INTRODUCTION

Papilloma is considered the most common benign laryngeal tumor with high tendency to recurrence and progression, regardless of the treatment approach 1. Some authors describe it as a pre-malignant condition 2. Normally, it is manifested by hoarseness, but it can also be detected with acute airway obstructions. The glottis is the most common impaired site. Some patients present lesions in other regions, such as the oral cavity, especially the palate. To its treatment, many procedures can be necessary, causing frustration both in physicians and patients.

Recurrent papillomatosis is normally characterized based on age at onset and severity of the affection. As to age at onset, it can be classified as juvenile or adult. The latter is defined when the disease affects patients after the age of 20 years 3. As to severity of the disease, it is divided into benign or aggressive. It is said to be benign when the disease is limited to the larynx, with few or no recurrences. Aggressive papillomatosis is defined by multiple recurrences, with dissemination to the tracheobronchial tree, progression of the disease before puberty, epithelial atypia and development of squamous cell carcinoma 4.

As to etiology, clinical experiments and optical and electron microscopy studies have suggested a correlation between laryngeal papillomatosis and viral infection 5, 6. As a result of molecular biology development and different techniques of viral DNA hybridization, it was possible to demonstrate this relation, which was confirmed by PCR (polymerase chain reaction) technique 7,8,9. Recently, it was possible to define human papilloma virus (HPV), a DNA-virus that belongs to the slow viruses of Papovaviridae family as the causal agent of laryngeal papillomatosis.

In the adult form, it has demonstrated that laryngeal papillomatosis is caused by at least 6 and/or 11 types of the 80 already identified types 7, 10. In located lesions, only one type is found, differently from multiple lesions in which both types can be detected. Multiple laryngeal papillomas are more seriously infected by HPV than isolated lesions. Moreover, in the occurrence of massive HPV infection with types 6 and/or 11, the prognosis is worse 11.

In the juvenile form, an association between HPV maternal cervical infection and incidence of recurrent papillomatosis has been described 12. The same types of HPV found in cervical condylomas were identified in laryngeal papillomatosis 13. Thus, children seem to acquire the disease from the birth canal, after getting in contact with condyloma acuminatum.

Other differences between the two clinical forms of laryngeal papillomatosis have been described. We conducted the present study to gather information about the clinical and evolution aspects of the disease and the long-term therapeutic results, defining the profile of the patients followed up by our service with diagnosis of recurrent laryngeal papillomatosis, comparing them to the literature. Thus, our objective was to compare both forms of presentation, juvenile and adult, trying to characterize each of the forms to observe and/or confirm the differences between them concerning the parameters we assessed.

MATERIAL AND METHOD

Sample

We conducted a retrospective study by reviewing the medical charts of all patients diagnosed, treated and followed up with preoperative diagnosis of laryngeal papillomatosis at the Division of Clinical Otorhinolaryngology, Hospital das Clínicas, University of Sao Paulo, between January 1990 and December 1999. Fifty-seven patients were identified. Out of the total, only fifty-one medical charts could be retrieved and reviewed. Of the 51 patients, seven had no confirmed preoperative diagnosis and were excluded from the study. The remaining 44 cases were the basis for this analysis.

Assessment of patients
Patients were assessed in the outpatient unit pre and postoperatively with rigid endoscope of 70o C (10mm) and/or flexible nasofibroscopy, both connected to a video system, for morphological characterization, location of the lesion and documentation. In children that did not allow the conduction of the endoscopic exam, we performed diagnostic direct laryngoscopy and repeated it for the follow-up. Our revision analyzed patients concerning age at onset, gender, race, clinical picture, personal history, location of papillomas, type of treatment adopted, number of recurrences, complications and tracheotomy history.

We classified the cases in juvenile or adult form, according to the division used in the literature, being 20 years the limit age between the two forms. We considered the adult form if the symptoms started after the age of 20 years 3.

Statistical analysis
In order to compare the forms of clinical presentation of laryngeal papillomatosis, we used chi-square test or Fisher's exact test. We also used the Relative Risk (RR) and its respective Confidence Interval (CI) of 95%. The significance level used was 95% (p<0.05).
RESULTS
Of the 44 studied cases, 21 (47.72%) presented the juvenile form and (52.27%) had the adult form.

