Neoplasms of the Larynx, Trachea, and Bronchi

Vocal Nodules

Saied Ghadersohi

James W. Schroeder

Vocal nodules , which are not true neoplasms, are the most common cause of chronic hoarseness in children. Chronic vocal abuse or misuse (i.e., frequent yelling and screaming) produces localized vascular congestion, edema, hyalinization, and epithelial thickening in the bilateral vocal cords. This grossly appears as nodules that disrupt the normal vibration of the cords during phonation. Vocal abuse is the main factor, and the voice is worse in the evenings. Differential can include unilateral lesions such as vocal cord cysts and polyps; however, these usually have an acute inciting event and are rarer in children.

Treatment is primarily nonsurgical with voice therapy used in children >4 yr of age who can participate in therapy, and clinical monitoring with behavioral therapy in younger children or those with developmental delay. In addition, laryngopharyngeal reflux commonly exacerbates vocal abuse–induced irritation of the cord, Therefore antireflux therapy can also be implemented (see Chapter 349 ). Surgical excision of vocal cord lesions in children is controversial and is rarely indicated but may be necessary if the child is unable to communicate adequately, becomes aphonic, or requires tension and straining to make any utterance whatsoever.

Recurrent Respiratory Papillomatosis

Saied Ghadersohi

James W. Schroeder

Papillomas are the most common respiratory tract neoplasms in children, occurring in 4.3 in 100,000. They are simply warts—benign tumors— caused by the human papillomavirus (HPV), most commonly types 6 and 11 (see Chapter 293 ). Seventy-five percent of recurrent respiratory papilloma cases occur in children younger than age 5 yr, but the diagnosis may be made at any age. In general, neonatal-onset disease is a negative prognostic factor with higher mortality and need for tracheostomy. Sixty-seven percent of children with RRP are born to mothers who had condylomas during pregnancy or parturition. The mode of HPV transmission is still not clear. Neonates have been reported to have RRP, suggesting intrauterine transmission of HPV. Despite close association with vaginal condylomata, only 1 in 231 to 400 vaginal births go on to develop respiratory papillomatosis. Therefore other risk factors contribute to transmission, and C-section delivery for prevention cannot be recommended. However, preventive measures can include the prospective widespread use of the quadrivalent HPV vaccine to help eliminate maternal and paternal HPV reservoirs and possibly decrease cases of RRP caused by HPV 6 and 11.

Clinical Manifestations

The clinical course involves remissions and exacerbations of recurrent papillomas most commonly on the larynx (usually the vocal cords), causing progressively worsening hoarseness, sleep-disordered breathing, exertional dyspnea, stridor, and, if left untreated, eventually severe airway obstruction ( Fig. 417.1 ). Although it is a benign disease, lesions can spread throughout the aerodigestive tract in 31% of patients, most commonly the oral cavity, trachea, and bronchi. Rarely these lesions can undergo malignant conversion (1.6%); however, some patients may have spontaneous remission. Patients may be initially diagnosed with asthma, croup, vocal nodules, or allergies.