Recurrent Respiratory Papillomatosis

Jeremy D. Prager and Sally R. Shott

History

A 3-year-old boy was taken to his primary care physician with a history of continuous and progressively worsening hoarseness over several months. His history was negative for respiratory complaints with the exception of viral upper respiratory infections, which were normal in course and character. His history was not consistent with vocal abuse or overuse. He did not have any dysphagia and was gaining weight appropriately. His birth history was normal. He was the first child of a young family in a nonsmoking household without pets. His review of systems was negative. Several rounds of antibiotics failed to alleviate the hoarseness, and the patient was referred to an otolaryngologist.

Physical examination in the office revealed a well-appearing child in no acute distress. Examination of the ears, nose, oral cavity, oropharynx, and neck was normal. The child was not retracting. His voice was moderately hoarse, and a mild amount of inspiratory stridor could be heard when the patient was breathing rapidly and deeply. A flexible nasopharyngoscopy revealed a warty, exophytic mass on the left true and false cord, extending to the anterior commissure.

Based on the history and physical examination, the patient was taken to the operating room for a microlaryngoscopy and bronchoscopy with biopsy.

Differential Diagnosis—Key Points

1. Hoarseness is never “normal.” It is a symptom that indicates that the apposing vocal cord surfaces have been altered. Hoarseness is, however, a common complaint. The differential diagnosis of hoarseness is lengthy, ranging from inflammation secondary to common viral upper respiratory infections and laryngopharyngeal reflux to more complex disorders, including nerve deficits and neoplastic processes.

2. Hoarseness secondary to viral upper respiratory infection is accompanied by other complaints consistent with the disease process. It is self-limiting. Hoarseness caused by allergic or irritant inflammation will be temporally related to exposure and may be accompanied by other symptoms as well.

4. Constant or progressive hoarseness is commonly due to a vocal cord lesion. The differential diagnosis of a vocal cord lesion differs from that in the adult population. The most common lesions are vocal cord nodules. These lesions are most consistent with vocal abuse. Symptoms can be expected to fluctuate somewhat. Other lesions include neoplastic processes, of which laryngeal papilloma is the most common. Less common lesions include hemangiomas, benign and malignant mesenchymal tumors, and squamous cell carcinoma. Biopsy is required for diagnostic confirmation in cases of neoplasia.

5. Impaired vocal cord mobility may cause hoarseness. This will likely be recognized on flexible nasopharyngoscopy. If impaired vocal cord mobility is a congenital problem or one acquired as an infant (e.g., postcardiac surgery), it is likely to have been identified earlier than 3 years of age. Acquired recurrent laryngeal nerve dysfunction may also be caused by metabolic disorders, nutritional deficiency, heavy metal poisoning, and as part of a postinfectious polyneuropathy. Recurrent laryngeal nerve paresis may result from an overinflated or high-riding endotracheal tube cuff. Vocal cord mobility problems may also cause trauma to the cricoarytenoid joint. causing arytenoid dislocation as can occur during traumatic intubation or blunt trauma to the external neck.

Test Interpretation