Voice Disorders - Papilloma

Voice Medicine by Lucian Sulica, MD

Voice Medicine by Lucian Sulica, MD

Voice Medicine by Lucian Sulica, MD

Voice Disorders

Figure 1: This magnified operating room view (upside down from the other photographs) shows the typical stippled appearance of a bulky Papilloma on the left vocal fold.

Figure 2: This single papilloma in an adult resembles a polyp in appearance. It did not come back following surgical removal

Figure 3: The large papilloma on the vocal fold on the right is accompanied by more smaller papillomas over both vocal folds, seen as smooth bulges. This person has already had two surgeries.

What is papilloma?

A papilloma is a warty growth of the larynx caused by a virus. Different types of the same family of viruses cause similar growths elsewhere in the body. The papilloma virus is probably transmitted from person to person by intimate contact. However, not everyone with who comes into contact with the virus will develop papillomas, and it may be that some people carry the virus unwittingly without developing growths, so understanding transmission is not straightforward. The growth of the lesions of papilloma probably represents an interaction between the virus and a susceptibility in a given person’s immune system. Voice use has no bearing on the formation of papillomas.

Papilloma is best known as a disease of young children, many of whom appear to be infected by passage through the birth canal (genital warts are caused by a papilloma virus). However, it can also affect adults. In adults, it is generally less aggressive than in children, meaning that papillomas grow slower and are less likely to grow outside of the larynx.

Like warts, papillomas are very resilient lesions which tend to grow back no matter how completely they are removed.

What are the symptoms of papilloma?

Papilloma generally causes painless hoarseness, roughly in proportion to its size and bulk. If allowed to grow unchecked, it may block the airway.

What does papilloma look like?

Papilloma has a characteristic appearance of a stippled mass, not unlike a raspberry. These surface irregularities, called papillae, give the growth its name.

Figure 1: This magnified operating room view (upside down
from the other photographs) shows the typical stippled
appearance of a bulky Papilloma on the left vocal fold.

Papilloma is a surface lesion, which grows outward from the mucosa

. For reasons unknown, human papilloma virus seems to prefer the mucosa of the vocal fold, although lesions can and do grow on surrounding surfaces. In adults, papilloma may be confined to a single area of the vocal fold, and grow mimicking the appearance of a polyp, or it may extend over the entire surface of one, or even both vocal folds.

Figure 2: This single papilloma in an adult resembles a polyp in
appearance. It did not come back following surgical removal.
Figure 2: This single papilloma in an adult resembles a polyp in appearance. It did not come back following surgical removal

In very rare cases, usually when there is immune disease, papilloma may extend outside of the larynx to involve the mouth, the throat and the lungs. There have been reports of papilloma turning into cancer, but this is also a rare event.

Figure 3: The large papilloma on the vocal fold on the right is accompanied
by more smaller papillomas over both vocal folds, seen as
smooth bulges. This person has already had two surgeries.
Figure 3: The large papilloma on the vocal fold on the right is accompanied by more smaller papillomas over both vocal folds, seen as smooth bulges. This person has already had two surgeries.

Figure 3: The large papilloma on the vocal fold on the right is accompanied by more smaller papillomas over both vocal folds, seen as smooth bulges. This person has already had two surgeries.

How is papilloma treated?

There is no reliable cure for papilloma. Surgery, which remains the mainstay of treatment, is used to keep the disease in check, but regrowth of papillomas is usually the rule, no matter how complete the excision. In some cases of disease in adults, particularly if the disease is limited to one site in the larynx, papilloma may disappear after one or a few surgical removals. This is probably due to a person’s own immune system mounting an effective defense against recurrence.

Because surgery does not cure papillomatosis, functional considerations, like voice quality, remain relevant in the operating room. There is often nothing to be gained from an aggressive resection that irreversibly compromises voice. Also, papillomatosis is a superficial disease. A surgery that removes deep tissue with the laser is not necessary and can cause damage.

If the disease recurs, repeat surgery is determined by disease bulk and impairment to voice. In people with widespread disease across the larynx, there is generally little reason to re-operate for each small area of recurrence, if it is not causing symptoms. This may be difficult for an affected person to accept, but operating more often does not affect the overall course of the disease, and may unnecessarily expose a person to the risks of surgery and cumulative damage from scar. Because the mucosa of the vocal fold must be removed in the area of papilloma, healing often results in impaired vocal fold vibration (see Normal Voice Function). It is rare that extensive disease can be operated multiple times without some permanent change in voice.

In the case of person who genuinely requires frequent surgery (and it may be called for as often as every month or two in exceptional cases), it is reasonable to consider investigational therapy. Because of the frustrating nature of the disease, there are a wide variety of alternative and investigational treatments, some better tested than others. Currently, medical focus rests upon cidofovir, a drug used intravenously against other viruses. In papillomas, it is injected directly into the lesions, and appears to help retard recurrence in aggressive disease. In a few cases, it appears to have eliminated recurrence, and these people are being closely followed. Ideal dosing and frequency of administration are currently being investigated. Researchers are also looking into ways to modify a person’s immune system so that it can better fight the disease.

There are many other investigative treatments of varying merit. To discuss them all requires a website devoted to the topic. Fortunately, www.rrpwebsite.org is a well-designed source of information regarding papilloma, kept current and complete by its webmaster and the interaction of its members.

Cyst

Polyp

Reflux

Cancer

Tremor

Nodules

Papilloma

Laryngitis

Granuloma

Aging Voice

Hemorrhage

Sulcus Vocalis

Vocal Fold Scar

Reinke’s Edema

Vocal Fold Paralysis

Spasmodic Dysphonia

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