Laryngeal papillomatosis

Introduction

Juvenile onset recurrent respiratory papillomatosis (JORRP) is the commonest benign neoplasm of the larynx, with an estimated incidence of 4.3 per 100,000 children.1 It has an unpredictable and recurrent course. Laryngeal JORRP is particularly resistant to treatment often requiring multiple and frequent surgical procedures with enormous financial, physical and psychological implications on the patient and the family.2,3 Numerous medical and surgical modalities have been used to treat JORRP, but in the absence of adequate evidence or controlled trials assessing adjuvant treatments, it is now widely accepted that CO2 laser excision is the current treatment of choice for most cases of laryngeal disease.4,5 CO2 laser treatment is not without its risks however and multiple studies performed in the last two decades have described many complications.6,7,8 The most catastrophic is an airway fire with significant morbidity and mortality. The majority of these complications however are delayed and relate to post-operative scarring, stenosis and web formation. Following the identification of Human Papilloma Virus in the CO2 laser plume9 it is also thought that laser treatment may contribute to for the distal seeding of papillomas in the tracheo-bronchial tree. Once the distal airway is involved, tracheal ablation becomes even more difficult, requiring the use of a laser bronchoscope and testing the skills of both the otolaryngologist and anaethestist to an advanced degree. The laser bronchoscope is difficult to use: the airway is unprotected and the laser beam is almost tangential to the papillomas, increasing the risk of collateral damage and further papilloma propagation. This article deseribes two cases of advanced laryngo-tracheal papillomatosis. Radio-frequency ablation was used to good effect in the ablation of obstructing tracheal papillomas, thus avoiding much of the inherent risk associated with the use of CO2 laser bronchoscope.

Case Reports

Two men in their mid-twenties, both diagnosed with JORRP in their infant years, present for ablation of their tracheal papillomatosis following multiple previous treatments to their airway with CO2 laser.

a) Operative Technique

Both patients were treated under general anaesthesia in the otolaryngology operating theatre. They were oxygenated using jet ventilation. A long 0-degree Hopkin's Rod endoscope down a Storz C laryngoscope was used to provide excellent visualization of the lesions and a modified Arthrocare orthopaedic 3-electrode probe radiofrequency ablation device (coblator) was used to ablate the papillomas (Figure 1). Before each insertion into the airway, the wand tip was placed in saline to ensure the formation of a plasma conduction field. With the controller panel set to a power level between two and four (providing 800-1200J of energy), the tip of the wand was placed at a 90-degree angle to the papillomas to avoid collateral mucosal damage. It was activated using a foot pedal and the lesions were ablated until the underlying submucosa came into view. The distal lesions that could not be reached by the coblator were ablated using the CO2 laser bronchoscope. Post-operatively the patients were observed overnight in a routine surgical ward and were discharged to home the following morning.

b) Patient 1

A 25 year old man diagnosed with JORRP at age 2, had undergone 77 CO2 laser treatments to papillomas involving his larynx and nasal septum prior to presenting for radiofrequency ablation. These treatments were at approximately at three month intervals. The complications he experienced as a consequence of the lasering were scarring of both cords and posterior inter-arytenoid space and anterior and posterior glottic webs. One treatment episode had to be abandoned after the patient developed bronchospasm. For the past 8 years, papillomata had been present in his upper trachea (up to 4cm below the vocal cord) and required intermittent laser ablation to prevent airway obstruction. With the patient under general anaesthesia, it was evident that he had extensive papillomatosis involving 270 of the anterior trachea from 1-4cm below the vocal cords (Figure 2). The lower trachea and main bronchi appeared clear of papillomata. The coblator device was used to debulk the superior tracheal papillomata and the supraglottic tracheal papillomata. The post-operative appearance is shown in

Figure 3. Subsequent procedures have demonstrated a dramatic reduction in disease recurrence and an extended time period between ablation sessions.

c) Patient 2

The second patient, a 26-year old man, had undergone 56 treatment episodes with CO2 laser since his initial diagnosis with JORRP at age 3. His disease was more widespread with most of his airway affected from the base of the epiglottis to the entrance of the right main bronchus. He also suffered several complications during the treatments including, bilateral pneumothoraces, proximal tracheal strictures, delayed bronchospasm and an asystolic cardiac arrest. At this presentation, suspension laryngoscopy revealed a largely unaffected larynx but massive circumferential papillomata in the trachea with less than 10% of the lumen visible (Figure 4). The Coblator was used for the proximal lesions and the CO2 laser delivering, a continuous beam of 5 watts in energy was used for the distal "out of reach" lesions. Figure 5 demonstrates post-operative appearances prior to the lasering of the distal lesions. Again, subsequent procedures demonstrated a reduction in papilloma regrowth.

