mkdir -p /home/daytona/workspace/larynx-ppt && ls /home/daytona/workspace/larynx…

~/larynx-ppt/create_ppt.js

const pptxgen = require("pptxgenjs");
const pres = new pptxgen();
pres.layout = "LAYOUT_WIDE"; // 13.3 x 7.5
pres.title = "Benign Laryngeal Tumors: RRP & Hemangioma";

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// ── HELPERS ──────────────────────────────────────────────────
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}

// ══════════════════════════════════════════════════
// SLIDE 1 — TITLE
// ══════════════════════════════════════════════════
addTitleSlide(
  "Benign Tumors of the Larynx",
  "Recurrent Respiratory Papillomatosis  ·  Hemangioma of the Larynx"
);

// SLIDE 2 — OUTLINE
contentSlide("Presentation Outline", [
  "PART I — Recurrent Respiratory Papillomatosis (RRP)",
  { text: "Definition, Epidemiology & Etiology", sub: true },
  { text: "Pathology & HPV Subtypes", sub: true },
  { text: "Clinical Features & Staging", sub: true },
  { text: "Diagnosis", sub: true },
  { text: "Surgical & Adjuvant Management", sub: true },
  { text: "Complications & Prognosis", sub: true },
  "PART II — Hemangioma of the Larynx",
  { text: "Definition, Types & Epidemiology", sub: true },
  { text: "Pathogenesis & Pathology", sub: true },
  { text: "Clinical Features & Diagnosis", sub: true },
  { text: "Management (Pediatric & Adult)", sub: true },
  "Comparison & Key Takeaways",
]);

// ══════════════════════════════════════════════════
// PART I — RRP
// ══════════════════════════════════════════════════
sectionDivider("PART I", "Recurrent Respiratory Papillomatosis (RRP)");

// SLIDE 4 — Definition & Epidemiology
contentSlide("RRP: Definition & Epidemiology", [
  "Most common benign neoplasm of the larynx — 84% of all benign laryngeal tumors (Jones et al.)",
  "Definition: Recurrent squamous papillomas of the aerodigestive tract caused by Human Papillomavirus (HPV)",
  "Two clinical forms:",
  { text: "Juvenile-onset (JoRRP): More aggressive; first two decades of life", sub: true },
  { text: "Adult-onset (AoRRP): Onset after 3rd decade; less frequent recurrence", sub: true },
  "Incidence:",
  { text: "Children: ~4.3 per 100,000", sub: true },
  { text: "Adults: ~1.8 per 100,000", sub: true },
  "Sites: Larynx (most common), trachea, bronchi, lung parenchyma (rare)",
  "Pediatric peak: 2–4 years; Adult peak: 20–40 years",
]);

// SLIDE 5 — Etiology & Transmission
contentSlide("RRP: Etiology & Transmission", [
  "Causative agent: Human Papillomavirus (HPV) — subtypes 6 & 11 account for the vast majority",
  "HPV subtype significance:",
  { text: "HPV-6: Less aggressive, lower recurrence rate", sub: true },
  { text: "HPV-11: More aggressive; higher surgical frequency; greater risk of tracheopulmonary spread", sub: true },
  { text: "HPV-16 & 18: Higher risk of malignant transformation (seen by the senior author)", sub: true },
  "Transmission (juvenile-onset): Vertical — maternal condylomata acuminata during vaginal delivery",
  { text: "~1 in 400 at-risk children develop RRP; rate ~7 per 1,000 births to genitally-infected mothers", sub: true },
  { text: "Cesarean section is NOT definitively protective; role remains controversial", sub: true },
  "Transmission (adult-onset): Presumed sexual/oral contact",
  "Cofactors: GERD (gastric acid worsens epithelial microenvironment), immunosuppression, sex hormones (estrogen increases HPV gene expression)",
]);

