Abstract
Juvenile recurrent respiratory papillomatosis (JRRP) is the most common benign tumor in the larynx. It is uncommon; however, it is potentially life-threatening because it compromises the respiratory tract and required several surgeries to manage recurrences. Currently, the carbon dioxide laser is the treatment of choice. There are no studies about the role of the diode laser which is easy to use and has lower usage cost. This case series presentation reported on the therapeutic effects and recurrence rate of JRRP when using Diode laser. This is a case series presentation of 13 children, who were diagnosed with JRRP and operated for laryngeal papillomatosis with Diode laser in Otorhinolaryngology and Head and Nick Surgery Department et al. Mouwasat Hospital, Damascus, Syria between 2015 and 2022. 13 children required 56 surgeries at a rate of 1–2 surgeries/year, mean number of surgeries for each child was 4.31. That suggests that Diode laser might have a role in reducing the number of surgeries compared to a study used cold instrument and CO2 laser. The complications rate was 30.8%, which is considered a high rate compared to the other studies. In conclusion, we encourage using it when the CO2 laser device is not available. However, we suggest, reducing the power as low as possible and avoiding of two opposing raw surfaces, especially at the anterior commissure and deep excision. Further longitudinal studies are recommended to validate these results.
Keywords: Juvenile recurrent respiratory papillomatosis, Diode laser, HPV
Introduction
Recurrent respiratory papillomatosis (RRP) is the most common benign laryngeal neoplasm and the second most common cause of the hoarseness in children. It is characterized by the proliferation of benign squamous papilloma anywhere in the aerodigestive tract; however, the most common site is the larynx [1]. There are two peaks of distribution related to age of onset. The juvenile-onset peak occurring at 3– 4 years of age, which is more aggressive and recurrent; and the adult-onset peak occurring at 20–30 years of age with less aggressive and recurrent behavior [2]. Juvenile-onset RRP is an uncommon condition, with a prevalence of about 4 in 100 000 children [3]. It is caused by Human papilloma virus (HPV) type 6 and 11, that transmits to the newborn during vaginal delivery. However, in-utero and transplacental transmission may play a minor role [4]. The vocal folds are usually the first and predominant site of papilloma`s lesions, hoarseness is the principal presenting symptom in RRP. The child’s voice is described as hoarse or weak. Stridor is often the second clinical symptom to develop [5]. The clinical diagnosis should be established with fireoptic nasolaryngoscopy. The current standard of care is surgical therapy (cold steel, laser, microdebrider) with the goal of complete removal of papilloma and preservation of the normal structures [6]. Although surgical management remains the mainstay therapy for RRP, some patients will require some forms of adjuvant therapy such as interferon α, cidofovir, MMR vaccine, indol-3-carbinol, etc. [7].
In the last decades, the carbon dioxide (CO2) laser has the superiority over cold instruments in the RRP management [8]. KTP and PDL are the other types of lasers have been used in the treatment of papilloma. Previous studies, reported successful outcomes with higher rates of regression up to 90% [9, 10]. Semiconductor Diode laser is a relatively new technology introduced in otolaryngology. The Diode laser pump source is an electrical current and the active laser medium is a semiconductor, such as gallium arsenide. The light emitted is in the near infrared range (800–1100 nm) [11]. Diode laser has many significant benefits include a much smaller spot size than other conventional lasers, lower usage cost, and the easy setup and fast procedure. Due to the penetration depth and the absorption of light beam by melanin and hemoglobin in the body tissue, photocoagulation introduced by Diode laser makes it superior compared to the CO2 laser [12]. Its most unique feature is flexibility and the ability to be directed around corners. Thus, it is proposed as an excellent alternative to the standard CO2 laser in patients with difficult laryngoscopy due to anatomical or other pathological reasons. Several previous studies reported, that Diode laser has an important role in treatment of various benign laryngeal lesions with few complications and good results [13–15]. However, there is no studies about the role of the Diode laser in treatment of recurrent respiratory papillomatosis and its effect on the clinical course of this disease. Thus, the current study aimed to find out the therapeutic effects and recurrence rate of PRP when using Diode laser. In this case series presentation, we reported the outcomes of using Diode laser in our center on the clinical course of the RRP in 13 children, as it is the only device available in our center and its results were comparable to other techniques.
Case Presentation
Patients
This is a case series presentation of 13 children, age 4.43 ± 3.4 years, who were diagnosed with respiratory papillomatosis by endoscopy and biopsy and operated for laryngeal papillomatosis with Diode laser in Otorhinolaryngology and Head and Nick Surgery Department at Al Mouwasat Hospital, Damascus, Syria between 2015 and 2022. The diagnosis was put pathologically as squamous papilloma by pathologist all participants had been treated using diode laser.
Procedure
We used the Diode laser (biolitec®), which has Wavelength: 980 nm, Power output: 25 watt (max), Pilot beam: 635 nm ± 30 nm; PWM 4 mW (max.) (Fig. 1).
Fig. 1.
diode laser device, a device screen, b device properties, c handpiece for the laser delivery system
For all cases, the treatment was carried out under general anesthesia and intubation, with a rigid laryngoscope. The intensity of Diode laser was 5–8 W. The follow up was scheduled every 1–3 month for all patients, however some of them, did not follow the instructions and visiting the center routinely, instead they came back only when recurrence occurred.
Results on Follow Up
31 children (11 males) were diagnosed at age between 2 and 9 years. The most common presenting symptom was Hoarseness or a weak crying sound. The location of the lesions at the first laryngoscopy was at more than one level in the most of children. See Table 1.
Table 1.
