ORIGINAL ARTICLE Can Mumps Vaccine Induce Remission in Recurrent Respiratory Papilloma? Nigel R. T. Pashley, MB,BS, FRCSC Objective: To describe our experience using laser exci- photographed with each treatment. Two consecutive dis- sion and locally injected mumps vaccine to induce remis- ease-free intervals and a follow-up of at least 1 year were sion in patients with recurrent respiratory papilloma (RRP). required criteria for remission. Setting: Tertiary care regional medical center. Results: In the pilot study, remission was induced in 9 (82%) of 11 patients by 1 to 10 injections, with fol- Participants: Initially, 11 children with RRP treated in low-up of 5 to 19 years. In the subsequent series, remis- a pilot study with laser excision at regular intervals for sion was induced in 29 (76%) of 38 patients by 4 to 26 at least a year without adjuvant therapy; later, a series of injections, and follow-up was 2 to 5 years. 18 children and 20 adults with RRP, some of whom had used various adjuvant therapy with interval laser excision. Conclusions: Combined with serial laser excision, Interventions: Both patient groups continued their same mumps vaccine positively influences induction of interval laser excision with the same or similar laser, same remission in children with RRP. The mechanisms of clinical setting, and same surgeon. Locally injected mumps this effect are unclear, but the treatment is readily vaccine was then administered into the excision site af- available, inexpensive, and has a low risk of adverse ter each laser removal of papilloma. effects. Outcome Measures: Larynx and trachea were micro- Arch Otolaryngol Head Neck Surg. 2002;128:783-786 ECURRENT RESPIRATORY pap- adjuvant treatments tried, there is im- illoma (RRP) is a protean plied agreement that a local immunoin- disease caused by infection competence to the viral agent may be pres- with the human papilloma- ent in susceptible patients. A variety of virus and for which there is adjuvant therapies for RRP have been tried Rcurrently no single effective treatment. In with varying success, including inter- children, frequent surgical removal is com- feron alfa, photodynamic therapy, indole- mon to maintain an airway. Adults and chil- 3-carbinol,2 acyclovir, retinoic acid, cido- dren suffer loss of voice and, in aggressive fovir,3 topical fluorouracil, and Thuja,a cases, a tracheostomy is sometimes re- homeopathic antiviral preparation. quired. Tracheal seeding and lung involve- Surgical removal has evolved from de- ment can occur with fatal outcome. bulking with cup forceps, which is still use- ful, to the more standard use of the laser and microscope. This latter treatment allows pre- See also page 787 cise removal but is not without the risks of scar, webbing, and stenosis. Rarely, fire from Recurrent respiratory papilloma is inadvertent endotracheal tube ignition has rare (254-763 US children affected per occurred, with tragic outcome, and many year) but may cost $40 million to $123 mil- surgeons have adopted a proximal jet ven- lion annually.1 It also is the most com- tilation technique that reduces this haz- mon benign laryngeal tumor in children. ard. Excision using a microdebrider has also Papillomas may develop in any mucosal been tried by some surgeons, and with the area of the aerodigestive tract, with the vo- recurrent nature of the disease, some sur- cal cords the most commonly affected site. geons set regular intervals for patients to re- From Presbyterian/St Luke’s Why this particular site is so consistently turn for laser endoscopy. This approach Hospital, Denver, Colo. involved is unclear, but from the various aims to keep the airway open and maxi- (REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 128, JULY 2002 WWW.ARCHOTO.COM 783 ©2002 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 METHODS Engineering, Nashville, Tenn) with an “ultrapulse” mode, which provides a 40-microsecond pause between energy bursts and allows tissue cooling and less char. I still use 2 to5Wof My first use of mumps vaccine as RRP therapy (in 1980) energy, but the spot size is smaller at 0.1 to 0.2 mm. To open and my second use (1989) were 9 years apart. Both re- the ventricle in the adult patients, a larger custom laryngo- sulted in spectacular remission, and a pilot study was then scope (Sontec) was made. prospectively undertaken in 9 patients who, without much Each ampule of mumps vaccine was initially recon- change in their recurrence interval, had been under treat- stituted to 2 mL (the needle for infiltration has a dead space ment for at least a year. The results in these first 11 cases of 0.5 mL) and injected into the tissue at the base of the were encouraging enough to continue using this off-label site of laser excision of any