// SLIDE 6 — Pathology
contentSlide("RRP: Pathology", [
  "Gross: Exophytic, warty, grape-like or polypoid masses — most commonly at the glottis (free edge of vocal folds)",
  "Histology:",
  { text: "Fibrovascular cores covered by squamous epithelium", sub: true },
  { text: "Koilocytic change — perinuclear halo with nuclear atypia — pathognomonic of HPV infection", sub: true },
  { text: "Contact endoscopy (150×): Koilocytes clearly identified in papilloma of larynx", sub: true },
  "NBI (Narrow-Band Imaging): Stippled vascularity — 'carpet variant' — allows detection of subtle mucosal disease; often misdiagnosed as acid reflux on white light",
  "Immunohistochemistry: Positive for HPV capsid antigens; subtyped by PCR",
  "Risk of malignant transformation: Low overall (<1%) but higher with HPV-16/18 and in immunocompromised patients; requires surveillance",
]);

// SLIDE 7 — Clinical Features
contentSlide("RRP: Clinical Features", [
  "Cardinal symptom: Hoarseness (most common presenting complaint)",
  "Progression: Gradual onset → progressive dysphonia → aphonia if untreated",
  "Stridor: High-pitched inspiratory or biphasic stridor when glottis/subglottis involved",
  "Voice change character guides lesion location:",
  { text: "Aphonia / breathy / cracking voice → glottic lesion", sub: true },
  { text: "Low-pitched, coarse, fluttering voice → subglottic lesion", sub: true },
  "Airway compromise: Tachypnea, use of accessory muscles, neck hyperextension, cyanosis in advanced disease",
  "Additional features: Chronic cough, recurrent pneumonia, failure to thrive (children), dysphagia",
  "Red flags requiring urgent evaluation: Respiratory distress, tachycardia, decreasing oxygen saturation",
  "Unlike laryngomalacia — no positional change in stridor; unlike vocal nodules — no vocal abuse history",
]);

// SLIDE 8 — Staging (Derkay / JORRP)
contentSlide("RRP: Staging — Derkay Score", [
  "Most widely used: Derkay Clinical Scoring System (used by the American Society of Pediatric Otolaryngology)",
  "Scores disease based on:",
  { text: "Anatomical subsites: Epiglottis, aryepiglottic folds, arytenoids, false cords, true cords, subglottis, trachea, bronchi, nasal cavity, nasopharynx, hypopharynx, esophagus", sub: true },
  { text: "Extent of papilloma at each site: 0 = none, 1 = surface lesion, 2 = raised lesion, 3 = bulky lesion", sub: true },
  { text: "Voice score: 0 (normal) → 3 (aphonic)", sub: true },
  { text: "Stridor score: 0 (none) → 3 (at rest)", sub: true },
  { text: "Urgency of last surgery: 1 (routine/elective) → 4 (emergency)", sub: true },
  "Clinical staging used to define disease severity and monitor treatment response over time",
  "Aggressive disease defined: ≥4 surgical procedures per year, tracheal/pulmonary involvement, or tracheotomy dependence",
]);

// SLIDE 9 — Diagnosis
contentSlide("RRP: Diagnosis", [
  "Gold standard: Laryngoscopy + biopsy",
  "Office flexible fiberoptic nasopharyngoscopy:",
  { text: "First-line; sequential inspection of pharynx → hypopharynx → larynx → subglottis", sub: true },
  { text: "Allows estimation of luminal size and vocal fold mobility", sub: true },
  { text: "Scopes as small as 1.8 mm available for neonates", sub: true },
  "NBI endoscopy: Reveals stippled vascularity — 'carpet variant' — earlier detection than white light",
  "Direct laryngoscopy under GA: Required for children who cannot cooperate; also the operative approach",
  "Contact endoscopy (150×): Demonstrates koilocytes; confirms HPV-induced change",
  "Imaging: CT chest/neck if tracheopulmonary spread is suspected (Types 11, 16, 18)",
  "HPV subtyping by PCR: Types 6, 11, 16, 18 — guides prognosis and monitoring",
  "Differential diagnosis: Vocal cord nodules, vocal fold paralysis, subglottic stenosis, subglottic hemangioma, laryngeal carcinoma",
]);