Demographic aspects
Of the 44 studied patients, 21 were male, being 10 in the juvenile group and 11 in the adult group. Twenty-three patients were female subjects, being 11 in the juvenile group and 12 in the adult group. Upon comparing both groups, we did not find statistically significant differences concerning gender of patients (p=0.98). As to race, 23 were Caucasian, eighteen were Afro-descendents and there were no Asian-descendents. There were no statistically significant differences concerning race.

Age at onset of symptoms
The age at onset of symptoms ranged from 2 months to 75 years, mean age of 28.9 years for the population as a whole. In the group of juvenile form, the age at onset ranged from 2 months to 17 years (mean of 5.33 ± 2.86 years). For the adult form group, the age at onset ranged from 20 to 75 years (mean age of 42.61 ± 12.75 years).

Personal history and symptomatology
Only in the adult group we found history of smoking and alcohol abuse and there were 12 patients who were smokers and 2, alcohol abusers.

As to initial symptomatology, we clinically observed that 24 patients presented only dysphonia (54.54%), 17 had dysphonia and dyspnea (36.63), two had dysphonia, dysphagia and bleeding (4.54%) and one had only dyspnea (2.27%).

Comparing both groups, we observed that 12 of the 21 patients in the juvenile group presented dyspnea in some step of the disease, whereas only six of the 23 patients of the adult group presented some symptomatology (p=0.03). In the other symptoms, we did not find statistically significant differences.

Intraoperative location of papillomas
After the inspection and palpation of lesions by direct laryngoscopy (microsurgery), it was possible to analyze the location of the papillomas. In the juvenile form, during the first surgery, we observed 12 patients with glottic lesion (57.14%), 3 (13%0 with supraglottis lesion, one with subglottis lesion (4.47%), and 5 (213.8%0 with lesions in more than one area of the larynx. In the adult form, 15 patients had glottic lesion (65.21%), 1 (4.34%) had supraglottis lesion, none had exclusive impairment of the subglottis and 7 (30.43%) had lesions in more than one laryngeal location. There were no statistically significant differences concerning location of lesions between the two groups. The location of lesions observed intraoperatively is demonstrated in graph 1.

Type of treatment
Thirty-eight patients of the 44 studied cases were submitted to surgical resection of the papillomas under direct laryngoscopy using cold instruments (conventional laryngeal microsurgery). In six patients, they vaporized the papillomas with CO2 laser, being that three were juvenile cases and three were adult subjects. There was no specific clinical or epidemiological criteria to define the surgical technique used. CO2 laser was the method of choice for the surgical treatment of papillomas as of 1998 in our clinic.

Number of recurrences and surgeries
Out of a total of 44 patients, 29 presented recurrence of papillomatosis, 16 of 21 in the juvenile group (76.19%) and 13 of 23 in the adult group (56.52%), with no statistically significant difference (p=0.17) (Graph 2).

A total of 139 surgeries were performed in the assessed population within 10 years, 73 in the juvenile group, with mean of 3.47 surgeries per patient and 66 in the adult group, with mean of 2.8 surgeries per patient. The number of surgeries in each form is compared in Graph 3 (p=0.17).
As to type of treatment used and incidence of recurrence, we observed that in the 6 patients operated on with CO2 laser, five had recurrences, whereas in the 38 operated with cold instruments, 24 had recurrence of papillomas. We did not find statistically significant differences concerning type of treatment and incidence of recurrence (p=0.33).

Interval between recurrences
In the 3 first months, we observed differences between the groups (p<0.001) with greater incidence of early recurrence in the juvenile form of presentation. There was no difference between 3 and 6 months (p=0.39), between 6 months and 1 year (p=0.46), and one year and 2 years (p=0.14) or after 2-year follow-up (p=0.06). These data are summed up in Graph 4.

Tracheotomy
Two patients in the studied population required emergency tracheotomy being both of them in the juvenile group and they were respectively aged 3 and 6 at the time of the surgery, when the disease was diagnosed. Both remained with tracheotomy for approximately 3 months, up to resection of the papillomas. After the removal of the canulla, they did not present other respiratory problems or need to perform a new tracheotomy regardless of the recurrence of the disease that occurred at the age of 2 years.

Complications
We did not find any case of death resultant from papillomatous disease in this population despite the fact that some patients presented significant respiratory symptoms and need for tracheotomy.

