surgical removal is rarely curative, so physicians really need to look at something else to manage this devastating disease, according to Seth Pransky, MD, Assistant Clinical Professor of Otolaryngology-Head and Neck Surgery at the University of California, San Diego.

Some promising new therapies are coming down the pike but what we currently have, from an antiviral perspective, are interferon and intralesional cidofovir, Dr. Pransky said. Interferon is really one of our mainstays that goes back a ways. With interferon, what we get is a tremendously variable response rate, but there are adverse reactions; it’s a prolonged treatment protocol and there are significant concerns about rebound.