Laryngeal Papillomatosis (Recurrent Respiratory Papillomatosis)

What causes laryngeal papillomatosis

HPV types 6 and 11, the same low-risk types that cause genital warts, infect the lining of the airway and cause the cells to grow into small, cauliflower-like papillomas. The vocal cords are the most common site, but growths can also appear in the throat, windpipe and, rarely, the lungs.

Juvenile-onset RRP

Usually diagnosed in children under 5. It is thought to be passed from mother to baby during birth when the mother has genital HPV infection. Most babies exposed to HPV never develop RRP. Risk factors include first-born child, vaginal delivery and young maternal age. Cesarean delivery does not fully prevent it and is not routinely recommended for this reason. Juvenile-onset disease tends to be more aggressive.

Adult-onset RRP

Usually appears in the 20s to 40s, more often in men. It may come from infection acquired through oral sex or reactivation of earlier infection. It is often less aggressive than the childhood form.

Symptoms

• hoarseness that gradually worsens, the most common symptom
• a weak, breathy or rough voice, or a weak cry in babies
• noisy breathing, especially a high-pitched sound when breathing in (stridor)
• shortness of breath, worse with exertion
• chronic cough
• swallowing difficulty
• in children, repeated "croup" or "asthma" diagnoses that do not respond to treatment, or poor feeding

Because hoarseness is common and usually harmless, and easily blamed on laryngitis or vocal cord nodules, RRP is often diagnosed late, particularly in children.

Diagnosis

• Laryngoscopy: a thin flexible camera passed through the nose shows the papillomas, usually in the clinic.
• Direct laryngoscopy and biopsy under general anesthesia confirms the diagnosis and checks how far the growths extend.
• HPV typing of the tissue.
• Chest imaging if lung involvement is suspected.

Treatment

There is no cure, but treatment keeps the airway open and preserves the voice.

Surgery

The mainstay of treatment is repeated surgical removal of the papillomas while protecting the normal vocal cord tissue:

• microdebrider (a small powered shaver)
• lasers such as CO2, KTP or pulsed dye lasers
• cold steel instruments

Some people need surgery a few times in their life, others every few weeks or months. Tracheostomy (a breathing hole in the neck) is avoided when possible because it may help papillomas spread down the airway, but is sometimes needed for severe obstruction.

Adjuvant treatments

For people needing frequent surgery, additional treatments are used to slow regrowth:

• bevacizumab, given into the papillomas or through an IV, which blocks blood vessel growth
• cidofovir, an antiviral injected into the lesions, used less often now
• HPV vaccine given after surgery, which may lengthen the interval between operations in some studies
• immunotherapy: in 2025 the US Food and Drug Administration approved a gene-based immunotherapy for adults with RRP, and other immune-based treatments are being studied

Voice therapy

A speech-language pathologist can help people make the most of their voice between procedures.

Complications

• airway obstruction, the main risk, especially in young children
• scarring of the vocal cords and permanent hoarseness from the disease or repeated surgery
• spread to the windpipe and lungs, which is uncommon but serious
• rarely, cancerous change (laryngeal cancer or lung cancer), mostly in lung involvement or with HPV type 11

Outlook

The course varies widely. Some people go into remission after a few years, while others need surgery for decades. Juvenile-onset RRP sometimes becomes less active around puberty. With modern surgical techniques and adjuvant treatments, most people maintain a safe airway and useful voice.

Prevention

HPV vaccination is the most important prevention. The CDC recommends routine HPV vaccination at age 11 to 12 (it can start at 9), with catch-up through age 26. Vaccines that cover types 6 and 11 prevent genital warts and are expected to prevent most cases of juvenile-onset RRP by reducing HPV in parents. Countries with high vaccination rates have already reported fewer childhood RRP cases.

Frequently asked questions

What is laryngeal papillomatosis?

It is a rare condition in which HPV causes noncancerous wart-like growths in the voice box and airway. The growths cause hoarseness and, as they grow, noisy breathing and breathing difficulty. They often recur after removal, requiring repeated surgery.

Is laryngeal papillomatosis cancer?

No. The papillomas are benign. Rarely, they can become cancerous, mainly when they spread into the lungs or with certain HPV types. Regular monitoring by an ear, nose and throat specialist is important.

Is laryngeal papillomatosis contagious?

HPV can spread through sexual contact and from mother to baby during birth. The risk of passing RRP itself to a partner or household member through everyday contact is very low. HPV vaccination protects against the types that cause it.

Can the HPV vaccine help laryngeal papillomatosis?

The vaccine prevents infection with HPV types 6 and 11, so widespread vaccination is expected to prevent most new cases. For people who already have RRP, studies suggest the vaccine may lengthen the time between surgeries in some cases.