What Is Recurrent Respiratory Papillomatosis?

Ullman first believed that the onset of JLP was related to human papilloma virus (HPV) infection in 1923. HPV is a type of DNA tumor virus with a belly structure. According to the homology of DNA, HPV can be divided into multiple subtypes. The subtypes that are homologous to HPV6 and HPV11 are called low-risk types and often cause benign lesions such as laryngeal papilloma. Humans are the only natural host for HPV. LP can occur in patients of any age, the youngest 1 day. The oldest is 84 years old. Kashima et al. [3] pointed out that juvenile recurrent respiratory papilloma is different from adult LP in epidemiology. The former is related to the birth of the first child, vaginal delivery and the mother's minor; the latter is more inclined to its sexual behavior. ; 50% to 68% of mothers of children with recurrent respiratory papillomatosis (RRP) have a history of vaginal warts. The risk of LP in babies born by caesarean section is significantly reduced. Studies by Yao Hongbing and others showed that CerbB-2 and HPV16 genes were expressed in laryngeal papilloma tissues.

Zhang Feng	(Attending physician)	Department of Otorhinolaryngology, Children's Hospital, Chongqing Medical University
Yao Hongbing	(Deputy Chief Physician)	Department of Otorhinolaryngology, Children's Hospital, Chongqing Medical University

Laryngeal papilloma is a benign tumor of the larynx and is more common clinically. Although laryngeal papilloma is a benign tumor in histology, it has multiple characteristics and is prone to recurrence, which is likely to cause respiratory tract obstruction. Multiple surgeries can cause larynx stenosis and vocal disturbance, which will cause heavy economic and economic harm to patients and their families. Psychological burden. Especially in recent years, with the increase of sexually transmitted diseases and infectious diseases, children's laryngeal papilloma has a tendency to increase significantly. The annual incidence of juvenile onset laryngeal papilloma (JLP) in children is 3.6 to 100,000 to 4.3 per 100,000, 80% of which occur before the age of 7, especially under 4 years old.

Western Medicine Name

Pediatric laryngeal papilloma

The main symptoms

Progressive hoarseness, throat wheezing

Main cause

Viral infection

Causes and mechanisms of pediatric laryngeal papilloma

Pediatric laryngeal papilloma virus infection theory

Ullman first believed that the onset of JLP was related to human papilloma virus (HPV) infection in 1923. HPV is a type of DNA tumor virus with a belly structure. According to the homology of DNA, HPV can be divided into multiple subtypes. The subtypes that are homologous to HPV6 and HPV11 are called low-risk types and often cause benign lesions such as laryngeal papilloma. Humans are the only natural host for HPV. LP can occur in patients of any age, the youngest 1 day. The oldest is 84 years old. Kashima et al. [3] pointed out that juvenile recurrent respiratory papilloma is different from adult LP in epidemiology. The former is related to the birth of the first child, vaginal delivery and the mother's minor; the latter is more inclined to its sexual behavior ; 50% to 68% of mothers of children with recurrent respiratory papillomatosis (RRP) have a history of vaginal warts. The risk of LP in babies born by caesarean section is significantly reduced. Studies by Yao Hongbing and others showed that CerbB-2 and HPV16 genes were expressed in laryngeal papilloma tissues.

Inhibition of Apoptosis of Laryngeal Papilloma in Children

Some scholars have detected that the expression of apoptosis-inhibiting gene BCI 2 is increased in laryngeal papilloma cells, while the expression of BCL-2 associated Xprotein. Bax is reduced, thereby promoting cell growth. Tang Qiao et al. [6] studied the relationship between the apoptosis-inhibiting protein Livin gene and laryngeal papilloma, and found that there was no Livin expression in normal laryngeal mucosa and no recurrent laryngeal papilloma, but it was expressed in recurrent papilloma. Highly expressed in multiple relapsed papillomas. This shows that Livin gene plays an important role in the occurrence, development and recurrence of laryngeal papilloma.

Chronic Inflammatory Stimulation Theory of Pediatric Laryngeal Papilloma

Some scholars have observed the signs of neutrophil swallowing by laryngeal papilloma cells with electron microscope, and it is speculated that the occurrence or recurrence of laryngeal papilloma is related to chronic inflammation stimulation.

Laryngeal papilloma and estrogen in children

Foreign scholars have reported that estrogen is closely related to the occurrence and development of laryngeal papilloma, so some people have promoted the use of estrogen replacement therapy to treat laryngeal papilloma. With age, laryngeal papilloma has a tendency to heal itself, and it is speculated that the occurrence of laryngeal papilloma may be related to hormone levels.