// SLIDE 10 — Surgical Management
contentSlide("RRP: Surgical Management", [
  "No cure exists — current standard of care is surgical debulking",
  "Goals of surgery:",
  { text: "Complete removal of papillomas; preservation of normal laryngeal structures", sub: true },
  { text: "Achieve safe, patent airway; optimize voice; prolong interval between procedures", sub: true },
  { text: "Staged removal at anterior commissure — prevents apposition of two raw surfaces → web formation", sub: true },
  "CO₂ Laser (10,600 nm): Most commonly used; vaporizes with precision; 'no-touch' technique minimizes scarring; couples to operating microscope",
  "KTP Laser (532 nm): Effective for glottic papilloma; in-office awake unsedated technique available; blanches and ablates lesions",
  "Powered Microdebrider (RPMI): Excellent tissue removal; reduced thermal injury vs. laser; popular for bulky disease",
  "Tracheotomy: Avoided if possible (disseminates disease to trachea); used only for impending airway compromise",
  "KEY PRINCIPLE: Accept residual papilloma rather than damage normal tissue — scarring worsens outcome",
]);

// SLIDE 11 — Adjuvant Medical Therapy
twoColSlide(
  "RRP: Adjuvant Medical Therapies",
  "First-Line Adjuvants",
  [
    "Intralesional Cidofovir (antiviral — CMV analog): Most studied; most commonly used adjuvant; reduces disease burden; injects at time of surgical debulking",
    "Bevacizumab (IV/intralesional): Anti-VEGF monoclonal antibody; off-label; promising in aggressive/refractory disease; shown to reduce recurrence frequency",
    "HPV Vaccine (Gardasil 9): Prophylactic; adjunctive role in patients with active RRP — reported partial clinical responses; recommended for adolescent/adult patients",
  ],
  "Other Adjuvants",
  [
    "Interferon-α: Inhibits viral replication; older agent; side effects limit use; disease may rebound on cessation",
    "Indole-3-carbinol (I3C): Inhibits estrogen metabolism; 70% partial/complete response; better in adults",
    "Antireflux therapy (PPI/H₂ blockers): Reduces mucosal inflammation; associated with fewer laryngeal webs",
    "Celecoxib (COX-2 inhibitor): Theoretical rationale; RCT did not show significant advantage",
    "Mumps vaccine (intralesional): Open-label positive results; not reproduced reliably",
    "Cimetidine: Immunomodulatory; small case series evidence only",
  ],
  { accent: C.red }
);

// SLIDE 12 — Complications & Prognosis
contentSlide("RRP: Complications & Prognosis", [
  "Tracheotomy dependence: High number of procedures → increased risk of tracheal seeding and spread",
  "Tracheopulmonary extension:",
  { text: "Occurs in ~1–5%; HPV-11 highest risk; tracheotomy + history of multiple procedures predispose", sub: true },
  { text: "May present as recurrent pneumonia, atelectasis, or pulmonary nodules", sub: true },
  "Glottic/subglottic stenosis and laryngeal web: From scarring after aggressive surgery or repeated anterior commissure involvement",
  "Malignant transformation: <1% overall; higher with HPV-16/18; immunocompromised patients",
  "Spontaneous remission: Occurs in some juvenile cases at puberty — hormonal influence postulated",
  "Quality of life: Chronic hoarseness, repeated surgeries, anxiety, missed school/work — significant psychosocial burden",
  "Prognostic factors for aggressive disease: HPV-11, early age of onset, tracheotomy history, long disease duration, high Derkay score",
]);

// ══════════════════════════════════════════════════
// PART II — HEMANGIOMA
// ══════════════════════════════════════════════════
sectionDivider("PART II", "Hemangioma of the Larynx");

