Recurrent Respiratory Papillomatosis Treatment & Management
- Author: Eloise M Harman, MD; Chief Editor: Zab Mosenifar, MD, FACP, FCCP more...
The goals of therapy are to relieve airway obstruction, improve voice quality, and facilitate remission. The primary treatment involves repeated surgical debulking, usually by means of microdebridement, angiolytic laser, cryotherapy, or carbon dioxide laser. This may be followed by an injection of cidofovir into the resection site in patients with moderate-to-severe disease. Compared with microdebridement and laser procedures, surgical resection may be associated with a higher risk of complications (eg, tracheal stenosis). Tracheostomy may be needed if significant airway obstruction occurs.
Because the disease is rare, large-scale trials of medical therapies have not been possible; however, several agents are available that appear to increase the intervals between need for resection. These include intralesional cidofovir,[12, 13, 14, 15] oral indole-3-carbinol,[16, 17] interferon,[18, 19, 20] and photodynamic therapy. Agents that demonstrate variable effect include acyclovir and retinoic acid.
The use of intralesional cidofovir in moderate-to-severe disease has been a major advance in the management of RRP. It is indicated if surgical debulking is required 6 or more times per year or every 2-3 months, and its administration must be guided by knowledge of safe dosing limits. With the increased use of intralesional cidofovir, interferon therapy is now infrequently used.
A quadrivalent vaccine for prevention of genital HPV infection was approved in 2006. This vaccine protects against HPV types 6, 11, 16, and 18 and therefore has promise for decreasing the incidence of RRP. Vaccine therapy for those already affected with HPV is under study. A bivalent vaccine for HPV is also available, but will not affect RRP incidence as it is protective against only HPV types 16 and 18.
Multiple resections are typical. Microdebridement of laryngeal lesions is often preferred to laser therapy. With anesthesia induction, take extreme care to maintain the already-compromised airway. The surgical team should be prepared for the possibility that emergency tracheostomy may be required. A survey of anesthesiologists regarding anesthesia techniques for patients undergoing laser procedures for RRP indicated the following preferences:
Laser-safe endotracheal tube (46%)
Jet ventilation (26%)
Apneic technique (16%)
Spontaneous ventilation (12%)
Preferred anesthetic agents - Halothane and propofol
Physicians may combine surgery with an injection of the surgical bed with medication that may slow regrowth. Cidofovir is effective in a significant proportion of patients and has replaced intralesional interferon.
The carbon dioxide laser previously was the preferred method for resection of papillomas because it affords good hemostasis and minimizes potential thermal injury of surrounding healthy tissues. The use of microdebridement using angled oscillating blades that incorporate suction and irrigation or the use of pulsed dye laser is now the preferred resection method at many centers. These offer the advantage of shorter operative times, potential for outpatient surgery, decreased risk to personnel, and avoidance of the risk of airway burns. These methods may also decrease recurrence rates. Repeat evaluation of the airway in newly diagnosed RRP may be required as frequently as every 2-4 weeks.
Photodynamic therapy, in small trials, has been shown to slow the rate of papilloma growth. Hematoporphyrins are taken up selectively by neoplastic cells and are used as photosensitizing agents for subsequent laser therapy. Dihematoporphyrin ether (DHE) usually is administered 2-3 days before surgery. Delivery of argon laser light to the affected area via laryngoscope or bronchoscope activates the drug.
The virus may be aerosolized during surgical procedures; therefore, staff should take particular care to wear goggles and a particulate barrier facemask or shield during procedures.
Consider participation in ongoing clinical trials of various therapies.
Animal studies and observational studies in patients with RRP indicate that a diet high in cruciferous vegetables (eg, cabbage, cauliflower, broccoli, Brussels sprouts) may have a favorable effect. Researchers hypothesize that indole-3-carbinol is the active agent in these vegetables. Treatment with indole-3-carbinol is beneficial for persons with RRP.
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