What is the most likely cause of dysphonia and mild stridor in a patient 1 month after laser treatment for Respiratory Papillomatosis (RP)?

Most Likely Cause: Recurrence of Papilloma

The most likely cause of dysphonia and mild stridor in this 10-year-old child one month after laser treatment for respiratory papillomatosis is recurrence of papilloma (option b). This represents the expected natural history of this disease rather than a complication of treatment.

Rationale for Recurrent Papilloma as Primary Diagnosis

Disease Characteristics Support Recurrence

• Recurrent respiratory papillomatosis (RRP) is inherently recurrent by definition, as the causative human papillomavirus (HPV types 6 and 11) persists in adjacent normal-appearing mucosa even after surgical removal 1
• Surgery for RRP is unlikely to be curative because the viral reservoir remains in surrounding tissue 1
• Younger age at diagnosis is associated with more aggressive disease and the need for more frequent surgical procedures 2
• The typical presentation of RRP includes hoarseness (dysphonia) as the most common symptom, followed by stridor 2

Timeline Consistent with Recurrence

• One month post-operatively is a plausible timeframe for papilloma regrowth to become symptomatic
• When surgical therapy is needed more frequently than four times in 12 months, this indicates aggressive disease requiring consideration of adjuvant medical therapy 2

Why Laryngeal Web is Less Likely

Webs Typically Cause Different Clinical Scenarios

• While laryngeal webs can occur as a complication of repeated laser surgery, they are more commonly associated with extensive or repeated surgical trauma rather than a single procedure one month prior 3
• One case report documented web formation only after repeated suction diathermy and later laser treatment, suggesting multiple procedures are typically required 3
• The guideline emphasizes that every effort must be made to avoid injury to underlying vibratory layers during RRP surgery specifically to prevent long-term dysphonia from scar formation 1

Clinical Presentation Differs

• A laryngeal web would more likely present with immediate post-operative symptoms or progressive worsening from scarring, rather than new-onset symptoms at one month
• The combination of dysphonia AND stridor is classic for papilloma recurrence 2, 4

Critical Management Implications

Immediate Evaluation Required

• Laryngoscopy should be performed promptly given the presence of stridor, which indicates potential airway compromise 1
• Respiratory distress or stridor warrants expedited laryngeal evaluation regardless of recent surgical history 1

Expected Disease Course

• This patient likely requires recurring surgical ablation as part of ongoing disease management 4
• The recurrent nature of this condition necessitates long-term surveillance and repeated interventions 5, 2

Common Pitfall to Avoid

Do not assume post-operative complications when dealing with RRP—the disease itself is characterized by recurrence, and new symptoms after surgery most commonly represent disease progression rather than surgical complications. The name "recurrent respiratory papillomatosis" reflects this fundamental characteristic 1, 2.