Recurrent Respiratory Papillomatosis Surgery Workup

Updated: Oct 13, 2016
  • Author: John E McClay, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Workup

Laboratory Studies

Laboratory studies for recurrent respiratory papillomatosis (RRP) do not exist, although biopsies of the papillomas themselves can be tested to determine the type of human papillomavirus (HPV) present. Some reports indicate that human papillomavirus (HPV) type 11 may be more aggressive than human papillomavirus (HPV) type 6; however, that is debatable.

Currently, no clinical reason exists to type human papillomavirus (HPV). Routinely or occasionally, however, obtaining a biopsy of the papilloma evaluated is important to detect squamous metaplasia or progression to carcinoma.

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Imaging Studies

If any papilloma is diagnosed on flexible fiberoptic nasopharyngoscopy, no imaging studies are necessary for initial diagnosis.

For children with airway obstructive symptoms for which no lesion is observed in the glottic larynx, certain imaging studies can be obtained for diagnosis of airway obstructive lesions of the trachea.

Fluoroscopy with barium swallow can be used to diagnose gastroesophageal reflux disease (GERD) and vascular abnormalities that compromise the trachea or esophagus. This test may also help diagnose dynamic or static tracheal stenosis.

Bronchoscopy is the single best diagnostic tool to initially evaluate a child in respiratory distress who has no lesion in the larynx.

CT scanning and MRI are not good initial imaging evaluators for a child with airway distress. For children with distal spread of papillomas into the trachea and bronchus, a CT scan of the chest is an appropriate method to evaluate for pulmonary disease.

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Diagnostic Procedures

The diagnostic procedure of choice for recurrent respiratory papillomatosis (RRP) is initial flexible laryngoscopy in the clinic. If this is not diagnostic, the secondary diagnostic procedure of choice is a rigid bronchoscopy in the operating room with biopsy of the lesion.

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Histologic Findings

The histologic appearance of laryngeal papillomas is characterized by papillary fronds of multilayered benign squamous epithelium that contain fibrovascular cores. No surface keratinization is observed. Koilocytes (vacuolated cells with clear cytoplasmic inclusions that signal presence of viral infection) are observed.

Biopsies for histologic evaluation taken during surgical excision should occur frequently enough to detect squamous metaplasia, dysplasia, or conversion to squamous cell carcinoma (SCC). The exact timing of biopsy intervals is not well documented. Surgical patterns of biopsy range from taking a biopsy during every surgical procedure to never taking a biopsy because the diagnosis is already known.

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Staging

A uniform staging system for laryngeal or tracheal papilloma does not exist. Both Kashima and Wiatrak have proposed staging systems to quantify disease for comparison of treatments. [11] Many studies evaluating medical therapy have their own internal scale or staging system.

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