Introduction
Recurrent respiratory papillomatosis
(RRP) is characterized by recurring benign papillomatous lesions in the
respiratory tract, particularly the larynx, causing dysphonia, airway
obstruction, and dysphagia occasionally. Existing evidence about disease
risk factors is limited but includes both maternal HPV infection and
patient smoking and sexual behaviors[1]. The age is an independent
factor affecting disease aggressiveness of RRP, due to which RRP is
usually categorized into juvenile onset and adult onset depending on
presentation before or after the age of 12 years, respectively[2].
Generally, Jo-onset RRP is the most common benign tumors in the larynx
of children, shows a high recurrence rate and diffuse involvement in the
respiratory tract, which are prone to recurrence, and require multiple
surgeries, causing heavy psychological pressure and financial burden on
families. On the contrary, Adult-onset RRP is more localized and appears
more frequently as a solitary lesion[3]. Malignant transformation of
adult-onset RRP to squamous cell carcinoma has been reported to occur in
3-7% of cases[4].
RRP is a rare disease. Treatment requires experience and may be very
difficult. Surgical debulking with or without adjuvant treatment remains
the mainstay of treatment, which mainly aims to reduce the number and
frequency of recurrences since no definitive curative therapy is known
so far.[5] However, there is no
standard guidelines for the choice of surgical technique nowadays.
Commonly used surgical modalities include traditional cold instruments,
microdebriders, 10,600nm carbon
dioxide(CO2) laser, 532-nm pulsed potassium-titanyl-phosphate(KTP)
laser[6]. Factors that can influence decision-making are the
effectiveness and safety of surgical techniques, patient factors,
surgeon preferences, and the availability of laser equipment in medical
institutions.
In the few studies that compare the
efficacy of different surgical modalities,
the researchers did not found the
optimal surgical modality to treat RRP. Papaspyrou presented the
experience in treating laryngeal papillomatosis in three institutions
over a period of 10 years wihiout distinction between children and
adults. In the experience, CO2 laser therapy was the most common
modality applied alone or combined with other treatment modalities and
no major complication was observed. They also presented that there was
no significant difference in repeat operation rate between the two
larger patient groups, the one treated with CO2 alone and the other
treated with cold instruments alone. El-Bitar[7] conducted a
retrospective study of seventy-three operations, the microdebrider was
proved to be less time-consuming than the carbon dioxide laser when used
in patients with juvenile-onset recurrent respiratory papillomatosis,
whit soft tissue complications were
nonexistent. In 2015, Murono
published a questionnaire to the department of otolaryngology at all 80
Chuo University hospitals in Japan with regard to the use of surgical
instruments. A trend was observed towards lasers (50 hospitals) rather
than micro devices (16 hospitals) or cold instruments (20 hospitals).
Among the 50 hospitals that regularly undergo laser surgery, the most
commonly used carbon dioxide (CO2) laser is followed by titanium-based
potassium phosphate laser[8]. In 2016, a Germany multicenter cohort
study reported that CO2 laser remained the most common surgical modality
used alone or in combination with other treatment modalities[5].
Papaioannou[9] reported that the treatment of choice is surgical
excision with the CO2 laser combined with the quadrivalent or polyvalent
vaccine. According to the consensus of the International Pediatric
Otolaryngology Group(IPOG) regarding operative considerations, the
surgical modality with the greatest support is laryngeal microdebrider
(65% “almost always” and 3% “almost never”), while the consensus
on the use of CO2 laser is 0% “almost always” and 68% “almost
never”, and the use of KTP lasers is 10% “almost always” and 71%
“almost never”[10].
Herein, we conducted a retrospective cohort study to obtain a better
understanding of RRP, and select the best surgical modality for RRP
among microdebrider, CO2 laser and KTP laser.