What is the treatment approach for a benign papilloma in the throat?

Treatment of Benign Papilloma in the Throat

Surgical excision is the primary treatment for benign papillomas of the throat, with repeated procedures often necessary due to the recurrent nature of these lesions, particularly in recurrent respiratory papillomatosis (RRP). 1, 2

Understanding the Disease

Benign throat papillomas are most commonly caused by HPV types 6 and 11, with RRP representing the most common benign neoplasm of the larynx in children and the second most frequent cause of childhood hoarseness. 2 These lesions, while histologically benign, can cause severe morbidity and even death due to airway obstruction. 2

Clinical Presentation to Recognize

• Primary symptoms: Hoarseness (most common), followed by stridor (initially inspiratory, then biphasic) 2
• Secondary symptoms: Chronic cough, recurrent pneumonia, failure to thrive, dyspnea, dysphagia, or acute respiratory distress 2
• Differential diagnoses to exclude: Asthma, croup, allergies, vocal nodules, or bronchitis 2

Primary Treatment Approach

Surgical Management

Repeated surgical debulking is the mainstay of treatment, with the goal of decreasing airway burden while preserving laryngeal function. 2 The specific surgical modalities include:

• Laser ablation: Effective for precise removal of papillomas while minimizing damage to surrounding tissue 3
• Electrocautery: Can physically destroy visible lesions in a single visit under local anesthesia 4
• Cryotherapy: Destroys lesions through thermal-induced cytolysis, effective for smaller lesions 4
• Conventional surgical excision: Recommended to ensure complete removal of infected epithelium and rule out dysplasia 4

Critical Surgical Principle

Complete removal of infected epithelium at the base of the lesion is crucial to prevent recurrence, as incomplete removal is the primary cause of lesion recurrence. 4

When to Consider Adjuvant Medical Therapy

Adjuvant medical therapy should be considered when surgical therapy is needed more frequently than four times in 12 months OR when there is evidence of RRP outside the larynx. 2

Adjuvant Options (None Curative)

While various adjuvant therapies have been investigated, none to date has "cured" RRP, and some carry serious side effects: 2

• Dietary supplements 2
• Control of extra-esophageal reflux disease 2
• Potent antiviral and chemotherapeutic agents 2
• Photodynamic therapy (PDT): Shows clearance rates of 66-95% with lower recurrence rates compared to conventional treatments 4
• Intralesional interferon: Has comparable efficacy but is not recommended for routine use due to administration route and systemic side effects 4

Special Considerations and Pitfalls

Age-Related Disease Severity

Younger age at diagnosis is associated with more aggressive disease and the need for more frequent surgical procedures. 2 Juvenile-onset RRP (JORRP) typically requires a median of 13 lifetime surgeries to maintain an open airway. 1

Malignant Transformation Risk

While rare, papillomas can transform to carcinoma, particularly in the larynx, esophagus, and bronchi. 1 Condylomata harboring high-risk HPV genotypes (16 and 18) are associated with increased risk for dysplasia and squamous cell carcinoma development, especially in immunosuppressed individuals. 4

Infection Control During Procedures

Intact HPV DNA can be isolated from vapor plume during laser or electrosurgery procedures. 1 Recommendations to minimize transmission risk include:

• Use of tight-fitting masks with small pore sizes 1
• Dedicated smoke evacuators 1
• Full barrier clothing (gowns, gloves, masks, eye shields) 1

Follow-Up Strategy

Regular follow-up is mandatory to monitor for recurrence and potential malignant transformation, particularly in immunosuppressed patients. 4 New lesions may appear due to continued reinfection or transition of subclinical lesions to clinical lesions. 4

Recurrence Patterns

Recurrence of warts is unusual after proper treatment with complete epithelial removal, but approximately 30% of anogenital warts recur whether clearance occurs spontaneously or following treatment. 1

Prevention Considerations

The quadrivalent HPV vaccine (covering types 6,11,16, and 18) has potential to reduce the incidence of RRP, as approximately 90% of anogenital warts and RRP cases are associated with HPV types 6 and 11. 1, 2