Squamous Cell Papillomatosis in the Setting of Recurrent Respiratory Papillomatosis

Pasha L. Bentley, Michael J. Coulter, Brenda L. Nelson

A 23 year old male presented to the Otolaryngology clinic with 6 months of hoarseness and poor voice projection without improvement from speech therapy or medical anti-reflux medication. Upon examination he was found to have multiple polypoid lesions emanating from bilateral false vocal folds, left true vocal fold, and the anterior commissure. Biopsy and potassium titanyl phosphate (KTP) laser ablation with bevacizumab injection provided treatment and confirmed the clinical suspicion of squamous cell papilloma. Despite 3 years of treatment, the papillomatosis proved difficult to control, requiring a procedure approximately every 3 months. In an attempt to control the course of the disease the patient received a series of three bevacizumab and three cidofovir injections. Serial biopsies showed mild atypia within the squamous cell papillomas. Two separate biopsies confirmed presence of human papillomavirus (HPV) 6/11 via in situ hybridization with appropriate controls. There is promising research that the quadrivalent HPV (types 6, 11, 16, and 18) vaccine both reduces the disease burden in patients with active disease and reduces the incidence of recurrent respiratory papillomatosis (RRP). Other studies have shown that local immunologic dysregulation may play a role in RRP pathogenesis. Therefore new treatment options, to include PDL-1 blockade, offer hope in treating this benign condition with high morbidity and rare mortality.