Laryngopharyngeal Reflux and Laryngeal Web Formation in Patients With Pediatric Recurrent Respiratory Papillomas

INTRODUCTION
Recurrent respiratory papillomatosis (RRP) is the most common benign tumor of the pediatric larynx. Since the 1970s, the surgical treatment of choice has been endoscopic excision, usually performed with a CO2 laser. However, this treatment is only palliative, and patients are often subjected to numerous procedures to keep the airway patent until the disease process regresses and the rate of growth decreases. The complications associated with each procedure can be grouped into those which are immediate (airway fire, hemorrhage, loss of airway, pneumothorax) and those which have delayed onset.

The laryngeal soft tissue complications from surgery for RRP have been described, and include laryngeal webs, stenosis, vocal fold scarring, and arytenoid fixation.  Surgical technique itself greatly influences the rate of complications, and the techniques of mucosal preservation, avoidance of bilateral laser treatment at the anterior commissure, and limitation of the depth of thermal injury are generally accepted as necessary to limit complications.  However, even the most experienced surgeons encounter soft tissue scarring, especially in patients requiring multiple procedures. A medical therapy that would minimize the conditions that cause or enhance scarring and web formation would be an ideal adjunct to surgical treatment.

There is increasing evidence that laryngopharyngeal reflux (LPR) is a contributing, if not causative, factor in numerous pediatric airway disorders. We have previously presented evidence of reflux in 23 of 30 patients with RRP, 5 of whom were pediatric patients.  Laryngopharyngeal reflux has also been implicated in other laryngeal disorders including recurrent croup, subglottic stenosis, and vocal fold nodules. Laryngopharyngeal reflux has been shown to increase the rate of soft tissue complications in children undergoing surgery for choanal atresia and in children with subglottic stenosis. A relationship between RRP and LPR has been suggested, and it has been postulated that controlling reflux may reduce the papilloma growth rate in a few anecdotal cases. Using 24-hour double pH probe data on several children with RRP, we sought to further investigate a potential relationship between reflux and RRP.

CONCLUSION
The incidence of delayed soft tissue complications from surgical treatments for RRP was reduced in our patients who were treated for LPR. In the patients who were tested, 100% had evidence of pharyngeal reflux to a pH value less than 4. Evaluation of patients with RRP for reflux by means of 24-hour double pH probe is warranted, and confirmation of reflux control by repeat pH testing on a medication regimen is recommended. Further prospective studies of the role reflux plays in RRP and other surgically treated pediatric airway disorders are planned.

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Bradford W. Holland, MD; Jamie A. Koufman, MD; Gregory N. Postma, MD; William F. McGuirt, Jr., MD

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