Practical current treatment plan

1. Assess airway urgency first

• Flexible laryngoscopy when safe
• Operative microlaryngoscopy and biopsy to confirm diagnosis and map disease
• Assessment for subglottic, tracheal, or pulmonary extension when clinically indicated
• Documentation of disease burden and voice/airway function at each visit

2. First-line treatment: conservative endoscopic removal

• Microdebrider
• KTP (angiolytic) laser
• CO2 laser
• Fine cold-instrument techniques for selected focal lesions

3. When to add adjuvant therapy

• Frequent repeat operations, often around 4 or more per year
• Very rapid regrowth
• Multilevel laryngeal, tracheal, or pulmonary involvement
• Recurrent airway compromise
• Progressive voice impairment despite careful surgery

Intralesional bevacizumab

Systemic bevacizumab

Intralesional cidofovir

4. HPV vaccination

• Ensure the child receives age-appropriate HPV vaccination according to the local immunization schedule.
• Vaccination does not replace surgery for established disease, but may reduce recurrence or surgical frequency in some patients.
• Vaccinate eligible family members as routine prevention.
• The strongest public-health effect is maternal and population HPV vaccination, which has been associated with falling JoRRP incidence in a 2025 systematic review (PMID: 39611396).

5. Newest therapy: important age distinction

Follow-up plan

• Regular pediatric ENT/laryngology review, with interval determined by symptoms and recurrence rate
• Voice assessment and speech-language therapy when dysphonia affects communication
• Pulmonary evaluation and imaging if persistent cough, recurrent pneumonia, distal airway disease, or concern for spread beyond the larynx
• Repeat biopsy if lesions look atypical, behave unusually aggressively, or there is concern for dysplasia or malignant change
• Family counseling on the recurrent nature of disease and signs of upper-airway obstruction

• Endoscopic microlaryngoscopic excision
• Microdebrider debulking
• KTP laser ablation
• CO₂ laser ablation
• Cold-steel microsurgical excision
• Intralesional bevacizumab
• Systemic bevacizumab
• Intralesional cidofovir
• HPV vaccination
• Tracheostomy only for critical airway obstruction

1. Tracheostomy
   • Indications
   • Types of tubes
   • Early and postoperative complications
   • Prevention through tracheostomy care
2. Hoarseness in children
   • Congenital, inflammatory, functional, traumatic, neurologic, and neoplastic causes
3. Juvenile recurrent respiratory papillomatosis
   • Clinical features
   • Endoscopic surgical treatment
   • Adjuvant and newer treatments
4. Glottic carcinoma
   • Clinical presentation
   • Diagnostic confirmation and staging
   • Stage-based treatment modalities
5. Clinical case: fixed vocal cord with no nodes/metastasis
   • Likely diagnosis and TNM stage
   • Investigations
   • Organ-preservation versus surgical treatment
6. Vocal nodules
   • Causes and pathogenesis
   • Clinical features
   • Voice therapy and surgical indications

1. Tracheostomy: postoperative complications and prevention by tracheostomy care
2. Hoarseness in children: causes
3. Recurrent respiratory papillomatosis: presentation, conventional and newer treatments
4. Glottic carcinoma: presentation, diagnosis, staging, and treatment
5. Case of vocal-cord growth with hemilaryngeal fixation: diagnosis, TNM staging work-up, and treatment
6. Vocal nodules: causes, pathogenesis, and treatment

• One topic: detailed long-answer format for one selected topic
• Questions 6-11: detailed answers for all six listed questions, delivered in parts
• Full set: detailed answers for Questions 1-11 after you provide the missing five questions

6. Postoperative complications of tracheostomy. How can proper tracheostomy care prevent them?

Postoperative complications of tracheostomy

A. Immediate complications

1. Hemorrhage
   • From thyroid isthmus, anterior jugular veins, inferior thyroid veins, or aberrant vessels.
   • Severe bleeding may occur from injury to a major vessel.
2. Apnea or hypoxia
   • Due to prolonged intubation attempts, loss of airway, or tube obstruction.
3. False passage and tube displacement
   • The tube may pass into pretracheal tissues instead of the tracheal lumen.
   • Particularly dangerous during the first few postoperative days before maturation of the tract.
4. Pneumothorax
   • More common in children and in low tracheostomy.
   • May result from injury to pleura or apical lung.
5. Pneumomediastinum and surgical emphysema
   • Caused by air leakage through the wound or injury to the airway.
6. Aspiration of blood or secretions
7. Injury to adjacent structures
   • Recurrent laryngeal nerve
   • Esophagus
   • Thyroid gland
   • Great vessels
8. Cardiac arrest
   • May result from severe hypoxia, hemorrhage, or vagal stimulation.

