Laryngeal papillomatosis: HPV-related growths in the voice box

The larynx, or voice box, contains the vocal cords that vibrate to produce the voice. University Hospital Southampton (UHS) describes laryngeal papilloma as a condition in which benign wart-like growths, called papillomas, develop in the larynx, usually appearing there but sometimes extending into the windpipe. If you repeatedly develop laryngeal papillomas, it says, this is known as recurrent respiratory papillomatosis (RRP) or laryngeal papillomatosis.

The growths are not cancerous, but they matter because of where they grow. Healthy voice production depends on the vocal cords moving together and vibrating, and UHS says papillomas disrupt this movement. When they grow larger they can narrow the airway.

UHS says laryngeal papilloma is caused by a very common virus, the human papillomavirus (HPV), and that while most people are exposed to HPV, only a small number go on to develop the condition. The NHS describes HPV as a common virus that is spread through skin contact, usually when having sex, and says most types are harmless.

The UHS factsheet notes that the condition can sometimes improve during hormonal changes, such as puberty, pregnancy and menopause.

Voice changes are the main early symptom. UHS lists hoarseness and a strained or breathy voice, and warns that if you unintentionally strain your voice further to compensate, this can make symptoms worse. In advanced cases, the growths can obstruct the windpipe and cause breathing difficulties. UHS says it is rare for this to happen quickly, but it is important to seek urgent medical attention at your local emergency department if you experience breathing difficulty.

The condition can also affect everyday life. UHS describes effects on emotional wellbeing, such as frustration, anxiety and social withdrawal, because voice difficulties can make communication hard, and on professional or social life where you rely on your voice. It says to discuss any such concerns with your healthcare team, who can offer advice, support and referrals.

UHS says to contact the team if you notice any change in your voice, or noisy breathing or a high-pitched wheezing sound when you breathe in, known as stridor. Breathing difficulty is an emergency: attend A&E or call 999. A hoarse voice that persists is worth discussing with a GP, who can refer you to an ENT specialist for the voice box to be examined.

UHS says your doctor will refer you to an ear, nose and throat (ENT) specialist. Diagnosis involves a laryngoscopy, in which the specialist inserts a small flexible tube with a light and video camera at one end (an endoscope) through the mouth, or in a nasoendoscopy through one nostril, and down the back of the throat to examine the larynx and vocal cords. It is usually done without anaesthetic, and if you find it uncomfortable the specialist can use local anaesthetic spray to numb your throat.

The ENT UK leaflet on microlaryngoscopy explains the more detailed operation under general anaesthetic in which the voice box is examined with a microscope, and a sample (biopsy) can be taken of any unusual tissue, which a pathologist then examines. It says the same operation may also allow the surgeon to treat the voice box using instruments such as a microdebrider or a laser.

UHS says the main treatment is surgery under general anaesthetic to remove the growths, usually as a day-case procedure so you can go home the same day. Most people's voices improve shortly after the procedure. However, it stresses that the procedure improves symptoms but does not cure the condition: papillomas often grow back, so it is likely you will need to have it repeated in the future.

UHS also recommends voice therapy from a speech and language therapist after surgery, which helps promote healing and prevent further strain on the voice, with guidance on vocal hygiene, posture and using your voice safely. ENT UK says after microlaryngoscopy your voice may sound worse, especially if biopsies have been taken, which should be temporary until the lining heals, and that you may be asked to rest your voice for a few days.

ENT UK says microlaryngoscopy is usually a safe procedure, and lists possible complications including a sore throat or stiff neck, damage to teeth, lips and gums, spitting blood, airway swelling and, if a laser is used, a very rare airway fire. It says most microlaryngoscopy is done as a day case, and if you have had a lot of work done on the voice box you may be kept overnight in hospital as a precaution. General anaesthetic carries its own small risks, which the anaesthetist explains.

UHS says that some people find they need ongoing management with regular surgeries and voice therapy. It says that laryngeal papillomas are non-cancerous and that the risk of the growths turning cancerous is very low, but that it is important to attend all regular monitoring and follow-up appointments so that any issues can be caught and treated as soon as possible.

On prevention, UHS discusses HPV vaccination, noting that the evidence is not very strong, and advises discussing with your team whether vaccination is appropriate for you or your family members. The NHS says HPV vaccination is offered to children aged 12 to 13 and to people at higher risk, and that it works very well in reducing the risk of getting HPV.

On the NHS, treatment and follow-up are managed by an ENT specialist, with speech and language therapy arranged around surgery. Some people choose a private ENT or voice specialist for a quicker laryngoscopy or a second opinion. The operations, laser and voice therapy are the same; because the condition tends to recur, it is useful to keep records of each operation and to know who to contact if the voice changes or breathing becomes noisy.