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Recurrent Respiratory Papillomatosis in a Parturient Presenting for Cesarean Section: a Case Report
Abstract Number: SU-05
Abstract Type: Case Report/Case Series
Introduction: Recurrent respiratory papillomatosis (RRP) is characterized by multiple benign squamous papillomas, primarily of the larynx which may be multifocal and recurrent, requiring surgical excision.(1,2) Lower respiratory tract involvement leads to respiratory obstruction, pneumonia, abscesses, parenchymal lung destruction, and respiratory failure.(3) We present a 37 wk pregnant female with congenital RRP, morbid obesity and GERD for cesarean delivery (C/S) and PPTL using combined spinal/epidural (CSE) anesthesia.
Case: A 24-year-old G2P1 female (BMI 51) at 37 wks was admitted for repeat C/S and management of RRP. Diagnosed at age 2, she required over 100 CO2 laser excisions to date, complicated by bronchial obstruction, bronchospasm, hypoxia, and bradycardia. After C/S #1 (epidural), she developed SOB, airway obstruction requiring emergent tracheal intubation, and papilloma debridement. A multi-disciplinary team of Obstetrics, Anesthesia, and Otolaryngology (ENT) planned this delivery. Both at 26 and 35 weeks she required bronchoscopic debridement under GA necessitating multiple periods of apnea, (continuous FHR monitoring) and we replaced the 6.0 ETT frequently as it became occluded with papillomas. At 37 wks, she underwent repeat C/S and PPTL with CSE.
Discussion: Papillomaviruses are double-stranded DNA viruses only infecting human epithelial cells.(5) The juvenile form (more prevalent and aggressive) is acquired during passage through the birth canal.(1,4,5) HPV 6 and 11 can undergo malignant transformation to squamous cell CA in the lungs but can be prevented with vaccination.(3) Common symptoms of RRP are hoarseness and stridor and it is often misdiagnosed as asthma in children. When surgery is needed > 4x/yr or lesions extend beyond the larynx, adjuvant therapy (interferon, etc.) is considered.(1) Pregnancy worsens RRP as with our patient.(3) The C/S was performed using CSE (ENT immediately available) to provide a dense spinal block of extended duration (2nd C/S, morbid obesity) and to avoid manipulating her narrow, friable papilloma filled airway. Securing a possibly difficult airway using GA was considered, however we intubated her in the past without problems. This case illustrates the need for multidisciplinary team planning and management to ensure a good outcome.
References 1. Otolaryngol Clin North Am 2012;45:671 2. Respirology 2009;14:137 3. JCA 2005;17: 610-613 4. Cancer Detect Prev 2007;31:276 5. Laryngoscope 2010; 120:1233