Recurrent Respiratory Papillomatosis (RRP)

What recurrent respiratory papillomatosis is

HPV types 6 and 11 are "low-risk" types that also cause genital warts. In RRP, they infect the lining of the airway, where they cause exophytic (outward-growing) papillomas that look like small clusters of grapes or cauliflower.

The larynx (voice box) is the most common site, especially where two types of lining meet on the vocal cords. Growths can also spread to the throat, trachea (windpipe), bronchi and, rarely, the lungs. The virus remains in normal-looking tissue around the growths, which is why papillomas keep returning after removal.

For a focus on growths of the voice box specifically, see laryngeal papillomatosis.

Juvenile vs adult RRP

Most babies exposed to HPV at birth never develop RRP. Risk factors for juvenile RRP include a first-born child, vaginal delivery and a young mother with genital warts. Caesarean delivery is not routinely recommended to prevent RRP, because the absolute risk is very low.

Symptoms

• Hoarseness that develops gradually and keeps worsening. It is the most common symptom.
• Weak cry or voice changes in infants.
• Noisy breathing (stridor), first with exertion, later at rest.
• Shortness of breath and chronic cough.
• Trouble swallowing, occasionally.
• Recurrent pneumonia if growths spread into the lungs.

Children are often first misdiagnosed with asthma, croup or bronchitis, because airway narrowing causes breathing noises.

Diagnosis

1. Flexible laryngoscopy: a thin camera passed through the nose to view the larynx, done in clinic.
2. Direct laryngoscopy under general anesthesia: to examine the entire airway, map the growths and remove them.
3. Biopsy: confirms papilloma, checks for abnormal cells (dysplasia) and identifies the HPV type. HPV 11 is linked with more aggressive disease.
4. CT scan of the chest if spread to the lungs is suspected.

Treatment for recurrent respiratory papillomatosis

Surgery

The aim is to remove as much papilloma as possible while protecting normal tissue and the voice. Methods include:

• Microdebrider: a tiny powered shaver.
• Lasers: CO2, KTP and other lasers.
• Cold instruments.

Surgery is repeated whenever growths return. Some children need surgery every few weeks or months during active periods. Overly aggressive surgery can scar the vocal cords and damage the voice, so a balance is struck. A tracheostomy (breathing tube through the neck) is avoided when possible, as it may encourage spread down the airway.

Adjuvant treatments

Added to surgery for people who need frequent operations (often more than 4 a year) or have spread beyond the larynx:

• Bevacizumab: an antibody that blocks blood vessel growth, given into the papillomas or, increasingly, by IV infusion. It can substantially reduce the need for surgery.
• Immunotherapy: in 2025, the FDA approved the first drug specifically for adult RRP, an immunotherapy that trains the immune system to attack HPV 6 and 11 infected cells.
• Cidofovir: an antiviral injected into the growths, now used less often.
• HPV vaccination after diagnosis: may lengthen the time between surgeries in some people; evidence is still developing.
• Other options: interferon, indole-3-carbinol and photodynamic therapy have been used, with varying evidence.

Voice and airway care

Speech and voice therapy, treatment of acid reflux (which may irritate the larynx), and close airway monitoring all help.

Complications

• Airway blockage, which can be life-threatening.
• Permanent voice changes from the disease or from scarring after repeated surgery.
• Spread to the trachea and lungs, which is harder to treat.
• Rarely, transformation into laryngeal cancer (squamous cell carcinoma), more often with lung involvement, smoking or HPV 11.
• Emotional and social effects from repeated surgeries and voice problems.

Outlook

RRP is unpredictable. Some people have a few surgeries and then long remissions; others need dozens over many years. Juvenile RRP often becomes less active around puberty, but it can return in adulthood. Newer treatments are reducing the number of surgeries many patients need.

Prevention

HPV vaccination prevents infection with types 6 and 11. In countries with high vaccination coverage, cases of juvenile RRP have fallen sharply, because fewer mothers carry these HPV types. The CDC recommends routine HPV vaccination at age 11 to 12 (it can start at 9), with catch-up vaccination through age 26.

Frequently asked questions

What causes recurrent respiratory papillomatosis?

RRP is caused by human papillomavirus, mainly types 6 and 11. Children usually acquire the virus from their mother during birth. Adults may acquire it through oral or sexual contact, or the disease may arise from virus that has been dormant for years. Most people exposed to HPV never develop RRP.

Is recurrent respiratory papillomatosis cancer?

No. The papillomas are benign. Their danger comes from their location: they can block the airway and damage the voice. In rare cases, especially with spread to the lungs or long-standing disease, they can turn into squamous cell cancer, so regular monitoring is important.

Is RRP contagious?

RRP is caused by HPV, which spreads through close contact. However, the risk of passing RRP itself to others through everyday contact or kissing is considered very low. Partners of adults with RRP do not usually develop the disease. HPV vaccination protects against the types that cause it.

Can RRP be cured?

There is no guaranteed cure yet, because HPV remains in the airway lining. However, many people go into long remissions, some children improve after puberty, and newer treatments such as bevacizumab and immunotherapy can greatly reduce how often papillomas come back.

How is RRP different from laryngeal papillomatosis?

The terms are often used interchangeably. Laryngeal papillomatosis refers to papillomas in the voice box, which is where RRP usually occurs. RRP is the broader term, covering papillomas anywhere in the respiratory tract, including the trachea and lungs, and emphasizing that they keep recurring.