In three cases we could confirm that the clinical pathology analysis presented the diagnosis of squamous cell carcinoma in the surgical piece. Out of the three patients, two of them had been submitted to previous surgeries, all of them with histology results of laryngeal papillomatosis, and the other had undergone two surgeries with the same diagnosis. The three cases were of adult form, showing a rate of malignant transformation of 13% in this form of disease presentation.





DISCUSSION

The existing classifications for papillomatosis are confusing and contradictory. Some are based on age at onset of symptoms, whereas others on severity of the disease. Many associate the aggressive form with onset of symptoms before puberty. However, about 33% of the young people present the non-aggressive form of papillomatosis 3. Thus, in our study, we preferred to classify based on age, since we believe that this is the easiest form, subject to fewer biases, and it provides comparisons that help us better characterize laryngeal papillomatosis.

There are reports suggesting male predominance of papillomatosis 3. In our sample, however, we did not detect statistically significant difference between the groups of juvenile and adult forms concerning gender. We did not detect statistically significant differences concerning race either. As to mean age at onset of symptoms, it was 28.9 years. In the adult group, mean age of onset was 42.6 years and in the juvenile group it was 5.33 years.

Symptoms included changes in voice, dysphonia, aphonia, stridor and dyspnea. The diagnosis was made by anamnesis, physical examination and complementary exams that included laryngoscopy and/or bronchoscopy and simple chest x-rays to rule out other causes of dyspnea. Approximately 55% of the patients presented dysphonia as the first symptom. However, we could observe that the most prevalent one was juvenile form dyspnea. The most probable cause to explain this fact is that it is owed to the proportionally reduced dimensions of children's larynges, especially in the subglottic region, causing obstruction in less advanced stages of the disease.

As to location of lesion, we observed that 61% of the patients presented isolated affection of the glottis in the first intervention (57% in the juvenile and 65% in the adult group). We did not observe statistically significant difference between the two groups concerning location of the lesion at the first presentation nor in subsequent recurrences. It is known that papillomatosis affects more frequently the glottic region, preferably the anterior portion of the larynx. However, papillomas can involve the whole digestive tract, including the nasal fossa, pharynx, trachea, bronchia and sometimes the esophagus 14. Tracheal papillomas grow slowly and remain sessile for a long time 15.

As to recurrence, we observed a rate of 76% in the juvenile group and 57% in the adult group, which was not a statistically significant difference. However, the interval between recurrences was shorter in the juvenile group, with the main incidence in the first three months. Another important piece of data is that the juvenile form presented a risk of recurrence 4.75 greater within the first 3 months than the adult form of papillomatosis. However, there seem to be other factors, in addition to age and form of presentation, involved in recurrence. It is assumed that the isolated presence of HPV is not enough to cause the disease. HPV has been identified in the vocal folds of patients without papillomatosis 16, suggesting that an additional event would be necessary to produce a clinical infection by HPV, such as steroid hormone effect, trauma, sepsis, malnutrition, immunosuppression or concomitance with other viruses 17. HPV seems to migrate from the mucosa of normal aspect to trauma areas (squamociliar junction) caused by previous exeresis, promoting recurrence 18. Steinberg et al. (1988)19 observed that the genome of Papova virus can be found both in impaired tissues and in normal aspect adjacent tissues. Possibly, these normal areas would serve as the origin of re-infections, leading to recurrence 17, 19. The prevalence of infection by this virus in both forms of presentation of papillomatosis has not been fully explained yet, as well as the speed of healing after surgical trauma. Maybe reepithelialization by adjacent tissues is quicker in younger subjects, which could contribute to earlier recurrence observed in the juvenile group.

As to recurrences, the adult group required 2.8 procedures per patient, on average. In the juvenile group, the mean number of surgeries per patient was 3.47, slightly higher than in the adult group. A mean of 4.5 to 13.7 has been described in adult form. The mean number of surgeries required in the juvenile group is about 2.24 to 4.44 times greater than in the adult group 3, 20. The absence of difference between the group concerning the number of recurrences can be related to the fact that there are subjects in the adult group whose evolution is more aggressive, suggesting that the association of juvenile form and aggressive behavior does not occur as linearly as had been proposed.