// SLIDE 14 — Definition & Types
contentSlide("Laryngeal Hemangioma: Definition & Types", [
  "Definition: Benign vascular tumor arising from hematopoietic progenitor cells or stem cells within the larynx",
  "Classified by age of presentation and morphology:",
  { text: "Subglottic (Congenital / Infantile): Most common neoplasm of the pediatric airway", sub: true },
  { text: "Adult laryngeal hemangioma: Usually supraglottic / at/above vocal fold level; cavernous type", sub: true },
  "Morphological types:",
  { text: "Capillary hemangioma: More common in infants; subglottic; proliferative growth then involution", sub: true },
  { text: "Cavernous hemangioma: More common in adults; larger vascular spaces; bluish discolored mass; covered by thinner mucosa", sub: true },
  "Female predominance: Twice as common in females (for subglottic / infantile type)",
  "Associated with systemic hemangiomas: 60% of infants with hemangiomata in 'beard distribution' (preauricular, mandibular, neck, lower lip) have a subglottic lesion",
]);

// SLIDE 15 — Pathogenesis
contentSlide("Laryngeal Hemangioma: Pathogenesis", [
  "Arise from hematopoietic progenitor cells (possibly placental origin) OR local stem cells following genetic alterations",
  "Key molecular mediators of growth:",
  { text: "MMP-9 (Matrix metalloproteinase-9) — promotes angiogenesis and tissue remodeling", sub: true },
  { text: "VEGF (Vascular Endothelial Growth Factor) — drives neovascularization", sub: true },
  { text: "b-FGF (basic Fibroblast Growth Factor) — stimulates endothelial proliferation", sub: true },
  { text: "TGF-β (Transforming Growth Factor-beta) — regulates cellular growth", sub: true },
  "Natural history (infantile type) — three phases:",
  { text: "Proliferative phase: Rapid growth from birth to ~12 months", sub: true },
  { text: "Plateau phase: Stabilization around 12 months of age", sub: true },
  { text: "Involution phase: Spontaneous regression by 18 months to 2 years of age", sub: true },
  "Adult hemangiomas: No involution; symptoms may persist for years; hemorrhage risk (spontaneous or surgical)",
]);

// SLIDE 16 — Clinical Features
twoColSlide(
  "Laryngeal Hemangioma: Clinical Features",
  "Pediatric / Subglottic",
  [
    "Biphasic stridor — onset at ~6 weeks of age (85% present by 6 months)",
    "Progressive respiratory distress during proliferative phase",
    "Soft, compressible subglottic swelling — usually LEFT-sided",
    "Worsening with crying / agitation (increased venous pressure)",
    "60% with 'beard distribution' facial hemangiomas have subglottic involvement",
    "PHACES syndrome association: Posterior fossa malformations, facial Hemangioma, Arterial lesions, Cardiac defects (coarctation of aorta), Eye abnormalities, Sternal cleft",
  ],
  "Adult Laryngeal",
  [
    "Hoarseness — dominant symptom",
    "Respiratory distress: NOT a feature (unlike pediatric type)",
    "Symptoms may have been present for many years",
    "Bluish discolored supraglottic/vocal fold mass on laryngoscopy",
    "Hemoptysis: Can occur — usually surgical complication",
    "Dysphagia if large supraglottic lesion",
    "Risk of significant hemorrhage if biopsied incautiously",
  ],
  { accent: C.accentAlt }
);

// SLIDE 17 — Diagnosis
contentSlide("Laryngeal Hemangioma: Diagnosis", [
  "High kV AP neck X-ray (Pediatric):",
  { text: "Classic finding: Unilateral subglottic soft-tissue mass — usually LEFT lateral wall", sub: true },
  { text: "Asymmetric narrowing of subglottis distinguishes from croup (symmetric subglottic narrowing)", sub: true },
  "Rigid bronchoscopy (Pediatric — diagnostic gold standard):",
  { text: "Do NOT intubate before visualizing — lesion may be compressed and missed", sub: true },
  { text: "Vascular blush on vocal cord; rounded vascular lesion in subglottis (usually left)", sub: true },
  { text: "Biopsy NOT required if typical location + typical age group — avoids hemorrhage", sub: true },
  { text: "Beware rare ALK-positive histiocytic lesion — mimicker of hemangioma", sub: true },
  "MRI with gadolinium: Demarcates extent of lesion; useful for large or atypical lesions; shows T2 high signal",
  "Rule out PHACES syndrome: Echo, MRI brain, ophthalmology review, thyroid function",
  "Adult: Flexible laryngoscopy / direct laryngoscopy → bluish vascular supraglottic/glottic mass; biopsy with caution",
]);

