Suspect Adult Respiratory Papillomatosis with Recurrent Hoarseness after Surgery

Dr. Rosen agreed. “The only suspicious item in the history would be repeat surgery with rapid recurrence of hoarseness,” he said. “That’s a tip-off.”

With any report of hoarseness, the otolaryngologist should next view the vocal apparatus with either a laryngoscope or with videostroboscopy. In the patient with papillomatosis, the view on the fiberoptic scope will show multiple lesions with grapelike projections on the vocal cords. The lesions will typically be on the true vocal folds, the intraglottis, and the supraglottic structures. “Each little projection has its own blood vessel,” Dr. Simpson said. “A lot of times you’ll see something that looks like a target, because the vessel creates a dot in the center. When you see multiple red dots inside circular lesions, it’s almost always papilloma. Multiple lesions and a target on the end of the lesion are the telltale signs.”

“The most important issue is how the larynx looks on physical exam,” Dr. Rosen said. “There are a variety of ways papilloma can look: bulky, exophytic, or superficial spreading.” He agreed with small Dr. Simpson that the characteristic that identifies papilloma is the blood vessel in the center of each of the lesions.

“Adult respiratory papillomatosis is going to be a much less aggressive course than what otolaryngologists are used to seeing with children.” – —Blake Simpson, MD

Although viewing such lesions will lead to a strong suspicion of papilloma, the otolaryngologist will typically obtain a biopsy with forceps and either send the specimen to the pathologist or do a frozen section in the operating room. “Squamous cell carcinoma can resemble papilloma, so you really can’t go forward until the diagnosis is confirmed,” Dr. Simpson said.

Choices for Removal

When the papilloma diagnosis has been confirmed, the lesions can be removed by several methods, including laser, microdebriding, and forceps. “There is no clear consensus regarding the best ways to remove papilloma lesions,” Dr. Simpson said. “There are a lot of ways to remove them correctly with good results, so the means of removal depends on what you’re comfortable with.”

Although he has used a CO₂ laser to remove papilloma lesions, Dr. Simpson primarily uses a microdebrider or shaver, which shaves off the lesion. “The CO₂ laser vaporizes the tissue,” he said. “If used improperly, it can cause damage from heating up of the surrounding tissue and can lead to scarring. Therefore, many people think the microdebrider is safer because it’s a cold instrument.” The microdebrider may also be less expensive, more accessible in settings without a CO₂ laser, and it avoids the risk of laser fire.