Pediatric laryngeal papilloma heme oxygenase

As an important biologically active substance, cyclooxygenase (C0X) exists widely in the microsomes of animal cells, and as an inducible heme oxygenase, COX-2, its up-regulation mechanism is caused by cancer. key step. Studies have shown that the expression of heme oxygenase in laryngeal papilloma tissue is significantly increased. The activation of heme oxygenase plays an important role in the growth of laryngeal papilloma cells. ^[1-3]

Pathophysiology of laryngeal papilloma in children

The incidence of pediatric laryngeal papilloma is generally considered to have its histological characteristics, that is, it is easy to occur at the junction of respiratory ciliary epithelium and squamous epithelium. The main anatomical parts with this histological feature are the nasal threshold, the soft nasal and nasopharyngeal planes, the epigolian laryngeal plane, the upper and lower edges of the larynx, below the vocal cords, the trachea, and the bronchial tree. Rough observation of typical mastoid tumor lesions has a characteristic flesh-colored cauliflower-like appearance, and benign squamous epithelial mastoid hyperplasia under a microscope. The structure of the nipple was neat and did not invade the basement membrane, and the tissue morphology of the recurrent tumor remained good.

Clinical manifestations of laryngeal papilloma in children

Pediatric laryngeal papilloma can occur in children of any age, mostly concentrated within 4 years of age, and the minimum age of onset is 1 day of age. The most common symptom is progressive hoarseness. Throat wheezing or even loss of sound may occur when the tumor is large. In severe cases, breathing may be difficult. Laryngoscopy showed multiple or single pale red or dark red, uneven surface, cauliflower or papillary tumors.

Papilloma can occur in various parts of the respiratory tract from the nasal vestibule to the lungs. The larynx is the most commonly affected part. About 96% of children involve the larynx, and the vocal cords are the most invasive parts of the larynx. They affect the vocal area. Normal closure of the vocal cords, resulting in hoarseness. When children are infected with HPV, which is more virulent, it can spread widely through the respiratory tract and reach the lung parenchyma. When the lungs are affected, it will be fatal.

Diagnosis and differential diagnosis of laryngeal papilloma in children

The typical symptoms of this disease are the triad of progressive hoarseness, wheezing, and dyspnea. Combining medical history and laryngoscopy to find broad-based multiple or single pale red, dark red, uneven surface, cauliflower or mastoid tumors can be initially diagnosed, but the final diagnosis requires pathological examination results. At the same time, it is necessary to attach great importance to the occurrence of multi-site involvement. CT scans can help diagnose lesions that spread outside the throat. In actual diagnosis, due to the slow development of the disease course, some patients are often suspected to have this disease until the tumor blocks the airway and causes dyspnea. At this time, tracheotomy is often required.

The disease needs to be differentiated from vocal nodules, vocal cord paralysis, subglottic cysts, and subglottic stenosis. This can be distinguished by soft laryngoscope and CT scan. If the child has symptoms of hypoxia such as shortness of breath, weakness, assisted breathing of the respiratory muscles, cyanosis of the mucous membranes, it is necessary to check under the equipment of tracheal intubation, endoscopy and tracheotomy. The oximeter can quantitatively analyze the respiratory status of children, which is more accurate. Patients with stable conditions may be diagnosed with asthma. Measurement of pulmonary function combined with arterial blood gas analysis can help identify. ^[4-5]

First aid measures for pediatric laryngeal papilloma

Parents of children with laryngeal papilloma should pay close attention to their breathing. When the child's upper airway is obstructed to have difficulty breathing, hypoxia manifestations, such as nasal agitation, nodding breathing, cyanosis of the lips, inhalation "triple depression", etc., and dyspnea - ° should be treated immediately. The attending physician gave oxygen inhalation, quickly established venous channels, performed continuous ECG monitoring, and arranged for special care, and closely observed the breathing frequency, rhythm, depth, blood oxygen saturation, and cyanosis. A rescue device such as a laryngoscope, tracheostomy bag, tracheal intubation, and aspirator is prepared at the bedside to keep patients as quiet as possible. Drug sedation can be given and simple breathing sacs can be given pressure and oxygen. Emergency tracheotomy is the only way to maintain airway patency when the symptoms mentioned above cannot be relieved.

Pediatric laryngeal papilloma disease treatment

Pediatric laryngeal mastoid tumor has always been a very difficult disease to treat. Although it is a benign lesion in nature, it has a special location and is easy to relapse after resection. There is even the possibility of spreading life threatening. No method has been found to effectively control or eliminate human papilloma virus. At present, the treatment methods are mostly combined with surgical treatment and drug treatment. Usually requires multiple operations to be cured.

