eMedicine Specialties > Pulmonology > Lung Tumors

Recurrent Respiratory Papillomatosis: Differential Diagnoses & Workup

Author: Eloise M Harman, MD, Professor, Department of Internal Medicine, Division of Pulmonary and Critical Care, University of Florida College of Medicine
Contributor Information and Disclosures

Updated: Mar 6, 2008

Differential Diagnoses

Benign Lung Tumors
Foreign Body Aspiration
Gastroesophageal Reflux Disease
Malingering
Polychondritis
Secondary Lung Tumors

Other Problems to Be Considered

Squamous cell lung cancer
Benign laryngeal or tracheal tumors
Malignant laryngeal or tracheal tumors
Laryngeal infection
Vocal cord dysfunction
Reflux
Relapsing polychondritis
Tracheomalacia
Subglottic stenosis
Vocal cord paralysis

Workup

Laboratory Studies

Once the physician diagnoses RRP via laryngoscopy or bronchoscopy, typing of the virus may be helpful for determining prognosis. This may be accomplished by polymerase chain reaction on fresh tissue. As noted, HPV-11 is associated with more severe disease and, possibly, with a greater risk of malignant transformation.

Imaging Studies

Chest radiographs rarely may reveal an intratracheal density. This may be observed best on the lateral view. In the uncommon instance of distal bronchial involvement, chest radiographs may reveal segmental or lobar atelectasis or postobstructive pneumonia. Nodules or cystic lesions on chest radiographs provide evidence of pulmonary parenchymal involvement.

CT scans of the upper airway may be helpful in revealing the tumorlike papillomatous growths on the larynx or in the trachea.

Other Tests

Pulmonary function studies may be helpful in suggesting the presence of upper airway obstruction. The flow-volume loop may show the characteristic flattening of the inspiratory limb, suggesting variable extrathoracic upper airway obstruction or flattening of both the inspiratory and expiratory limbs if the upper airway obstruction is fixed.

Procedures

Laryngoscopy or bronchoscopy findings provide confirmation of the diagnosis of RRP. Confirmation in patients presenting with hoarseness or voice change requires visualization of the vocal cords. Because laryngeal involvement occurs in more than 95% of patients, direct laryngoscopy reveals the characteristic warty growths. Rarely, the trachea is involved without laryngeal lesions, and bronchoscopy may be required for diagnosis. These procedures reveal the characteristic cauliflowerlike warty growths.

Obtaining a biopsy specimen of visualized lesions is essential for histologic confirmation of respiratory papillomatosis. Biopsy is necessary both for viral typing and for histologic examination to rule out malignant transformation. Atypical histologic features often are noted, sometimes making the diagnosis of malignant transformation difficult.

Histologic Findings

Under low power, the lesion has a papillary appearance. This results from the exophytic growth of keratinized squamous epithelium overlying a fibrovascular core. Koilocytes, vacuolated cells with clear cytoplasmic inclusions, are noted and are indicative of viral infection. Metaplasia and dysplasia occur in varying degrees.

More on Recurrent Respiratory Papillomatosis

Overview: Recurrent Respiratory Papillomatosis
Differential Diagnoses & Workup: Recurrent Respiratory Papillomatosis
Treatment & Medication: Recurrent Respiratory Papillomatosis
Follow-up: Recurrent Respiratory Papillomatosis
Multimedia: Recurrent Respiratory Papillomatosis
References
[ CLOSE WINDOW ]

References

  1. Kosko JR, Derkay CS. Role of cesarean section in prevention of recurrent respiratory papillomatosis--is there one?. Int J Pediatr Otorhinolaryngol. Mar 1996;35(1):31-8. [Medline].

  2. Shah KV, Stern WF, Shah FK, Bishai D, Kashima HK. Risk factors for juvenile onset recurrent respiratory papillomatosis. Pediatr Infect Dis J. May 1998;17(5):372-6. [Medline].

  3. Armstrong LR, Derkay CS, Reeves WC. Initial results from the national registry for juvenile-onset recurrent respiratory papillomatosis. RRP Task Force. Arch Otolaryngol Head Neck Surg. Jul 1999;125(7):743-8. [Medline].

  4. Bishai D, Kashima H, Shah K. The cost of juvenile-onset recurrent respiratory papillomatosis. Arch Otolaryngol Head Neck Surg. Aug 2000;126(8):935-9. [Medline].

  5. Chhetri DK, Shapiro NL. A scheduled protocol for the treatment of juvenile recurrent respiratory papillomatosis with intralesional cidofovir. Arch Otolaryngol Head Neck Surg. Oct 2003;129(10):1081-5. [Medline].

  6. Derkay C; Multi-Disciplinary Task Force on Recurrent Respiratory Papillomas. Cidofovir for recurrent respiratory papillomatosis (RRP): a re-assessment of risks. Int J Pediatr Otorhinolaryngol. Nov 2005;69(11):1465-7. [Medline].

