Haskins K. Kashima

Carbon Dioxide Laser Posterior Cordectomy for Treatment of Bilateral Vocal Cord Paralysis

Upper airway obstruction due to bilateral vocal cord paralysis was successfully relieved by carbon dioxide laser posterior cordectomy. All patients achieved satisfactory airway and decannulation. Flow-volume loop spirograms obtained preoperatively and postoperatively documented improved flow rates on inspiration and expiration. Final voice quality was subjectively good in all patients. Follow-up has ranged from 1 year 10 months to 5 years 8 months, and initial improvement has been sustained in all cases. Carbon dioxide laser posterior partial cordectomy is an alternative management option for relief of upper airway obstruction due to bilateral vocal cord paralysis. The procedure can be performed without prophylactic tracheotomy. Subjectively good voice quality is preserved.

Sites of Predilection in Recurrent Respiratory Papillomatosis

Florid and widespread respiratory papillomatosis is a devastating disorder occurring in a subset of patients with recurrent respiratory papillomatosis, and it poses a major dilemma for the patient and the surgeon. Contrary to common belief, the distribution of papilloma lesions is not random, but follows a predictable pattern, with lesions occurring at anatomic sites in which ciliated and squamous epithelia are juxtaposed. The predominant sites of disease in recurrent respiratory papillomatosis are the limen vestibuli, the nasopharyngeal surface of the soft palate, the midzone of the laryngeal surface of the epiglottis, the upper and lower margins of the ventricle, the undersurface of the vocal folds, the carina, and bronchial spurs. These sites have the common histologic feature of a squamociliary junction. Papillomata also occur at the tracheostomy tract and at the midthoracic trachea in patients with tracheostomies. At the latter sites, abrasion injury to ciliated epithelium heals with metaplastic squamous epithelium and creates an iatrogenic squamociliary junction. The apparent preferential localization of papilloma at squamociliary junctions has at least 2 implications: first, that detection of occult asymptomatic papillomata is enhanced by careful examination of squamociliary junctions, and, second, that iatrogenic papilloma “implantation” is preventable by avoiding injury to nondiseased squamous and ciliated epithelia.

A comparison of risk factors in juvenile‐onset and adult‐onset recurrent respiratory papillomatosis

The clinical triad of a firstborn delivered vaginally to a young (teenage) mother has been previously noted among juvenile onset recurrent respiratory papillomatosis (JO‐RRP) patients. This study was based on a questionnaire survey of JO‐RRP patients, adult onset recurrent respiratory papillomatosis (AO‐RRP) patients, and juvenile and adult controls. The survey results revealed that the complete or partial triad was observed in 72% of JO‐RRP patients, 36% of AO‐RRP patients, 29% of juvenile controls, and 38% of adult controls. As compared with juvenile controls, JO‐RRP patients were more often firstborn (P <.05), delivered vaginally (P <.05), and born to a teenage mother (P <.01). Among adult participants, AO‐RRP patients reported more lifetime sex partners (P <.01) and a higher frequency of oral sex (P <.05) than reported by adult controls.

A Staging System for Assessing Severity of Disease and Response to Therapy in Recurrent Respiratory Papillomatosis

INTRODUCTION Recurrent respiratory papillomatosis (RRP) is a perplexing and frustrating disease for both the families it afflicts and the physicians who care for them. Although RRP is a benign disease of viral etiology (most commonly HPV types 6 and ll), it has potentially morbid consequences owing to its involvement of the airway and the risk of malignant conversion. Treatment of RRP has been mainly surgical over the past half century, relying on operative debulking, although adjuvant medical therapies have been utilized for recalcitrant cases. Among the most frustrating aspects of this disease is the observation that whereas some patients demonstrate limited disease with an infrequent need for intervention, others are confronted with recurrent airway compromise and a repeated need for laser surgery. Although it is considered the most common benign neoplasm of the larynx,l RRP is an orphan disease with an incidence in the United States estimated at between 1500 and 2500 new cases per year.2 Owing to the relative paucity of cases and the complicated nature of their treatment, the

Human papillomavirus in squamous cell carcinoma, leukoplakia, lichen planus, and clinically normal epithelium of the oral cavity

Tissue specimens of carcinoma, leukoplakia, and clinically normal epithelium obtained at sites separate from the lesions were examined for the presence of human papillomavirus (HPV). Twenty-two paraffinized specimens of previously diagnosed oral lichen planus were also studied. The carcinoma and leukoplakia specimens were examined by Southern transfer hybridization and reverse blot hybridization; specimens HPV-positive by Southern hybridization were additionally examined by in situ hybridization and an immunoperoxidase technique. The lichen planus specimens were examined by in situ hybridization and immunoperoxidase techniques only. The HPV identification rates were in the range reported in previous studies, and the detection rates were similar for carcinoma, leukoplakia, histologically normal epithelium, and lichen planus. The clinical significance of HPV presence in carcinoma, leukoplakia, and lichen planus was not evaluable because of the short duration of follow-up.