Pediatric laryngeal papilloma drug treatment

Including various antiviral and immunotherapeutic methods, among which interferon has the functions of regulating the immune system, antiviral and resistance to cell division and proliferation. Interferon-type interferon is a commonly used drug in clinical practice. After its effect, it can resist HPV gene expression inducing boarding Apoptosis of cells, inhibition of tumor angiogenesis, localization of papilloma growth sites, prolonged recurrence time, in addition to antiviral effects of -type interferons "regulates the body's immunity" may be through enhanced inhibition of viral protein synthesis The expression of protein kinases and endonucleases regulates the host's immune response [7]. In addition to the measles vaccine's therapeutic effect, in addition to enhancing the host's immunity, there may be other factors, such as biological immunity, which may be the symbiosis of two viruses, which have the effect of inhibiting and interfering with each other. These are the other two drugs. do not have.

In addition, in recent years, new therapeutic drugs have continuously emerged, and research on human papilloma virus vaccines has made great progress. Some studies have shown that [8]: Pidotimod has a certain effect on enhancing the immunity and reducing recurrence of children with laryngeal papilloma.

Surgical treatment of laryngeal papilloma in children

Main purpose: Relieve airway obstruction, maintain breathing patency, and reduce airway resistance. Protect the laryngeal mucosa and the integrity of the larynx, reduce the damage to the vocal fold tissues, and avoid iatrogenic secondary injuries such as the formation of larynx webs due to vocal cord adhesions. Prolong the recurrence time and reduce the number of operations.

Thoracic papilloma resection is the only method of treatment. Most scholars believe that intermittent high frequency ventilation under general anesthesia and direct laryngoscope to clamp the tumor is currently the most effective treatment. Commonly used techniques for surgery: micro-incision aspiration technology, low-temperature plasma radiofrequency ablation technology, laser technology, etc. In the treatment of children with multiple recurrent respiratory mastoid tumors, multiple surgical procedures are necessary when necessary, but tracheotomy is still important for children who have difficulty breathing or who have multiple relapses in the short term. One of the treatments. Regardless of the surgical technique, it should be fully understood that the tumor tissue may not be completely removed, and sometimes a small amount of diseased tissue is allowed to remain.

Micro-suction-to-suction technique is currently the main surgical resection technique for the treatment of pediatric laryngeal mastoid tumors. Its special suction-suction head can accurately resect the diseased tissue and cause less damage to normal mucosa. The advantages of low-temperature plasma knife radiofrequency ablation It does not need to protect the endotracheal tube, there is no bleeding, no pressure, and it is widely used.

Tracheotomy: Tracheotomy is the only way to maintain airway patency when the laryngeal obstruction is severe or it is difficult to relieve the child's dyspnea through intra-laryngeal surgery [9]. In our department, tracheotomy is performed for some recurrent laryngeal papilloma. The results of long-term clinical follow-up studies show that the number of operations performed in children with tracheotomy and without tracheotomy is significantly more significant than the latter. Reduced, significantly prolonged the interval between operations, can reduce vocal cord damage caused by surgery, adhesions and various complications caused by general anesthesia, and can significantly reduce the financial burden of children's parents. Therefore, we consider tracheotomy to be an effective method. But care after tracheotomy is essential.

Surgical complications: mainly including posterior glottal stenosis, anterior commissural larynx formation, and stenosis. In addition, it also includes subglottic stenosis and tracheal stenosis. Serious complications include pneumothorax and intratracheal combustion, which will cause severe trachea. With lung injury. For children with multiple recurrences more than 4 times a year, a strict surgical plan is required. Regular surgery is performed according to changes in the condition. For children with long recurrence intervals, laryngoscopes should be reviewed regularly to determine the extent of the disease and the timing of surgery.

Prognosis of laryngeal papilloma disease in children

Due to the possibility of multiple relapses. There are many reasons for its recurrence, which are related to the autoproliferative tendency of the tumor, and the scope of viral infection larger than the scope of tumor growth, and may be related to the effect of bleeding during laryngoscope surgery, which makes it difficult to completely remove the tumor. The mechanism of recurrence is currently described in two ways, one is planting, and the other is activating the inactive virus. The interval between tumor recurrences is different in different children. Generally, it recurs within 2 to 6 months after surgery, but with the increase of the number of operations, the interval between recurrences gradually increases. After puberty, the trend of recurrence diminishes, and some of them can disappear on their own.

