Surgical therapy for recurrent respiratory papillomatosis.
Surgical technique can be broadly categorized as using either cold instruments or lasers. In the realm of elective management, the pendulum of physician popular preference has drifted in each direction during the past 40 years.
From the time of the early indexed reports in the 1950s, we used the tools available to us: the microscope, laryngoscope, and steel instruments. After the topical application of a vasoconstricting agent, visible disease is excised with an eye toward minimizing complications, such as vocal fold scarring, glottic webs, and stenosis of the supra- or subglottic airway. The routine use of submucosal infusion can diminish the likelihood of these events. (1) By filling Reinke's space with fluid, one can decrease the risk of injury to the deep lamina propria and vocalis muscle. The addition of phonosurgical techniques has further evolved this approach. (2) While cold excision demands precision on the part of a well-trained operator, it remains a cost-effective, technology-independent, safe way of managing RRP and has been proposed as the preferred strategy for adults. (3) Yet another option exists in the context of microlaryngoscopy-cryotherapy. This involves the controlled application of liquid nitrogen in order to induce hypothermic damage to the papilloma. The tissue may then be abraded and suctioned away. However, the depth of tissue damage is often inadequately assessed at the time of surgery, and there is the danger of inadvertent spills resulting in "cold burns."
The introduction of the carbon dioxide (C[O.sub.2]) laser for clinical use in the 1970s ushered in a new era. This laser's wavelength is optimally absorbed by water and, therefore, it results in direct vaporization of tissue. (4) It was adopted with enthusiasm because it provided precise tissue destruction as well as hemostasis of capillaries and small vessels.
Large, published series on laser excision have demonstrated its effectiveness in controlling disease when applied with appropriate frequency. (5,6) This leap forward came with several costs, however. The risk of fire from an energy source in the potentially oxygen-rich environment of the laryngoscope and airway necessitated the development of equipment, (7) anesthetic techniques, (8) and protocols (9) to safeguard the patient. In addition, laser technology does not eliminate the challenges intrinsic to laryngeal excision outlined above. Furthermore, the clinical manifestations of complications may be insidious and cumulative, since most patients require multiple procedures. (10)
In addition to risks for the patient, there has remained the specter of aerosolized viral dissemination. However, although viral DNA identical to that found in the source patient can be identified in the plume of smoke generated as the tissue is vaporized, (11) there have been no reports to date of physician or support staff contracting and activating aerodigestive papillomatosis after exposure to this technique. Nevertheless, this concern is addressed by the active suctioning of the smoke/plume from within the laryngoscope, thus preventing its escape into the ambient environment.
Technology continued to broaden, and the microdebrider, familiar from endoscopic sinus applications, was adapted for use in the airway. This returned cold excision, albeit a variant, to popularity as lasers fell out of favor with some practitioners. The operating telescope may be used in place of the microscope, as it provides appropriate magnification. The powered instrumentation employs a technique similar to that used in manual excision, as one applies a topical vasoconstrictive agent and takes care neither to enter the deep structure of the vocal fold nor to denude the anterior commissure. (12) Although this approach does not provide for hemostasis, it has several advantages over laser therapy: (1) the risk of combustion is absent, (2) no special certifications are required for its operation, and (3) as the suction is integrated into the instrument, the field remains clear of obstructions.
A small prospective, randomized, matched clinical trial comparing C[O.sub.2] laser ablation with microdebrider excision demonstrated reduced operative time and expense and greater improvement in voice quality, while postoperative pain was unchanged. (13)
As otolaryngologists, we now have several techniques at our disposal for the management of RRP. It remains the duty of the clinician to be familiar with these methods, as well as the growing number of nonsurgical treatment options, and to apply the right approach to the right patient at the right time.
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(2.) Zeitels SM, Sataloff RT. Phonomicrosurgical resection of glottal papillomatosis. J Voice 1999; 13:123-7.
(3.) Zeitels SM, Casiano RR, Gardner GM, et al. Voice and Swallowing Committee, American Academy of Otolaryngology-Head and Neck Surgery. Management of common voice problems: Committee report. Otolaryngol Head Neck Surg 2002;126:333-48.
(4.) Mihashi S, Jako GJ, Incze J, et al. Laser surgery in otolaryngology: Interaction of CO2 laser and soft tissue. Ann N Y Acad Sci 1976;267:263-94.
(5.) Strong MS, Vaughan CW, Cooperband SR, et al. Recurrent respiratory papillomatosis: Management with the CO2 laser Ann Otol Rhinol Laryngol 1976;85:508-16.
(6.) Dedo HH, Yu KC. CO2 laser treatment in 244 patients with respiratory papillomas. Laryngoscope 2001;111:1639-44.
(7.) Shaker MH, Konchigeri HN, Andrews AH Jr., Holinger PH. Anesthetic management for carbon dioxide laser surgery of the larynx. Laryngoscope 1976;86:857-61.
(8.) Ruder CB, Rapheal NL, Abramson AL, Oliverio RM Jr. Anesthesia for carbon dioxide laser microsurgery of the larynx. Otolaryngol Head Neck Surg 1981;89:732-7.
(9.) Mohr RM, McDonnell BC, Unger M, Mauer TP. Safety considerations and safety protocol for laser surgery. Surg Clin North Am 1984;64:851-9.
(10.) Crockett DM, McCabe BF, Shive CJ. Complications of laser surgery for recurrent respiratory papillomatosis. Ann Otol Rhinol Laryngol 1987;96:639-44.
(11.) Kashima HK, Kessis T, Mounts P, Shah K. Polymerase chain reaction identification of human papillomavirus DNA in CO2 laser plume from recurrent respiratory papillomatosis. Otolaryngol Head Neck Surg 1991;104:191-5.
(12.) Parsons DS, Bothwell MR. Powered instrument papilloma excision: An alternative to laser therapy for recurrent respiratory papilloma. Laryngoscope 2001;111:1494-6.
(13.) Pasquale K, Wiatrak B, Woolley A, Lewis L. Microdebrider versus CO2 laser removal of recurrent respiratory papillomas: A prospective analysis. Laryngoscope 2003;113:139-43.
RONDA E. ALEXANDER, MD Department of Otorhinolaryngology--Head & Neck Surgery Montefiore Medical Center/ Albert Einstein College of Medicine Bronx, N.Y.
MARVIN P. FRIED, MD University Chairman and Professor Department of Otorhinolaryngology--Head & Neck Surgery Montefiore Medical Center/ Albert Einstein College of Medicine Bronx, N.Y.