Case Report
Intersurgical interval increased with use of quadrivalent human papillomavirus vaccine (Gardasil) in a pediatric patient with recurrent respiratory papillomatosis: A case report

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Abstract

This is a case of a 4 year old female with recalcitrant recurrent respiratory papillomatosis with decreasing intersurgical interval that had improvement in clinical course after administration of the quadrivalent HPV vaccine.

Introduction

Recurrent respiratory papillomatosis (RRP) is an unpredictable, benign upper aerodigestive tract infection, most commonly effecting the larynx with an approximate incidence of 4.3 per 100,000 people in the United States [1]. There is a bimodal age distribution whereas patients present in either early childhood or adulthood [2]. If RRP is diagnosed in early childhood it has shown to take on a more aggressive and recurring course of disease. Due to the laryngeal involvement, hoarseness is the first clinically apparent symptom with other findings localizing the lesion to the upper airway—dyspnea, stridor, recurrent upper respiratory infections, pneumonia, dysphagia, chronic cough, and/or failure to thrive [1].

Although benign in nature, RRP, which has no known cure, has shown to have significant morbidity due to the multiple surgeries. Thus, adjuvant therapies have been sought to increase the intersurgical interval and decrease the overall surgeries undergone by patients.

Human papillomavirus (HPV) types 6 and 11 account for most cases of RRP, with HPV-11 being the most common and aggressive type. Due to these findings, the quadrivalent HPV vaccine (Gardasil) has been examined in adjuvant therapies with the standard of care, surgical management.

Section snippets

Case report

A 4 year old female with RRP due to HPV type 11, requiring multiple surgical interventions, subsequently received the quadrivalent human papillomavirus (HPV) vaccine (Gardasil) with a positive clinical response. She was born to a G4P3 mother HPV+ mother with and delivered vaginally while mother had active papilloma. She presented with biphasic stridor at 12 months of age found to have obstructing papilloma. The patient was given bevacizumab injections to the surgical site three times in total

Recurrence

RRP has shown to take on an unpredictable course spanning from aggressive leading to multiple debridements to control airway patency to spontaneous remission. The staging of the disease is from the combination of subjective (patient's stridor, voice quality, respiratory distress, etc.) and objective (direct laryngoscopy highlighting the extent and location of the lesion) measures [1]. With tendencies to relapse, patients endure multiple surgical excisions. According to the 1999 National

Conclusion

Recurrent respiratory papillomatosis (RRP) is a benign upper aerodigestive tract infection that has an unpredictable course requiring many surgical interventions resulting in increased morbidity. Surgical debulking along with adjuvant therapy is the current standard of care. Included in various adjuvant therapies being studied is the quadrivalent HPV vaccine (Gardasil), which has shown to be associated with a significant increase in the interval between interventions with improvement in voice

Funding support

This project is supported by intramural funding from the Department of Otolaryngology at Nationwide Children's Hospital. The authors have no relevant financial conflicts of interest to disclose.

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