Use of a powered shaver to remove multiple oral cavity papillomas.

Abstract

We report a previously undescribed method of removing multiple oral papillomas, which we performed on 5 men with human immunodeficiency virus (HIV) infection. Patients were brought to the operating room and placed under general anesthesia. In addition, 1% lidocaine with 1:100,000 epinephrine was injected under and around the lesions. We then removed the lesions with a Tricut laryngeal blade attached to a handheld powered shaver. Postoperatively, patients' were sent home on clindamycin, a pain medication, and Peridex. At the 1-week follow-up, patients" reported only minimal pain, and their wounds" were well healed. We observed no adverse events' associated with the shaving procedure. Our method expedites the process of removing multiple oral cavity papillomas while reducing the morbidity generally associated with other procedures.

Introduction

Oral papillomas are a problem for many patients, particularly those who are immunocompromised. In most cases, papillomas are recurrent and must be repeatedly excised. In this article, we describe a method of using a powered instrument to remove multiple papillomas from the oral mucosa of patients with human immunodeficiency virus (HIV) infection. To the best of our knowledge, such a method has not been previously described in the literature. Our primary goals were to remove the papillomas with minimal deep-tissue loss and scarring, and to shorten the recovery time associated with other methods of removing oral papillomas.

Patients and methods

Our series included 5 men with known HIV infection and multiple oral cavity papillomas. Their primary preoperative complaints were oral cavity irritation and cosmetic deformity of the tongue (figure, A).

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Patients were taken to the operating room and placed under general anesthesia. In addition, 1% lidocaine with 1:100,000 epinephrine was injected under and around the lesions. We then used the Xomed powered shaver and a 4-mm Tricut laryngeal blade (Medtronic Xomed; Jacksonville, Fla.) to remove the papillomas (figure, B). The shaver was set at 1,500 rotations per minute. The length of the operations ranged from 25 to 40 minutes.

Postoperatively, patients were sent home on clindamycin for 3 days, a pain medication, and Peridex oral rinse three times daily along with routine oral care.

Results

All 5 patients tolerated the procedure well. At the 1-week follow-up, no wound-healing complications were evident (figure, C), and no patient complained of pain that required medication. All patients were followed for a minimum of 6 months postoperatively. During that period, only 1 of the 5 patients required reexcision of multiple papillomas.

Discussion

Human papillomavirus (HPV) is the cause of multiple lesions of the upper aerodigestive tract, particularly in immunocompromised hosts. (1-4) HPV 6, 11, 16, and 18 are associated with the development of squamous papilloma, condyloma acuminatum, verruca vulgaris, and epithelial hyperplasia of the oral cavity. (5-7) HPV 16 and 18 have been isolated from squamous cell carcinoma of the oropharynx. (8-10) Papillomas are well described as being multifocal and characterized by the presence of large, confluent lesions? (11,12) Care must be taken when diagnosing HPV lesions because they resemble several other oral lesions, including other malignancies, vascular lesions, and lesions caused by sexually transmitted diseases and other contagious infections. (13)

Various forms of treatment have been proposed to manage oral papillomas and other oral lesions. They include Nd:YAG and C[O.sub.2] laser ablation, (14-16) drug therapy with methotrexate (17) and interferon alpha-2a, (18) gene therapy, (19) photodynamic therapy, (20) and excision with and without skin grafting. (21) However, our experience with these treatment methods has been disappointing. They can be painful, expensive, or unavailable for routine use, and they still require reexcision of recurrent lesions. In this article, we propose a new method of removing (although not curing) oral papillomas.

We learned two important lessons during this experience:

* First, adequate tension must be maintained on the papilloma so that the surgeon does not remove excessive amounts of the surrounding mucosa. During the removal of lesions from the tongue, this required placing a towel clip on the anterior aspect of the tongue and retracting the tongue out of the mouth. During treatment of the soft palate, this necessitated that we apply inferior distraction to the uvula with a forceps.

* Second, we found that holding the opening of the shaver approximately 60[degrees] off the horizontal plane of the mucosal surface allowed us to elevate the papillomas without excessively removing the underlying tissue. This was especially useful while working on the tongue and the buccal mucosa.

Finally, we were able to remove several papillomas from the lips, but we did not cross onto the epidermis.

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From the Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati.

Reprint requests: Robert Sean Miller, MD, Department of Otolaryngology-Head and Neck Surgery, University of Virginia, P.O. Box 800713, Charlottesville, VA 22908. Phone: [phone]; fax: [phone]; e-mail: [e-mail]