Bilateral vocal process papillomas: report of a case.

Abstract

We describe a case of bilateral vocal process lesions in a 65-year-old man. His history was strongly suggestive of vocal process granulomas: previous gastroesophageal reflux, intubation, smoking, and oral squamous cell carcinoma. Medical management with a proton-pump inhibitor, reflux precautions, voice therapy, and adequate hydration yielded no results. Subsequent surgical intervention revealed that he had squamous papillomas. We also provide a brief review of vocal process granulomas and squamous papillomas.

Introduction

Laryngeal granulomas have long been attributed to gastroesophageal reflux. (1) Histologically, the pathology of these lesions is similar to that seen in cases of reflux esophagitis. (1) In this article, we describe a case of suspected bilateral vocal process granulomas in a patient who had a history of gastroesophageal reflux and other suggestive factors.

Case report

A 65-year-old man came to us with complaints of worsening hoarseness, throat clearing, and a globus sensation of 4 months' duration. He had a history of gastroesophageal reflux, intubation, and smoking. He also had a remote history of T1N0M0 squamous cell carcinoma on the floor of the mouth that had been removed by wide local excision. Physical examination revealed that the man was well nourished but had a weak and moderately hoarse voice. Inspection of his oral cavity revealed a well-healed skin graft on the left side of the floor of the mouth and the ventral aspect of the tongue; there was no evidence of recurrent carcinoma. Rigid endoscopy (70[degrees]) of the larynx detected bilateral vocal process lesions (figure 1). The masses were granular protuberances and appeared to be pedunculated. We also observed interarytenoid pachyderma and mild arytenoid edema and erythema. The vocal folds were mobile.

The patient was treated aggressively with a proton-pump inhibitor for laryngopharyngeal reflux and instructed in reflux precautions, voice therapy, and adequate hydration. At the 1-month follow-up, he continued to complain of hoarseness, throat clearing, and the globus sensation. Endoscopy at that time revealed that the bilateral vocal fold lesions appeared to have increased in size. In light of the clinical failure of the proton-pump inhibitor, the persistence of the suspicious lesions, and the patient's history of squamous cell carcinoma, surgery was planned.

The patient was taken to the operating room for elective microscopic direct laryngoscopy and tracheobronchoscopy. The papillomatous-type lesions obstructed the posterior aspect of the glottis. Exploration of the oral cavity, supraglottic structures, and tracheobronchial tree detected no additional lesions. The masses were excised with medium up-biting forceps and a [CO.sub.2] laser. The normalappearing mucosa was preserved.

Paraffin-section analysis of the resected lesions identified a narrow stalk of fibrovascular tissue with numerous finger-like projections that are characteristic of squamous papillomas (figure 2). These projections were lined with squamous epithelium that featured a variably thick parakeratin layer. A few koilocytes (cells with shrunken, irregular nuclei surrounded by a clear space) were observed, but they were not as numerous as they are in cases of more-sessile condyloma or cup-shaped verruca vulgaris. At the 1-year follow-up, the patient was diseasefree.

Discussion

Information gathered from the history and physical examination of this patient suggested a diagnosis of vocal process granulomas. Supporting evidence for this diagnosis included the presence of the laryngopharyngeal reflux symptoms, the symmetry of the lesions, the patient's age (i.e., adult onset), and the location of the lesions at the vocal process.

Granulomas. The treatment of vocal fold granulomas involves proton-pump inhibitor medication, reflux precautions, voice therapy, and hydration. Treatment of typical vocal process granulomas can take as long as 6 or even 12 months before they resolve completely. Surgical intervention should be considered if conservative management fails, if the lesions mature or enlarge, if the airway becomes obstructed, or if the lesion is suspicious. (2) Although the complex of symptoms and findings initially confounded the diagnosis in our patient, surgical management did lead to the correct diagnosis and allowed for proper treatment.

Papillomas. Unlike vocal process granulomas, recurrent respiratory papillomas have been determined to be viral in nature; the most common pathogens are human papillomavirus types 6 and 11. (3,4) Treatment of respiratory papillomatosis primarily involves surgical excision and [CO.sub.2] laser vaporization. (5) The goals of surgery are to maintain airway patency, provide a useful voice, and eradicate the disease. Patients with solitary or localized lesions of the larynx have been shown to have a better prognosis and a reduced likelihood of needing future surgical intervention. (6) Recurrent respiratory papillomatosis can occur at any age, but it is more common in children than in adults. Although the disease appears to be less aggressive in adults, rapid growth can quickly compromise a previously asymptomatic airway.

Our case demonstrates that the clinician must maintain a high index of suspicion when dealing with recalcitrant, benign-appearing lesions of the larynx. The correct diagnosis can be masked by clinical signs and symptoms that suggest other pathology. Although it is appropriate to manage these lesions conservatively for up to several months, microscopic direct laryngoscopy, a procedure that causes little morbidity, should be employed early when dealing with lesions that are refractory to conservative management. Patients with localized papillomas of the larynx, if they are recognized early and treated appropriately, have a good prognosis and a reduced likelihood of needing future surgical intervention.

References

(1.) Goldberg M, Noyek AM, Pritzker KP. Laryngeal granuloma secondary to gastro-esophageal reflux. J Otolaryngol 1978;7: 196-202.

(2.) Havas TE, Priestley J, Lowinger DS. A management strategy for vocal process granulomas. Laryngoscope 1999;109:301-6.

(3.) Gissmann L, Diehl V, Schultz-Coulon HJ, zur Hausen H. Molecular cloning and characterization of human papilloma virus DNA derived from a laryngeal papilloma. J Virol 1982;44:393-400.

(4.) Mounts P. Kashima H. Association of human papillomavirus subtype and clinical course in respiratory papillomatosis. Laryngoscope 1984;94:28-33.

(5.) Strong MS. Vaughan CW, Cooperband SR, et al. Recurrent respiratory papillomatosis: Management with the [CO.sub.2] laser. Ann Otol Rhinol Laryngol 1976;85:508-16.

(6.) Cohen SR. Geller KA, Seltzer S. Thompson SW. Papilloma of the larynx and tracheobronchial tree in children. A retrospective study. Ann Otol Rhinol Laryngol 1980;89:497-503.

From the Department of Otolaryngology-Head and Neck Surgery (Dr. Sidle and Dr. Altman) and the Department of Pathology (Dr. Haines), Northwestern University Medical School, Chicago.

Reprint requests: Ken W. Altman, MD, PhD, Department of Otolaryngology-Head and Neck Surgery, Northwestern University Medical School, 303 E. Chicago Ave., Searle 12-561, Chicago, IL 60611. Phone: [phone]; fax: [phone]; e-mail: [e-mail]