Long-Term Response of Recurrent Respiratory Papillomatosis to Treatment with Lymphoblastoid Interferon Alfa-N1

Abstract Background. We earlier reported that patients with recurrent respiratory papillomatosis responded to six months of treatment with lymphoblastoid interferon alfa-n1. Because another study of patients treated for one year with leukocyte interferon alfa-n3 found that the growth rate of papillomas was slowed in the first six months but returned to base line during months 7 through 12 despite persistent interferon treatment, we now report the long-term results in our original study patients who were followed for a median of four years after the original one-year crossover study. Methods. After the patients in our study had completed the first study year, their physicians could continue or recommence treatment with lymphoblastoid interferon alfa-n1 in a dose of either 2 MU per square meter of body-surface area per day or 4 MU per square meter every other day. The extent of disease was measured by endoscopy when clinically indicated. Results. Data on late-follow-up were obtained for 60 of the 66 patient...

Risk factors for juvenile onset recurrent respiratory papillomatosis

Background.Children born to condylomatous mothers are at risk for developing juvenile onset recurrent respiratory papillomatosis (JORRP). We inquired whether the triad of vaginal delivery, being firstborn and maternal age of <20 years are also risk factors for JORRP.Methods.Data for JORRP and adu

Polymerase chain reaction identification of human papillomavirus DNA in CO2 laser plume from recurrent respiratory papillomatosis.

Human papillomavirus (HPV) DNA was identified in the plume produced during CO2 laser vaporization of respiratory tract papillomata. The plume produced from CO2 vaporization was collected on Gelfoam pledgets that were affixed to suction tips evacuating the vapor plume from the operative field. The Gelfoam pledgets were snap frozen in liquid nitrogen, processed, and examined for HPV-6 and HPV-11 DNA by a polymerase chain reaction technique. Tissue and vapor-plume specimens were collected from 22 patients undergoing CO2 laser excision of laryngeal lesions. Seven patients had adult-onset recurrent respiratory laryngeal papillomatosis (RRP), 12 had Juvenile-onset RRP, two had laryngeal carcinoma, and one had nonspecific laryngitis. HPV-6 or HPV-11 was identified in 17 of 27 vapor-plume specimens from RRP and in none of three from non-RRP lesions. All but one RRP tissue specimen contained HPV-DNA, and none of the non-RRP tissues contained HPV-DNA. When HPV was present in vapor, the same HPV type was found in the corresponding tissue specimen. Identification of HPV-DNA in the laser plume raises concern regarding potential risks from exposure to the plume—particularly to the endoscopic surgeon and the operating team. The practical concerns and effectiveness of the plume scavenging systems are discussed.

Bilateral Vocal Fold Motion Impairment: Pathophysiology and Management by Transverse Cordotomy

Although bilateral vocal fold paralysis (BVFP) is an uncommon disorder, bilateral vocal fold motion impairment (BVFMI) resulting from a variety of laryngeal derangements is encountered with increasing frequency. Moreover, pure BVFP accounts for only a small proportion of BVFMI. When antecedent factors associated with BVFP are absent, recognition of BVFMI is often delayed and frequently overlooked. The requirements for assessment and successful management of BVFMI are 1) recognition of its presence, 2) identification of the constituent factors restricting vocal fold motion, 3) objective assessment of airway patency, and 4) selection of a reliable management plan. More often than not, two or more BVFMI-causing factors are present; only rarely is BVFMI attributable to a single vocal fold motion-limiting cause. The clinical and endoscopic examinations should evaluate the relative contributions of vocal fold paralysis, cricoarytenoid joint fixation, infiltrative disorders, and webs and synechiae that cause restricted vocal fold motion. The flow-volume loop examination documents airflow rate and volume and the site, nature, and severity of the obstructing lesion(s). This presentation describes the evaluation and rationale for management in BVFMI. The surgical techniques currently used to address BVFMI are compared to determine their respective merits and drawbacks, depending upon the constituent factors causing vocal fold motion limitation.

Systemic lupus erythematosus in a child receiving long-term interferon therapy

Systemic lupus erythematosus (SLE) developed in a 10 1/2-year-old white boy with juvenile laryngeal papillomatosis who had been treated with interferon alfa-n1 for 7 years. His age, gender, and fast recovery after discontinuation of interferon therapy and institution of appropriate treatment for SLE are compatible with a diagnosis of drug-induced SLE. Autoimmune disorders may occur as a complication of interferon therapy.