// SLIDE 18 — Management Pediatric
contentSlide("Laryngeal Hemangioma: Management — Pediatric (Subglottic)", [
  "First-line: Systemic Propranolol (non-selective β-blocker)",
  { text: "Mechanism: Vasoconstriction (immediate), ↓VEGF/bFGF (medium-term), ↑apoptosis (long-term)", sub: true },
  { text: "Dose: 1–3 mg/kg/day orally; monitor HR, BP, blood glucose; inpatient initiation if <8 weeks", sub: true },
  { text: "Response: Usually dramatic — lesion shrinks within weeks; continued until age ~12–18 months", sub: true },
  "Alternative: Nadolol (once-daily dosing; some evidence of superior CNS safety profile)",
  "Second-line / adjuncts:",
  { text: "IV / intralesional corticosteroids: Inhibit growth in proliferative phase; used if β-blockers contraindicated", sub: true },
  { text: "CO₂ laser vaporization: Superior to radiotherapy/steroids; begin with biopsy, then vaporize; may require 2 procedures", sub: true },
  { text: "Open surgical excision: Reserved for failed medical management or large obstructing lesions", sub: true },
  { text: "Interferon-α: Neurotoxicity risk in infants — NOT first-line; historical use only", sub: true },
  "Tracheotomy: Airway rescue only; decannulation once lesion involutes",
  "Minimal manipulation under anesthesia — awaken patient; secure airway via intubation only if essential",
]);

// SLIDE 19 — Management Adult
contentSlide("Laryngeal Hemangioma: Management — Adult", [
  "Conservative management is preferred (no spontaneous involution expected)",
  "Monitor: Adult laryngeal hemangiomas often stable for years — observe if asymptomatic and not enlarging",
  "Indications for intervention:",
  { text: "Progressive enlargement involving additional laryngeal subsites", sub: true },
  { text: "Significant hoarseness / airway compromise", sub: true },
  { text: "Recurrent hemoptysis", sub: true },
  "Corticosteroid therapy: Systemic or intralesional — reduces lesion size; used when surgery is not immediately required",
  "Radiotherapy: Effective; reserved for inaccessible or recurrent lesions; modern use limited given morbidity",
  "Surgical options:",
  { text: "CO₂ laser: NOT generally advised for cavernous hemangioma — vascular space diameter exceeds coagulating ability", sub: true },
  { text: "KTP / Nd:YAG laser: Better coagulating ability for cavernous lesions", sub: true },
  { text: "Open resection: Laryngofissure approach for extensive lesions; high hemorrhage risk — requires blood availability", sub: true },
  "Propranolol: Emerging evidence in adult hemangiomas; may be used as primary or adjunctive therapy",
]);

// SLIDE 20 — Comparison Table
tableSlide(
  "RRP vs. Laryngeal Hemangioma: Comparison at a Glance",
  ["Feature", "RRP", "Laryngeal Hemangioma"],
  [
    ["Etiology", "HPV (types 6, 11 most common)", "Vascular tumor – hematopoietic progenitors"],
    ["Age peak", "Juvenile (2–4 yr) & Adult (20–40 yr)", "Subglottic: <6 months; Adult: any age"],
    ["Sex predilection", "Equal (M=F)", "Female 2:1 (subglottic type)"],
    ["Site", "Glottis (true vocal folds) most common", "Subglottis (pediatric); Supraglottis (adult)"],
    ["Symptom onset", "Progressive hoarseness, stridor", "Biphasic stridor at 6 weeks (pediatric); Hoarseness (adult)"],
    ["Natural history", "Recurrent; no spontaneous cure", "Involution by 18 mo–2 yr (pediatric); persistent (adult)"],
    ["Diagnosis", "Flexible laryngoscopy + biopsy; NBI", "Rigid bronchoscopy (no pre-intubation); MRI"],
    ["First-line Rx", "Surgical debulking (CO₂/KTP/Microdebrider)", "Propranolol (pediatric); Conservative (adult)"],
    ["Key adjuvant", "Cidofovir / Bevacizumab / HPV vaccine", "Corticosteroids; CO₂ laser (pediatric)"],
    ["Malignant potential", "Low (<1%); higher HPV 16/18", "Extremely rare"],
  ],
  { colW: [2.8, 4.75, 4.75], accent: C.accentAlt }
);