papilloma using microscopic treatment in a subsequent group of patients. No patient control and a laryngeal injection needle (Piling Co, Phila- agreed to participate in a prospective blinded trial, even delphia, Pa) with a working length of 30 cm. From my ex- though crossover would have ensured that all participants periences with adult patients, I theorized that their re- could have eventually received mumps vaccine. This re- sponse to treatment with mumps vaccine was related to the port should therefore be considered as preliminary. Addi- number of ampules administered. The dilution of each am- tionally, there were no controls. pule was reduced to 0.5 mL to allow the number of am- Each patient was treated with laser vaporization of pap- pules injected with each treatment to be increased, and this illoma in an identical manner at a treatment interval deter- is my current technique in adults and children. mined by the extent and severity of their disease. I used a pro- No oral or parenteral steroid medication was used dur- spective approach to recurrence, shortening the treatment ing or after laser therapy despite the presence of (injected) interval when recurrence increased in extent, and lengthen- edema. This was based on my supposition that any steroid ing it when recurrence had diminished. Photography through administered might be immunosuppressive; it is impor- an endoscope and an illustration by the surgeon were used tant that all treating staff, particularly the anesthesiolo- for retrospective analysis of disease severity. No phenotypic gist, be alerted to this. Edema or bleeding intraoperatively analysis of the causative virus was performed. The criteria for was managed by the use of topically applied 0.25% phen- remission were at least 2 consecutive disease-free intervals, ylephrine on a cotton pledget. After the mumps vaccine was with a follow-up of at least 1 year. injected, virtually complete occlusion of the airway was com- I used proximal jet ventilation through a custom-made mon. This was managed by gentle suspension of the air- suspension laryngoscope (Sontec, Denver, Colo) to apply la- way for a few minutes, using the laryngoscope or a bron- ser vaporization to affected areas after removal of tissue for choscope, but neither was forced into the airway, and histologic examination by cup forceps. Settings were 2 to 5 commonly a topical application of racemic epinephrine was W with a spot size of 0.5 to 0.75 mm and continuous mode used. This can be applied by direct instillation of a mea- on a carbon dioxide laser (Coherent, Santa Clara, Calif). In sured dose based on weight, with the larynx suspended, the last 2 years, I have used a carbon dioxide laser (SSI Laser or by nebulized droplets in a postanesthesia recovery unit. mize the voice while avoiding tracheostomy. The treat- to site, extent, or severity of involvement, and coinfec- ment interval can be shortened or lengthened as needed. tion with up to 6 different types of virus in the larynx at Although spontaneous remission is alleged to oc- once have been noted. cur, I have never seen it. Accurate reporting of the varied therapies used has been improved by the adoption of a scor- RESULTS ing system proposed in 1998 by Derkay et al.4 This al- lows the surgeon to stage and/or score a patient’s disease INITIAL PATIENTS manually or directly into a computer. The operating sur- geon assigns a score of 0 to 3 where 0 indicates no lesion; In 1980, the first patient for whom I used mumps vaccine 1, surface lesion; 2, raised lesion; and 3, bulky lesion. Four as a treatment for RRP was a 5-year-old girl who, after 3 years questions about voice, stridor, the urgency of that day’s of regular laser treatment, suddenly saw her treatment in- intervention, and the level of respiratory distress are also terval shorten from every 6 weeks to every 14 days. A single scored, and a clinical score is generated by summation. intralaryngeal immunization into the base of the lasered area Mumps is a viral illness against which most children was used, and immediately the patient was able to revert are immunized at around age 1 year (measles, mumps, and to a 6-week treatment interval. With 3 subsequent intrale- rubella immunizations are given together). Mumps vac- sional injections at the time of laser removal of papilloma, cine contains a live attenuated virus of the Jeryl Lynn strain there was complete remission. This was not immediately with a long history of safe use.5-7 In 1980, it was sug- apparent, however, because there was a 6-year interval gested that the mumps and human papillomaviruses might between the last treatment and the next contact for treat- have similarities that could translate into papilloma treat- ment of a small anterior web causing hoarse voice.