Tracheal Papillomatosis

What tracheal papillomatosis is

Recurrent respiratory papillomatosis (RRP) is a chronic HPV infection of the airway lining. In most people it affects only the voice box (laryngeal papillomatosis). When papillomas also grow below the vocal cords, in the trachea, it is called tracheal or distal airway papillomatosis.

Spread beyond the larynx happens in roughly 1 in 4 to 1 in 3 people with RRP at some point. It is more common in children with aggressive disease that starts at a young age and in people who have had many surgeries or a tracheostomy (a breathing tube through the neck), which can carry virus into the lower airway. Spread into the lung tissue itself is uncommon, at about 1% to 5%.

Causes and who gets it

The cause is HPV types 6 and 11. These low-risk types rarely cause cancer but establish persistent infection in airway cells.

There are two age peaks:

• Juvenile-onset RRP: usually diagnosed before age 5. It is thought to come from exposure to HPV during birth when the mother has genital HPV infection. It tends to be more aggressive and more likely to spread to the trachea.
• Adult-onset RRP: usually diagnosed between 20 and 40. It is thought to come from sexual transmission or reactivation of earlier infection.

Symptoms

• Stridor: a high-pitched, noisy sound when breathing in, which can be mistaken for croup in children
• Wheezing, often misdiagnosed as asthma
• Chronic cough
• Shortness of breath, first on exertion and then at rest as the airway narrows
• Hoarseness or a weak voice, from papillomas on the vocal cords
• Recurrent chest infections or pneumonia from blocked airways
• Occasionally coughing up blood

How it is diagnosed

1. Laryngoscopy: a camera examines the voice box, usually where papillomas are first found.
2. Bronchoscopy: a camera passes through the vocal cords to inspect the trachea and main airways. This is the key test for tracheal disease.
3. Biopsy: confirms the growths are papillomas, identifies the HPV type and checks for abnormal or cancerous cells.
4. CT scan of the chest: shows airway narrowing and any spread into the lungs, which appears as nodules or cavities.
5. Breathing tests may show a pattern of fixed airway obstruction.

Treatment

There is no cure that eliminates HPV from the airway. Treatment aims to keep the airway open, preserve the voice and limit damage.

Surgical removal

• Microdebrider (a small rotating blade), CO2 laser, KTP or pulsed-dye laser, or coblation are used to remove papillomas through the mouth under general anesthesia.
• Surgery is repeated whenever growths regrow, which may be every few weeks to every few years. Some people need many procedures over their lifetime.
• Surgeons try to avoid a tracheostomy where possible, because it may promote spread down the airway.

Adjuvant medicines

• Bevacizumab: a drug that blocks blood vessel growth. Given into a vein (systemic) or injected into lesions, it has significantly reduced the need for surgery in many people with aggressive or tracheal and lung disease.
• Cidofovir injections into lesions, an antiviral, are used less often now.
• Immunotherapy: a therapeutic vaccine (PRGN-2012) approved in the US in 2025 for adults with RRP, and checkpoint inhibitors under study.
• HPV vaccination after diagnosis may lengthen the interval between surgeries in some people, though evidence is still limited.

Complications and outlook

• Airway obstruction: the main danger, needing regular monitoring
• Voice damage from repeated surgeries and scarring
• Lung involvement: papillomas in the lungs can form cysts and cause infections and progressive lung damage
• Malignant transformation: rare, a few percent, more likely with lung involvement, HPV type 11, smoking or long-standing disease

The course varies. Some people, especially those with adult-onset disease, have long remissions. Children often improve around puberty. Tracheal and lung spread mark more aggressive disease and need care at a specialist airway center.

Prevention

HPV vaccination is the most effective prevention. Vaccinating before exposure, typically at age 11 to 12, protects against HPV 6 and 11 and should, over time, reduce juvenile RRP by preventing genital HPV in future parents. Countries with high vaccination rates have already seen falls in juvenile RRP.

Frequently asked questions

Is tracheal papillomatosis cancer?

No. The papillomas are benign growths caused by low-risk HPV types. However, a small number of cases transform into squamous cell cancer over time, especially with lung involvement or smoking, so regular monitoring and biopsies are part of care.

Is tracheal papillomatosis contagious?

The papillomas are not considered contagious through casual contact. HPV types 6 and 11 spread mainly through sexual contact and from mother to baby during birth. Spouses and children of adults with RRP do not appear to have a significantly higher risk.

How is tracheal papillomatosis different from laryngeal papillomatosis?

Both are forms of recurrent respiratory papillomatosis. Laryngeal papillomatosis affects the voice box and mainly causes hoarseness. Tracheal papillomatosis means growths have spread lower, into the windpipe, which can narrow the airway and cause noisy breathing, cough and breathlessness.

Can tracheal papillomatosis be cured?

There is currently no cure that removes HPV from the airway, but long remissions are possible. Surgery controls growths, and newer treatments such as bevacizumab and immunotherapy have greatly reduced the number of operations many people need.