The incidence of tracheotomy in patients with laryngeal papillomatosis observed in the literature ranged from 1.8 to 64% 3. In our sample, 9.5% of the patients in the juvenile group (4.5% of the total) required tracheotomy for approximately 3 months, up to resection of papillomas. This surgery can be associated with dissemination of the disease to the trachea, bronchia and lungs 21. Conversely, the patients that required tracheotomy were those that presented the aggressive form of the disease. Therefore, probably, there would be dissemination through the lower airways regardless of the performance of tracheotomy 15. Despite these differences, most authors agree that if possible, tracheotomy should be avoided and, whenever necessary, decannulation should be conducted as early as possible.

Concerning treatment, many methods have been described including the use of antibiotics, hormones, electrocoagulation, cryotherapy, radiation, ultrasound, surgical exeresis, autogenous vaccine 2, interlesional application of cidofovir 22, 23, and use of microdebrider to remove the lesions 24. However, no measures are sufficiently efficient to control multiple papillomas or recurrences. Conventional treatment for papillomatosis consists of removal of the lesion with cold instruments or using laser vaporization. The latter provides a combination of precise excision method with good hemostasis, especially in friable lesions 15, 25. In past decades, it became the procedure of choice for the treatment of recurrent laryngeal papillomatosis, owing to the advantages in relation to conventional microsurgeries, cryotherapy and cauterization 25, 26. A protocol with microsurgery and laser CO2 use has been followed in the past years in our service, requiring a larger number of cases to allow comparison with the results obtained in conventional treatment with cold instruments, so as to confirm or not the advantages of using laser in the treatment of laryngeal papillomatosis.

We did not observe in our study cases of death resultant from papillomatosis and/or consequences of treatment, despite the fact that some of them had had significant dyspnea. However, many complications of the disease and its treatment have been presented as synechia, laryngeal webs, formation of granulation tissue, stenosis, tracheal perforation, tracheoesophageal fistulae, bronchitis, pneumonia, pneumothorax, hemorrhage, respiratory failure and death 16. The frequency and severity of tissue injury are proportional to the number of procedures.

Squamous cell carcinoma was evidenced in three subjects with the previous diagnosis of recurrent laryngeal papillomatosis. About 40% of invasive laryngeal squamous cell carcinomas present type 16 HPV 27. We cannot, however, state that malignant transformation of papillomatosis occur exclusively associated with the presence of HPV, or that this is a parallel phenomenon associated with other carcinogenic stimuli to which the larynx is exposed. Co-factors capable of modifying the cell genes and/or intracell controllers such as alcohol, tobacco, herpes simplex virus, and cytomegalovirus can act as triggers responsible for oncogenesis 8, 28, 29. The association of HPV and squamous cell carcinoma of the larynx and pharynx is still being studied.

CONCLUSION

Laryngeal papillomatosis is frequently a benign lesion with tendency to recurrence and progression. In the juvenile form there were early recurrences associated with dyspnea episodes, requiring repetitive interventions. In the adult form, we also observed high rate of recurrence, with high level of malignant transformation. Treatments that increase the time between the recurrences are necessary in both forms of presentation of the disease.

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1 Ph.D. in Otorhinolaryngology, FMUSP. Assistant Physician (volunteer), Service of Otorhinolaryngology, University Hospital, Medical School, Federal University of Ceará.
2 Ph.D. in Otorhinolaryngology under course, Medical School, University of Sao Paulo - FMUSP.
3 Assistant Physician, Ph.D., Division of Clinical Otorhinolaryngology, HC-FMUSP.
4 Full Professor, Responsible for the Group of Voice, Division of Clinical Otorhinolaryngology, HC-FMUSP.
5 Full Professor, Associate Professor, Discipline of Otorhinolaryngology, FMUSP, Director of the Service of Bucopharyngolaryngology, Hospital das Clínicas FMUSP.
Study conducted at the Division of Clinical Otorhinolaryngology, Hospital das Clínicas, Medical School, University of Sao Paulo (HC-FMUSP).
Address correspondence to: João Aragão Ximenes Filho - R. Paula Ney, 700 ap. 1202 Fortaleza CE 60140-200.
Tel (55 85) 268 3641 - E-mail: joaoximenesf@bol.com.br
Article submitted on May 30, 2002. Article accepted on July 17, 2003.