// SLIDE 21 — Key Takeaways
contentSlide("Key Takeaways for Specialist Practice", [
  "RRP is the most common benign laryngeal neoplasm; HPV-11 signals aggressive behavior and greater tracheopulmonary risk",
  "No cure exists for RRP — serial surgical debulking + adjuvant therapy (cidofovir, bevacizumab, HPV vaccine) remains the standard",
  "Staged removal at the anterior commissure is mandatory to prevent laryngeal web formation",
  "Avoid tracheotomy in RRP whenever possible — it seeds disease and predicts worse outcomes",
  "Subglottic hemangioma: First-line is systemic propranolol; avoid biopsy at initial endoscopy; rule out PHACES",
  "Adult laryngeal hemangioma: Cavernous type — conservative first; CO₂ laser is NOT ideal due to vessel caliber; KTP/Nd:YAG preferred if laser needed",
  "NBI endoscopy is a valuable adjunct in RRP to detect subtle 'carpet variant' disease misdiagnosed as reflux laryngitis",
  "HPV-16/18 in papillomatosis mandates closer surveillance for malignant transformation",
  "GERD treatment improves RRP outcomes — evaluate and treat reflux in all RRP patients",
]);

// SLIDE 22 — References
contentSlide("Key References", [
  "Cummings Otolaryngology: Head & Neck Surgery, 7th Ed. — Chapters 60 & 208 (RRP); Chapter 206 (Pediatric Larynx)",
  "K.J. Lee's Essential Otolaryngology, 11th Ed. — Subglottic Hemangioma (pp. 1028–1029)",
  "Scott-Brown's Otorhinolaryngology Head & Neck Surgery, Vol 1 & 2 — Papilloma & Laser Surgery",
  "Robbins & Cotran: Pathologic Basis of Disease, 10th Ed. — Squamous Papilloma & Papillomatosis of Larynx",
  "Derkay CS, et al. Staging severity of recurrent respiratory papillomatosis. ASPRH Staging System",
  "Hoeve LJ, et al. Treatment of infantile haemangiomas. Eur J Pediatr Surg 2010",
  "Leaute-Labreze C, et al. Propranolol for severe infantile hemangiomas. NEJM 2008;358:2649",
  "Zur KB, et al. Primary bevacizumab therapy for aggressive juvenile RRP. Int J Pediatr Otorhinolaryngol 2015",
  "Derkay CS & Wiatrak B. Recurrent respiratory papillomatosis: a review. Laryngoscope 2008;118:1236–47",
]);

// ══════════════════════════════════════════════════
// WRITE FILE
// ══════════════════════════════════════════════════
pres.writeFile({ fileName: "/home/daytona/workspace/larynx-ppt/RRP_Hemangioma_Larynx.pptx" })
  .then(() => console.log("✅ Presentation created successfully."))
  .catch(e => { console.error("❌ Error:", e); process.exit(1); });

~/larynx-ppt/create_ppt.js

Successfully replaced 1 instance(s) of the string in '/home/daytona/workspace/larynx-ppt/create_ppt.js'

cat > /home/daytona/workspace/larynx-ppt/create_ppt.js << 'ENDOFSCRIPT' const pp…

cd /home/daytona/workspace/larynx-ppt && node create_ppt.js

ls -lh /home/daytona/workspace/larynx-ppt/RRP_Hemangioma_Larynx.pptx