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Education  |   November 2014
Laryngeal Papillomatosis
Author Notes
  • From the Department of Anesthesiology, Perioperative, and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts (L.R.K.U.).
  • Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org).
    Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org).×
  • Address correspondence to Dr. Kelly Ugarte: lauren.kellyugarte@childrens.harvard.edu
Article Information
Education / Images in Anesthesiology / Respiratory System
Education   |   November 2014
Laryngeal Papillomatosis
Anesthesiology 11 2014, Vol.121, 1092. doi:10.1097/ALN.0b013e3182a35336
Anesthesiology 11 2014, Vol.121, 1092. doi:10.1097/ALN.0b013e3182a35336
LARYNGEAL papillomatosis, the most common benign neoplasm of the pediatric larynx, is often initially misdiagnosed by pediatricians as asthma, croup, or tracheomalacia.1,2  Definitive diagnosis may not occur before an age of more than 2 yr,1  at which time the lesions may grow significantly and present to the anesthesiologist as significant airway obstruction.1,2 
A 9-yr-old girl weighing 33 kg, born at 28 weeks gestation, with a history of laryngomalacia and “almost no voice since birth,” presented to our hospital with difficulty breathing for evaluation and treatment. On examination, the patient was in no distress with a melodic tone on inspiration and exhalation. Her voice was soft and hoarse, and her saturation on room air was 99%. According to her mother, her breathing was very noisy when upset. Neck tissue radiograph (fig.) showed a soft tissue mass within the subglottic airway/larynx. Bedside flexible bronchoscopy revealed a vocal cord papilloma intermittently obstructing the airway.
The patient was at high risk for complete airway obstruction on induction.2  After a thorough discussion with the Otorhinolaryngologist regarding our plan for spontaneous mask ventilation induction and immediate availability of a rigid bronchoscope and tracheostomy kit, the patient was brought to the operating room. She received 0.5 mg IV midazolam premedication (0.015 mg/kg), dosed judiciously to provide anxiolysis and a smooth respiratory pattern while avoiding respiratory depression,3  and an inhalational sevoflurane induction proceeded as planned. A video of the obstructing, ball-valving papilloma was taken during direct laryngoscopy (see video, Supplemental Digital Content 1, http://links.lww.com/ALN/A965) during which time the patient was able to maintain saturations. A 4.0 cuffed tracheal tube was then used to uneventfully secure the airway for initial microdebridement of the lesion.
Competing Interests
The authors declare no competing interests.
References
Zacharisen, MC, Conley, SF Recurrent respiratory papillomatosis in children: Masquerader of common respiratory diseases.. Pediatrics. (2006). 118 1925–31 [Article] [PubMed]
Dalmeida, RE, Mayhew, JF, Driscoll, B, McLaughlin, R Total airway obstruction by papillomas during induction of general anesthesia.. Anesth Analg. (1996). 83 1332–4 [PubMed]
Zur, KB, Litman, RS Pediatric airway foreign body retrieval and anesthetic perspectives.. Pediatric Anesthesia. (2009). 19s1 109–17 [Article]