A case of squamous papilloma after uvulopalatopharyngoplasty.

Abstract

We report the case of an adult who developed an isolated-solitary papilloma on the margin of the soft palate 1 month after he had undergone a uvulopalatopharyngoplasty. We describe the clinical and cellular characteristics of this common lesion.

Introduction

Squamous papillary neoplasia are common in the upper aerodigestive tract. They include a spectrum of benign epithelial proliferations, which can appear at any mucosal site of the upper aerodigestive tract. [2]

Case report

A45 -year-old man underwent uvulopalatopharyngoplasty (UPPP) to correct upper airway resistance syndrome and heavy snoring, both of which were confirmed by a sleep study. His medical history included a tonsillectomy. He did not smoke or abuse alcohol.

Surgery was performed by the usual technique, and there were no complications. One week after surgery, the palate had healed and the four remaining absorbable Vicryl sutures were removed.

During a followup visit 1 month after surgery, an exophytic solitary lesion was noted on the margin of the soft palate on the left side of the UPPP incision (figure). Fiberoptic endoscopy did not reveal any other lesions in the upper aerodigestive tract. A biopsy was performed under local anesthesia. The histopathologic examination revealed a squamous papilloma. The lesion was treated with [CO.sup.2] laser ablation. The patient was reexamined 2 months later, and no persistent or recurrent lesions could be identified in any part of the upper aerodigestive tract.

Discussion

In the oral cavity, the most common locations of squamous papillary neoplasia are the surfaces of the hard and soft palates, the lips, and the tongue. [2,3] Because some forms of mucosal change have a gross exophytic or papillary appearance that can be confused with papillary neoplasia, some authors reserve the term papilloma to describe a squamous mucosal proliferation with an exophytic growth pattern. [1] Most oral pathology texts define squamous papilloma as a benign epithelial neoplasia. However, some authors speculate that this condition might actually be a reaction of the tissue to injury rather than a true neoplasia. Others have suggested that a disturbed mucociliary clearance with squamous metaplasia could be involved in its etiology. [4] In recent years, a connection has been clearly established between human papillomavirus (HPV) and the development of squamous papilloma. [1,2,4] The primary means of HPV transmission to children is the ingestion of viral particles of infected cells from the birth can al, whereas in adults HPV is mainly transmitted through sexual contact.

Squamous papillomas are traditionally divided into two types: isolated-solitary and multiple-recurring. The former is usually found in an adult's oral cavity, while the latter is mostly found in a child's laryngotracheobronchial complex.

The isolated-solitary lesions are exophytic, pedunculated growths that resemble a cauliflower in appearance. They are usually white, occasionally pink. Histologically, they feature numerous finger-like projections of squamous epithelium, and their surface is composed of keratin. Cellular atypia and mitoses are not common, but when they are detected, a papillary carcinoma should be suspected. DNA analysis reveals a diploid pattern. Multiple-recurring papillomas appear to be associated with cytologic atypia and abnormal DNA content. Malignant transformation of a papilloma is more common in the multiple-recurring type.

Isolated-solitary papillomas occur mostly between the ages of 30 and 50. They have a slight predilection toward men, and they are five times more common among whites than blacks. Treatment options include surgical excision, electrocautery, cryosurgery, laser ablation, cytotoxic agents, and systemic or intralesional interferon. Lesions do recur, but the recurrence rate is low.

In the case reported here, our assumption is that the surgical trauma and the disturbed mucociliary clearance caused by the UPPP had reactivated dormant HPV, which inevitably led to the development of a papilloma in the rapidly healing wound.

From the Department of Otolaryngology--Head and Neck Surgery, Hadassah University Hospital, Jerusalem (Dr. Eliashar), and the Department of Otolaryngology and Communicative Disorders, the Cleveland Clinic (Dr. Eliachar).

References

(1.) Crissman JD, Kessis T, Shah KV, et al. Squamous papillary neoplasia of the adult upper aerodigestive tract. Hum Pathol 1988;19:1387-96.

(2.) Briskin KB, Kerner MM, Calcaterra TC. Squamous papillomas of the nasopharynx treated by a uvulopalatopharyngoplasty approach. Am J Otolaryngol 1994;15:379-82.

(3.) Abbey LM, Page DG, Sawyer DR. The clinical and histopathologic features of a series of 464 oral squamous cell papillomas. Oral Surg Oral Med Oral Pathol 1980;49:419-28.

(4.) Harries ML, Juman S, Bailey CM. Recurrent respiratory papillomatosis in the larynx: Re-emergence of clinical disease following surgery. Int J Pediatr Otorhinolaryngol 1995;31:259-62.