Review Question - QID 214715

This patient has laryngeal papillomatosis as demonstrated by warts in the larynx (Figure A), chronic cough, shortness of breath, and hoarseness. Laryngeal papillomatosis is caused by the human papillomavirus, which can also cause genital warts.

The human papillomavirus (HPV) is a double-stranded DNA virus with more than 200 types. It is the most common sexually transmitted infection globally; most HPV infections typically resolve within 12 months. Different HPV types have a propensity to infect different body sites and subsequently result in different diseases. For example, cutaneous warts (e.g., plantar warts) are associated with HPV types 1, 2, and 4, while cervical cancer is most frequently associated with HPV types 16 and 18. Recurrent respiratory/laryngeal papillomatosis is most frequently associated with HPV types 6 and 11. The disease is separated into juvenile and adult papillomatosis. Patients typically present with hoarseness, shortness of breath, chronic cough, and stridor. More severe symptoms include dysphagia, pneumonia, recurrent upper respiratory infections, and failure to thrive. Diagnosis is made through visualization of the lesion, usually present in the larynx, using indirect laryngoscopy and confirmed via biopsy. The first-line treatment is the surgical removal of the papilloma though recurrence rates are high. Nonsurgical adjuvant treatments including antiviral drugs (e.g., cidofovir) have been used.

Figure/Illustration A is an indirect laryngoscopy study demonstrating cauliflower-like growths (red arrows) on the vocal cord characteristic of laryngeal papillomatosis.

Incorrect Answers:
Answer 1: Allergic rhinitis is associated with postnasal drip, which is a common cause of chronic cough. Patients typically present with itching, rhinorrhea, sneezing, and nasal congestion. This patient’s clinical presentation is inconsistent as he denies any rhinorrhea, sneezing, or congestion.

Answer 2: Barrett esophagus is associated with gastroesophageal reflux disease (GERD), which is also a common cause of chronic cough and can be associated with hoarseness. Constant reflux of gastric acid into the esophagus leads to the metaplastic change of the stratified squamous epithelium into simple columnar epithelium. However, this patient does not complain of heartburn, and his laryngoscopy findings are suggestive of laryngeal papillomatosis.

Answer 3: Chronic obstructive pulmonary disease (COPD) is associated with smoking, which can cause chronic bronchitis. Tobacco smoke causes inflammation and subsequent secretion of mucous in the airway. Cessation in smoking often leads to resolution of the symptoms. However, hoarseness is not a common presentation of the disease, and it is not associated with laryngeal lesions.

Answer 4: Eczema is a condition that is associated with asthma, which is a common cause of chronic cough. This patient has mild intermittent asthma that is, judging by his irregular albuterol use, well-controlled. Although his asthma may be contributing to his symptoms, his laryngoscope findings are more suggestive of laryngeal papillomatosis.

Bullet Summary:
Laryngeal papillomatosis is caused by the human papillomavirus, which is responsible for other disease states including genital warts.