  7. Lee AS, Rosen CA. Efficacy of cidofovir injection for the treatment of recurrent respiratory papillomatosis. J Voice. Dec 2004;18(4):551-6. [Medline].

  8. Shehab N, Sweet BV, Hogikyan ND. Cidofovir for the treatment of recurrent respiratory papillomatosis: a review of the literature. Pharmacotherapy. Jul 2005;25(7):977-89. [Medline].

  9. Higdon JV, Delage B, Williams DE, Dashwood RH. Cruciferous vegetables and human cancer risk: epidemiologic evidence and mechanistic basis. Pharmacol Res. Mar 2007;55(3):224-36. [Medline].

  10. Rosen CA, Bryson PC. Indole-3-carbinol for recurrent respiratory papillomatosis: long term results. J of Voice. 2003;18:248-53.

  11. Healy GB, Gelber RD, Trowbridge AL, Grundfast KM, Ruben RJ, Price KN. Treatment of recurrent respiratory papillomatosis with human leukocyte interferon. Results of a multicenter randomized clinical trial. N Engl J Med. Aug 18 1988;319(7):401-7. [Medline].

  12. Leventhal BG, Kashima HK, Mounts P, Thurmond L, Chapman S, Buckley S, et al. Long-term response of recurrent respiratory papillomatosis to treatment with lymphoblastoid interferon alfa-N1. Papilloma Study Group. N Engl J Med. Aug 29 1991;325(9):613-7. [Medline].

  13. Shikowitz MJ, Abramson AL, Freeman K, Steinberg BM, Nouri M. Efficacy of DHE photodynamic therapy for respiratory papillomatosis: immediate and long-term results. Laryngoscope. Jul 1998;108(7):962-7. [Medline].

  14. Endres DR, Bauman NM, Burke D, Smith RJ. Acyclovir in the treatment of recurrent respiratory papillomatosis. A pilot study. Ann Otol Rhinol Laryngol. Apr 1994;103(4 Pt 1):301-5. [Medline].

  15. Lippman SM, Donovan DT, Frankenthaler RA, Weber RS, Earley CL, Hong WK, et al. 13-Cis-retinoic acid plus interferon-alpha 2a in recurrent respiratory papillomatosis. J Natl Cancer Inst. Jun 1 1994;86(11):859-61. [Medline].

  16. Freed GL, Derkay CS. Prevention of recurrent respiratory papillomatosis: role of HPV vaccination. Int J Pediatr Otorhinolaryngol. Oct 2006;70(10):1799-803. [Medline].

  17. Shapiro AM, Rimell FL, Shoemaker D, Pou A, Stool SE. Tracheotomy in children with juvenile-onset recurrent respiratory papillomatosis: the Children's Hospital of Pittsburgh experience. Ann Otol Rhinol Laryngol. Jan 1996;105(1):1-5. [Medline].

  18. Andrus JG, Shapshay SM. Contemporary management of laryngeal papilloma in adults and children. Otolaryngol Clin North Am. Feb 2006;39(1):135-58. [Medline].

  19. Avidano MA, Singleton GT. Adjuvant drug strategies in the treatment of recurrent respiratory papillomatosis. Otolaryngol Head Neck Surg. Feb 1995;112(2):197-202. [Medline].

  20. Baker GE, Tyring SK. Therapeutic approaches to papillomavirus infections. Dermatol Clin. Apr 1997;15(2):331-40. [Medline].

  21. Burns JA, Zeitels SM, Akst LM, Broadhurst MS, Hillman RE, Anderson R. 532 nm pulsed potassium-titanyl-phosphate laser treatment of laryngeal papillomatosis under general anesthesia. Laryngoscope. Aug 2007;117(8):1500-4. [Medline].

  22. Chadha NK, James AL. Antiviral agents for the treatment of recurrent respiratory papillomatosis: a systematic review of the English-language literature. Otolaryngol Head Neck Surg. Jun 2007;136(6):863-9. [Medline].

  23. Derkay CS, Smith RJ, McClay J, van Burik JA, Wiatrak BJ, Arnold J, et al. HspE7 treatment of pediatric recurrent respiratory papillomatosis: final results of an open-label trial. Ann Otol Rhinol Laryngol. Sep 2005;114(9):730-7. [Medline].

  24. Green GE, Bauman NM, Smith RJ. Pathogenesis and treatment of juvenile onset recurrent respiratory papillomatosis. Otolaryngol Clin North Am. Feb 2000;33(1):187-207. [Medline].

  25. Hawkes M, Campisi P, Zafar R, Punthakee X, Dupuis A, Forte V, et al. Time course of juvenile onset recurrent respiratory papillomatosis caused by human papillomavirus. Pediatr Infect Dis J. Feb 2008;27(2):149-54. [Medline].

  26. Kimberlin DW. Current status of antiviral therapy for juvenile-onset recurrent respiratory papillomatosis. Antiviral Res. Sep 2004;63(3):141-51. [Medline].

