Vocal PapillomasGrowths that occur in the airway, most commonly on the vocal cords.
What are vocal papillomas?
Vocal papillomas are growths that occur in the airway, most commonly on the vocal cords. They are caused by human papilloma virus (HPV). Because the growths are located on the vocal cords (the entry to the lungs), if they grow large enough they can impair the ability to breathe. Also, if left untreated, papillomas may spread into the lungs and can cause serious complications.
Because the papillomas tend to regrow, the disease is called recurrent respiratory papillomatosis (RRP).
What does that mean?
Vocal folds (also called vocal cords or, by some, vocal chords) are folds of tissue with a delicate lining on the outside.
When seen from above, the vocal folds look like a “V.”
That delicate lining may become infected with HPV and warts will grow in the vocal cord lining. These growths will spread and continue to enlarge until treatment is started.
Recurrent respiratory papillomatosis means:
- Recurrent: the disease tends to come back repeatedly, requiring repeated interventions
- Respiratory: the disease occurs in the respiratory tract, most commonly in the larynx
- Papillomatosis: this is the name of the warty growths that occur
What are the symptoms?
Symptoms of papilloma vary based on the severity of disease and your voice demands.
You will possibly notice:
- Hoarseness in your speaking voice
- Hoarseness (irregular, inconsistent quality) in your professional voice (singing, voiceover, etc)
- Difficulty breathing
- A sensation of a foreign body in the throat
- Hearing two pitches at the same time
- Decreased range (no longer hitting higher notes easily)
- Inability to sing quietly
- Throat discomfort, pain, or tightness
- Neck pain?
In children, symptoms are different and may include:
- Weak cry
- Episodes of choking
- Poor growth/failure to thrive
What do papilloma look like?
How do I know if I have a papilloma?
The only way to know if your symptoms are due to a papilloma is to have your vocal cords examined. This requires the use of videostroboscopy by a laryngologist.
Complications of papillomas
There are complications to papillomas. By definition, this is a surgical disease that often requires several surgeries to adequately control. If surgery is done by someone who is not skilled in microlaryngeal surgery, this will lead to:
- Permanent hoarseness
- Painful phonation/voice use
- Permanent loss of vocal range
Papillomas also have potentially life-threatening complications:
- Malignant transformation: 3-5% of papillomas may become cancerous
- Distal spread: if left untreated, papillomas can spread further into the airway, specifically into the lungs. Here they can cause devastating consequences, including death
How can I avoid having a complication?
Early diagnosis is the key to avoiding these complications. As soon as diagnosis is suspected, treatment must be initiated quickly to avoid the complications listed above.
Truths & Myths
I hear conflicting things about papilloma. What is the truth?
One of the most common myths about nodules is the diagnosis itself! Usually doctor’s don’t have the necessary equipment (stroboscopy) to diagnose vocal problems. So all problems are called nodules. Every singer has a colleague who had “nodules” for this reason.
Myth: Papillomas only occur in adults.
Truth: Papillomas occur in two general age groups: children (usually younger than 5 years old) and adults who are 30-40 years old. It is critical to have children evaluated if they are hoarse for more than one month. This is not normal and may be due to various problems. The only way to know if it is something serious, such as papilloma, is to have a laryngologist examine the child.
Myth: Papilloma only occurs in sexually active people.
Truth: It is true that papilloma is caused by human papilloma virus, the same virus that causes genital warts. However, papilloma is known to occur in infants as well as adults who are not sexually active. It is still not clearly understood why papilloma occurs in certain individuals. However, risk factors include having multiple sexual partners and engaging in frequent oral sex.
Myth: Papilloma is not curable.
Truth: Papilloma is a difficult disease to treat, and recurrence is very common. However, when managed with proper surgical technique and medical therapy, it can be treated effectively.
Myth: I will need many surgeries to treat my papilloma.
Truth: It used to be that children with papilloma would have to undergo 20-30 surgeries over the course of a lifetime to control their disease. However, when proper treatment is quickly instituted by an expert in papilloma removal, this can be significantly reduced.
Myth: I will be permanently hoarse due to papillomas or treatment of them. There’s no point to having surgery if I’m going to be hoarse either way.
Truth: It is true that papilloma will cause permanent hoarseness if untreated. However, leaving papilloma untreated is not an option. The risk of disease spread is very high and may be fatal. Surgical treatment does risk permanent voice changes. However, cutting-edge voice medicine done by a trained laryngologist limits this risk. Many patients, when managed correctly, can have control of their disease and a perfectly normal voice as well.
What is the treatment?
Treatment is most effective when papilloma is caught early and diagnosed correctly.
This may seem simple, but without videostroboscopy is nearly impossible.
How do you handle vocal papilloma?
At the Division of Voice at the Osborne Head and Neck Institute (OHNI), we pride ourselves on unparalleled care of complex diseases, such as recurrent respiratory papilloma. We take the utmost care to prevent poor voice outcomes. Your evaluation at OHNI includes:
- A complete history
- A complete physical exam of the head and neck
- Treatment planning
Appropriate treatment of papilloma is extremely complicated and involves management of medical problems as well as complex surgical and in-office techniques. This includes laser and microlaryngeal surgery as well as utilization of the newest anti-viral medications available. It is only with access to all these modalities that papilloma may be treated with minimal impact on the voice, as seen (and heard) in the videos below.
The video on the left demonstrates a patient with moderate papilloma disease. While stroboscopy demonstrates some disease, surgical evaluation demonstrated more papilloma involving both vocal cords and extending below the vocal cords. The video on the right demonstrates the patient’s vocal cords after aggressive initial management with control of his disease and return of normal voice. After initial management, the patient has been disease free and has not required surgery for several years.
Can I just see my regular doctor?
Unfortunately, few people are trained to correctly diagnose and treat voice disorders. Further, many general practitioners will ignore hoarseness, especially when other concerning symptoms are not present (difficulty breathing, etc). However, this delay could have serious consequences.
Only a laryngologist can accurately diagnose and treat you, and help prevent you from having a worse problem.
What should I ask my doctor when I see him/her to ensure I’m getting the right treatment?
It is very difficult for a patient to differentiate a qualified voice physician from a general ENT.
You should ask your voice physician/laryngologist the following questions to ensure you are getting the treatment you deserve:
- Are you board certified in ENT?
- Are you fellowship-trained in laryngology?
- Do you perform videostroboscopy?
- Do you perform the examination on your patients?*
- When surgery is needed, do you perform the surgery yourself or are there other doctors or doctors-in-training involved?*
- Are you able to use multiple modalities, including medical and surgical management, to control the disease?
- What vocal outcomes do your patients have?
*Often, laryngologists are located in facilities where residents or fellows (doctors-in-training) perform a large portion of the services.
Does insurance pay for a laryngologist visit?
If the laryngologist accepts insurance, your visit is usually covered. Laryngoscopy with stroboscopy is also usually covered. It is best to ask your doctor’s office billers to clarify insurance issues.