Descriptive data of the studied cases
| Presenting symptoms* | |
|---|---|
| Hoarseness or a weak crying sound | 11 (84.6%) |
| Dyspnea | 4 (30.8%) |
| Stridor | – |
| Cyanosis | – |
| Cough | 2 (15.4%) |
| location of the lesions supraglottic/glottic/more than one level |
2/5/6 15.4%/38.5%/46.2% |
*Many patients had more than one presenting symptom
The total number of surgeries was 56, ranged between 2 and 8 surgeries for each child, at a rate of 1–2 surgeries/year. Complications occurred in 4 children (30.8%). They required 10 additional surgical interventions to treat the complications (during these surgeries there was no papilloma). Tracheostomy was performed for four patients (30.8%), all of them had distant spread of lesions at the tracheostomy stoma only and none of them had distant spread to trachea and bronchi (Table 2).
Table 2.
follow up after laser therapy
| Total number of surgeries | 56 |
|---|---|
| Number of surgeries per year | |
| 1 | 4 (30.8%) |
| 2 | 9 (69.2%) |
| Total number of surgeries for each child | |
| 2 | 5 (38.6%) |
| 4 | 4 (30.8%) |
| 7 | 2 (15.4%) |
| 8 | 2 (15.4%) |
| Complications* | |
| Anterior web | 2 (15.4%) |
| Supraglottic stenosis | 2 (15.4%) |
| Glottic stenosis | 2 (15.4%) |
| Number of additional surgeries to treat complications | |
| 1 | 2 (15.4%) |
| 4 | 2 (15.4%) |
| Tracheostomy | 4 (30.8%) |
| Distant spread of lesions | |
| Tracheostomy stoma only | 4 (30.8%) |
*Many patients had more than one complication
Discussion
Juvenile Recurrent respiratory papillomatosis is uncommon; however, it is potentially life-threatening because it compromises the respiratory tract and required several surgeries to manage recurrences. Currently, the carbon dioxide laser is the treatment of choice. Diode laser has many significant benefits include a much smaller spot size than other conventional lasers, lower usage cost, easy setup and fast procedure. It has an excellent photocoagulation ability because it is absorbed by melanin and hemoglobin. Several previous studies reported, that diode laser has an important role in treatment cord paralysis, subglottic vascular lesion, and other laryngeal lesions with few complications and results was similar to the CO2 laser [13–15]. However, there is no studies about the role of the diode laser in treatment of recurrent respiratory papillomatosis. This case series presentation reported on the therapeutic effects and recurrence rate of JRRP when using Diode laser.
In this case series presentation, 13 children required 56 surgical interventions (mean number of surgeries for each child was 4.31) using Diode laser. That suggests that Diode laser might have a role in reducing the number of surgeries, and thus improving the course of the disease, through the ability of the Diode laser to coagulate the lesions precisely with minimal bleeding, and the less trauma of the healthy epithelium, which predisposes to arise new lesions at the site of the trauma. The latent HPV virus in basal cells is reactivated if any trauma occurs [16]. In a similar German study on 27 children with recurrent respiratory papillomatosis, these children required 173 surgical interventions (mean number of surgeries for each child was 6.41) using CO2 laser and cold instrument [17].
On follow up, the complications rate was 30.8%, which is considered a high rate compared to the other studies, used this type of laser in management various laryngeal lesions [15]. Such a clinical observation might be due to the thermal effects of Diode laser on tissues, where some researchers noticed that Diode laser with 3-5 watt can results thermal coagulation that CO2 laser can not do at this same level of power [18]. In a systematic review (2022) the complications rate was 17.7% in a group of patients with recurrent respiratory papillomatosis that were operated using CO2 laser [19].
In conclusion, the diode laser had good results in the treatment of RRP, we encourage using it when the CO2 laser device is not available. However, we suggest, reducing the power as low as possible and avoiding of two opposing raw surfaces, especially at the anterior commissure and deep excision. Further longitudinal studies are recommended to validate these results.
As a limitation of this study we have not a post-operative voice assessment because the center in which this study was conducted does not have specialists to assess the voice nor the necessary tools for that, although a post-operative voice comparison between CO2 and Diode Laser would have been a better indicator of comparison rather than complication, since complications may be result of extensive lesion and not just the nature of the LASER.
Acknowledgements
We thank all patients who participated in this research.
Abbreviations
- JRRP
Juvenile recurrent respiratory papillomatosis
- CO2 laser
Carbon dioxide laser
- KTP laser
Potassium titanyl phosphate laser
- PDL laser
Pulsed dye laser
Author’s Contribution
SK collected and analyzed data and wrote the paper; SM wrote the paper.
Funding
No funding was received to assist with preparation of this manuscript.
Data Availability
Information from the archive of Otorhinolaryngology and Head and Nick Surgery Department in Al Mouwasat Hospital, Damascus, Syria between 2015 and 2022 were utilized. We used the diode laser(biolitec®), which has Wavelength: 980 nm, Power output:25 W (max), Pilot beam: 635 nm ± 30 nm; PWM 4 mW (max.).
Declarations
Competing interests
The authors have no competing interests to declare that are relevant to the content of this article.
Ethics approval
This study was a part of a master degree dissertation project in the otolaryngology that was accepted and approved by Faculty of Medicine Damascus University.It respects the ethics of medical research and the principles of Helsinki.
Consent to participate
Informed consent was obtained from all individual participants included in the study.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Information from the archive of Otorhinolaryngology and Head and Nick Surgery Department in Al Mouwasat Hospital, Damascus, Syria between 2015 and 2022 were utilized. We used the diode laser(biolitec®), which has Wavelength: 980 nm, Power output:25 W (max), Pilot beam: 635 nm ± 30 nm; PWM 4 mW (max.).