Discussion

Radiofrequency ablation is now used for the treatment of a variety of otolaryngological conditions including obstructive sleep apnoea10, recurrent tonsillitis", turbinate hypertrophy12 and benign tumours of the head and neck.13 The coblation device used in the treatment of the above two patients differs from most electrosurgical techniques in that it is a controlled non-heat driven process. The energy generated using radiofrequency ablation does not come from the probe but rather from vibrations it generates within the cells.13 These intracellular vibrations have sufficient energy to break organic molecular bonds and in doing so cause denaturing of local proteins without damaging the surrounding tissue. This combined with the rapid dissipation of energy from the radiofrequency probe in a ratio inverse to the radius4,14 allows for very precise tissue ablation with a cooler tissue effect than that occurs following other methods of tissue ablation.

The use of radiofrequency tissue ablation (RFA) in the treatment of tracheal papillomatosis offers several advantages over the CO2 laser. It is easy to use, creates lower surface temperatures, avoids the risk of laser fires, ablates the tissue more precisely and minimizes collateral and distal tissue damage, all problems identified with the use of the CO2 laser. Another theoretical advantage of RFA is that it denatures viral proteins without a plume and its by products are elementary molecules and low molecular weight inert gases. Thus the risk of distal airway seeding of viral particles, seen with the CO2 laser may also be abolished. Further experimental and clinical studies need to be performed before this theoretical advantage can be confirmed. RFA also appears to extend the time between surgical treatments, although more cases will be needed to substantiate this claim. The disadvantages of this modality however are the current lack of a specific probe for tracheal work and the longer time taken to complete the procedure. The probe used in the above two cases was originally designed for orthopaedic use in the ablation of knee menisci and only reaches to 5 cm below the vocal cords. It therefore cannot be used to ablate papillomas in the distal half of the trachea. Work is currently underway with the manufacturers to design a longer probe. The second disadvantage mentioned of longer intra-operative treatment time would more than likely improve as the learning curve advances.

Although this technique has not yet been used for the treatment of laryngeal papillomas, if the local tissue injury and oedema can be shown to be comparable to or less than that of the CO2 laser, treatment of isolated laryngeal disease would also be possible, and probably less technically difficult than the tracheal procedures as described in this paper.

Numerous other adjuvant treatments have been advocated for the treatment of advanced respiratory papillomatosis, including the use of systemic and intralesional antiviral agents15,16, interferon4, indol-3-carbinol17 and photodynamic therapy18. Despite these advances, local ablation of obstructing papillomas continues to be required for the treatment of patients unfortunate to have tracheobronchial disease. The need for multiple procedures over a patient's lifetime substantially increases the chances of a local tissue or laser complication. As such, if the length of time between procedures can be extended and a safer method of ablating papillomas exists, radiofrequency ablation may emerge as a very real contender to CO2 laser therapy for the treatment of patients with advanced recurrent respiratory papillomatosis.

References

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15. Snoeck R, Wellens W, Desloovere C. Treatment of severe laryngeal papillomatosis with intralcsional injections of Cidovidir. J Med Virol 1998; 54:219-225.

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17. Rosen CA, Woodson GE, Thompson JW, Hengesteg AP, Bradlow HL. Preliminary results of the use of indole-3-carbinol for recurrent respiratory papillomatosis. Otolaryngol Head and Neck Surg 1998;118:810-8I5.

18. Abramson AL, Shikowitz MJ, Mullooly VM Steinberg BM, Asmella CA, Rothstein HR. Variable Light-Dose Effect on Photodynamic Therapy for Laryngeal Papillomas. Arch Otolaryngol, Head and Neck Surg 1998; 120: 852-855.

ALKIS PSALTIS and A. SIMON CARNEY

Flinders Medical Centre and Flinders University

Adelaide

South Australia

Alkis Psaltis, M.B.B.S.(Hons)

A. Simon Carney, M.B.Ch.B., B.Sc., F.R.C.S.(Orl), F.R.A.C.S.

Department of Otolaryngology,

Flinders Medical Centre and Flinders University

Adelaide, South Australia

Correspondence to:

Dr A. Simon Carney

Flinders Medical Centre

Bedford Park, South Australia 5042

E-mail: scarney@ent-surgery.com

Tel: 0401 051 183

Fax: (08) 8204 5843

Copyright Australian Society of Otolaryngology Head & Neck Surgery Ltd. Dec 2003
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