Nursing care of children with laryngeal papilloma

Laryngeal papilloma has a certain self-limiting nature, the tendency of relapse after puberty decreases, and it can even disappear on its own. Parents of children should establish confidence in treatment. Due to the recurrent nature of this disease, children must be treated for a long period of time, tolerate the pain that many peers do not have, and often show different levels of psychological reactions, such as autism, lack of self-confidence, and rebellion. Psychological and financial stress and showing bad moods and attitudes can increase anxiety in children. As medical workers, they should provide adequate psychological support, help children adjust their bad psychology, treat the disease scientifically, and make them better adapt to society.

For children with laryngeal papilloma undergoing tracheotomy, postoperative care and home care are essential for recovery. First, children should be provided with a quiet, clean, fresh air living environment, maintaining a room temperature of 20-22 ° C and a humidity of 60% to 70%. This kind of children should be taken care of by a special person. If the children are already in school, teachers and classmates should be advised to avoid any accidents. Oral secretions entering the lower respiratory tract are an important source of infection, and oral care should be strengthened. Use oral care solution according to oral pH, scrub 2% -3% boric acid when pH is high, scrub 2% sodium bicarbonate when pH is low, and use 1% -3% hydrogen peroxide or saline when pH is neutral Scrub to reduce the chance of a lung infection. Prevent water from splashing into the tracheal tube when bathing. To strengthen nutrition, it is advisable to enter a high-calorie, high-protein, high-vitamin diet, and ban strong tea, coffee, and spicy foods.

Secondly, the airway should be kept open and the inner cannula should be cleaned from time to time. Before discharge, the family members should be instructed to remove and insert the inner cannula, clean and disinfect the inner cannula, and replace the skin dressing around the tracheotomy. When removing the inner cannula, first suction the sputum, hold the ears of the outer tube with one hand, and rotate the flap on the mouth of the inner cannula with the other hand, and gently remove it. Do not pull it out forcibly. Bring out. There are two methods of disinfection: (1) soaking method. After the inner catheter is pulled out, first soak in 3% hydrogen peroxide for 15 minutes, wash the sputum and soak in 3% hydrogen peroxide for 15 minutes, and then flush it with normal saline to insert it naturally along the airway. (2) The boiling method. First take out the inner tube for preliminary cleaning, put it in a special pot and boil it for 15 minutes, take it out and wash it in another container, boil it, boil it for another 15 minutes, and insert it after cooling. People with sputum should first suction and then place the tube, depending on the amount of sputum 3 to 4 times a day. The removal time should not exceed 30 minutes. The surrounding skin of the trachea was sterilized with 75% alcohol daily, and the sterile gauze was changed once, keeping the local dry and clean. If there is redness and swelling, local care should be strengthened, and more than one hundred states or erythromycin ointment can be applied. Before leaving the hospital for sputum suction, family members should be trained in proper suctioning methods. Pay attention to the changes in breathing sounds. Normally, it should be a tube breathing sound. When there is sputum, a sputum sound appears. When the pseudo-membrane of the lower end of the sleeve is covered, you will hear a crackling sound with the breath. When the lower end is blocked by phlegm or blood, the breathing becomes sharp and laborious. When the sleeve makes a sound when breathing, it means that there is a sticky secretion in the sleeve that should not be coughed. It should be sucked out in time. After suctioning, drop the medicine into the trachea and cover the mouth of the sleeve with a wet single layer of saline gauze. Humidification can increase the humidity of the inhaled air. The depth of the suction tube is generally 5 to 10 cm. The method of rotation, suction, and withdrawal should be adopted. The suction should be no more than 15 seconds each time. If the sputum is more needed to be re-attracted, it should be rested for 3 ~ 5 wan and then sucked, during which the condition can be given oxygen inhalation. Strictly perform aseptic procedures to reduce the chance of infection. The suction tube is changed one at a time to enter the airway for suction. Once the suction tube has been withdrawn from the tracheal tube, it cannot be reinserted. The suction tube entering the airway must not be contaminated, and it should be replaced in time if it is suspected to be contaminated. The connecting pipe and drainage pipe of the suction device should be replaced every day. If the sputum is thick and sticky, it can be given to Mousutan atomization, and cooperate with row back. Tracheal tube detubation is one of the serious complications after tracheotomy, and it must be strictly prevented.

Because pediatric laryngeal papilloma is very easy to recur, parents should learn to observe the patient's breathing and judge whether the patient has breathing difficulties based on the presence of throat soreness, blue lips and irritability. Follow up regularly every month. If there is any abnormality in normal times, immediately go to the Otolaryngology Clinic for clear diagnosis and treatment. ^[6]