  27. Kimberlin DW, Malis DJ. Juvenile onset recurrent respiratory papillomatosis: possibilities for successful antiviral therapy. Antiviral Res. Feb 2000;45(2):83-93. [Medline].

  28. Mouadeb DA, Belafsky PC. In-office laryngeal surgery with the 585nm pulsed dye laser (PDL). Otolaryngol Head Neck Surg. Sep 2007;137(3):477-81. [Medline].

  29. Naiman AN, Ceruse P, Coulombeau B, Froehlich P. Intralesional cidofovir and surgical excision for laryngeal papillomatosis. Laryngoscope. Dec 2003;113(12):2174-81. [Medline].

  30. Pasquale K, Wiatrak B, Woolley A, Lewis L. Microdebrider versus CO2 laser removal of recurrent respiratory papillomas: a prospective analysis. Laryngoscope. Jan 2003;113(1):139-43. [Medline].

  31. Pransky SM, Magit AE, Kearns DB, Kang DR, Duncan NO. Intralesional cidofovir for recurrent respiratory papillomatosis in children. Arch Otolaryngol Head Neck Surg. Oct 1999;125(10):1143-8. [Medline].

  32. Preuss SF, Klussmann JP, Jungehulsing M, Eckel HE, Guntinas-Lichius O, Damm M. Long-term results of surgical treatment for recurrent respiratory papillomatosis. Acta Otolaryngol. Nov 2007;127(11):1196-201. [Medline].

  33. Rady PL, Schnadig VJ, Weiss RL, Hughes TK, Tyring SK. Malignant transformation of recurrent respiratory papillomatosis associated with integrated human papillomavirus type 11 DNA and mutation of p53. Laryngoscope. May 1998;108(5):735-40. [Medline].

  34. Rimell FL, Shoemaker DL, Pou AM, Jordan JA, Post JC, Ehrlich GD. Pediatric respiratory papillomatosis: prognostic role of viral typing and cofactors. Laryngoscope. Jul 1997;107(7):915-8. [Medline].

  35. Schraff S, Derkay CS, Burke B, Lawson L. American Society of Pediatric Otolaryngology members' experience with recurrent respiratory papillomatosis and the use of adjuvant therapy. Arch Otolaryngol Head Neck Surg. Sep 2004;130(9):1039-42. [Medline].

  36. Soma MA, Albert DM. Cidofovir: to use or not to use?. Curr Opin Otolaryngol Head Neck Surg. Feb 2008;16(1):86-90. [Medline].

  37. Stamataki S, Nikolopoulos TP, Korres S, Felekis D, Tzangaroulakis A, Ferekidis E. Juvenile recurrent respiratory papillomatosis: still a mystery disease with difficult management. Head Neck. Feb 2007;29(2):155-62. [Medline].

  38. Wiatrak BJ. Overview of recurrent respiratory papillomatosis. Curr Opin Otolaryngol Head Neck Surg. Dec 2003;11(6):433-41. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

RRP, juvenile-onset recurrent respiratory papillomatosis, JORRP, adult-onset recurrent respiratory papillomatosis, AORRP, human papilloma virus, HPV, human papillomavirus, airway obstruction, voice change, warts, sexually transmitted diseases, STDs

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Eloise M Harman, MD, Professor, Department of Internal Medicine, Division of Pulmonary and Critical Care, University of Florida College of Medicine
Eloise M Harman, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Chest Physicians, American Medical Women's Association, American Thoracic Society, Phi Beta Kappa, and Sigma Xi
Disclosure: Nothing to disclose.

Medical Editor

Sat Sharma, MD, FRCPC, Professor and Head, Division of Pulmonary Medicine, Department of Internal Medicine, University of Manitoba; Site Director, Respiratory Medicine, St Boniface General Hospital
Sat Sharma, MD, FRCPC is a member of the following medical societies: American Academy of Sleep Medicine, American College of Chest Physicians, American College of Physicians-American Society of Internal Medicine, American Thoracic Society, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada, Royal Society of Medicine, Society of Critical Care Medicine, and World Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Harold L Manning, MD, Associate Professor, Departments of Medicine, Anesthesiology and Physiology, Section of Pulmonary and Critical Care Medicine, Dartmouth Medical School
Harold L Manning, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and American Thoracic Society
Disclosure: Nothing to disclose.

CME Editor

Timothy D Rice, MD, Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, Saint Louis University School of Medicine
Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians
Disclosure: Nothing to disclose.

Chief Editor

Zab Mosenifar, MD, Director, Division of Pulmonary and Critical Care Medicine, Director, Women's Guild Pulmonary Disease Institute, Executive Vice Chair, Department of Medicine, Cedars Sinai Medical Center; Professor of Medicine, David Geffen School of Medicine at UCLA
Zab Mosenifar, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, and American Thoracic Society
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.