A 40-year-old man comes to the office for evaluation of hoarseness. The patient first noticed the symptoms 4 months ago. Since then, his voice has gotten progressively more "raspy." He has no fever, throat pain, shortness of breath, or trouble swallowing. Medical history includes asthma and gastroesophageal reflux disease. Medications include inhaled budesonide, albuterol, and omeprazole. The patient smokes 3 or 4 cigarettes per day. Vital signs are within normal limits. Flexible laryngoscopy shows irregular, exophytic growths in clusters on the surfaces of the vocal cords. Pathology shows no malignant features. Which of the following is the most likely cause of this patient's laryngeal lesions?

Question

A 40-year-old man comes to the office for evaluation of hoarseness.  The patient first noticed the symptoms 4 months ago.  Since then, his voice has gotten progressively more "raspy."  He has no fever, throat pain, shortness of breath, or trouble swallowing.  Medical history includes asthma and gastroesophageal reflux disease.  Medications include inhaled budesonide, albuterol, and omeprazole.  The patient smokes 3 or 4 cigarettes per day.  Vital signs are within normal limits.  Flexible laryngoscopy shows irregular, exophytic growths in clusters on the surfaces of the vocal cords.  Pathology shows no malignant features.  Which of the following is the most likely cause of this patient's laryngeal lesions?

Quizplus · Accepted Answer

11ec25c8_d8c5_7a11_bc81_45feb20f2ea8_MD0003_00 Constant (≥1 month) or progressive hoarseness is often related to a vocal cord lesion and requires evaluation by laryngoscopy. This patient with irregular, exophytic growths in clusters on the surfaces of his vocal cords likely has laryngeal papillomas due to recurrent respiratory papillomatosis (RRP). These lesions are often warty or grapelike and, as with skin papillomas, have dark-red punctate areas corresponding to blood vessels. Laryngeal papillomas are caused by human papillomavirus (HPV) subtypes 6 and 11. Infants typically acquire HPV via vertical transmission; adults may develop symptoms due to reactivation of vertically transmitted HPV or from exposure to HPV through sexual contact. Although benign, RRP is associated with significant morbidity (eg, voice outcomes, airway obstruction, repeated operative interventions). In addition, the clinical course is variable and unpredictable with fluctuations in severity. In rare instances, it can spread beyond the vocal cords to involve the lower respiratory tract. Medical therapy (eg, interferon, cidofovir) has limited efficacy; therefore, the mainstay of treatment remains surgical debridement, and patients often require many procedures. (Choice A) Cigarette smoking can cause a variety of laryngeal lesions including leukoplakia and squamous cell carcinoma. Although smoking can cause malignant degeneration of RRP lesions, this patient's pathology has no malignant features. (Choice B) Environmental allergens can cause chronic inflammation of nasal and sinus mucosa, which can produce thick secretions that cause hoarseness. Inflammation may be seen but not wartlike growths. (Choice C) Fungal infection of the larynx typically causes thickened, white patches on an erythematous base (similar to that seen in oral thrush). (Choice D) Gastroesophageal reflux may affect the larynx and cause hoarseness and laryngeal lesions such as focal swelling, erythema, or granulation tissue. However, it generally has a fluctuating course (often worse when laying down) and would not cause wartlike growths. (Choice F) Polyps and nodules can form on the vocal cords due to chronic irritation from vocal abuse (eg, yelling or using voice excessively). However, both polyps and nodules tend to have more smooth edges and would not form in clusters. Educational objective: Human papillomavirus can cause recurrent respiratory papillomatosis, which results in hoarseness due to wartlike growths on the true vocal cords. References: Update on recurrent respiratory papillomatosis. (http://www.ncbi.nlm.nih.gov/pubmed/31078306)

A 40-Year-Old Man Comes to the Office for Evaluation of Hoarseness