B. Early postoperative complications

1. Tube obstruction by mucus plug, crust, blood clot, or thick secretions
2. Accidental decannulation or displacement of the tube
3. Wound infection and cellulitis
4. Peristomal skin excoriation and pressure necrosis
5. Subcutaneous emphysema
6. Atelectasis due to retained secretions
7. Aspiration pneumonia
8. Tracheitis, tracheobronchitis, or bronchopneumonia
9. Cuff-related mucosal ischemia, ulceration, or necrosis
10. Dysphagia and aspiration, especially with cuff deflation or impaired laryngeal function

C. Late complications

1. Tracheal stenosis:
   • Stomal stenosis
   • Suprastomal stenosis
   • Subglottic stenosis
   • Cuff-site tracheal stenosis
2. Tracheomalacia
3. Granulation tissue:
   • At stoma
   • At tube tip
   • Suprastomal granulation causing difficulty in decannulation
4. Persistent tracheocutaneous fistula after decannulation
5. Tracheoesophageal fistula
6. Tracheo-innominate artery fistula:
   • Rare but catastrophic.
   • Presents with a “sentinel bleed” followed by massive hemorrhage.
7. Unsightly scar or keloid
8. Difficulty in phonation and swallowing
9. Recurrent lower respiratory infection
10. Difficulty in decannulation due to airway stenosis, granulation, vocal-cord paralysis, or poor pulmonary reserve

Prevention by proper tracheostomy care

7. Enumerate the causes of hoarseness in children

A. Functional and phonotraumatic causes

1. Vocal nodules - most common cause of chronic hoarseness in school-aged children
2. Vocal misuse or abuse:
   • Shouting
   • Screaming
   • Loud talking
   • Excessive crying
   • Singing with poor technique
3. Muscle-tension dysphonia
4. Psychogenic or functional dysphonia

B. Inflammatory and infective causes

1. Acute viral laryngitis
2. Chronic laryngitis
3. Laryngotracheobronchitis or croup
4. Bacterial laryngitis
5. Tuberculosis, fungal infection, or other chronic infections in selected settings
6. Laryngopharyngeal reflux or gastroesophageal reflux-related laryngitis
7. Allergy and postnasal drip

C. Congenital and structural lesions

1. Laryngomalacia
2. Congenital laryngeal web
3. Laryngeal cyst
4. Laryngocele
5. Subglottic stenosis
6. Vocal-fold sulcus or congenital vocal-fold abnormalities
7. Laryngeal cleft

D. Benign lesions of vocal folds and larynx

1. Vocal nodules
2. Vocal polyp
3. Vocal-fold cyst
4. Granuloma
5. Reinke edema, though uncommon in children
6. Hemangioma
7. Lymphangioma

E. Neoplastic lesions

1. Recurrent respiratory papillomatosis
2. Rare benign tumors, such as neurofibroma or schwannoma
3. Malignancy - rare, but should be considered in persistent or progressive hoarseness, especially with airway symptoms or neck nodes

F. Neurological causes

1. Unilateral vocal-fold paralysis
2. Bilateral vocal-fold paralysis
3. Central neurological disorders:
   • Cerebral palsy
   • Brainstem lesions
   • Neuromuscular disorders
4. Recurrent laryngeal nerve injury after cardiac, neck, mediastinal, thyroid, or esophageal surgery

G. Traumatic and iatrogenic causes

1. Prolonged endotracheal intubation
2. Laryngeal trauma
3. Foreign body injury
4. Chemical or thermal injury
5. Postoperative vocal-fold immobility

H. Systemic causes

1. Hypothyroidism
2. Dehydration
3. Chronic respiratory disease with excessive coughing
4. Autoimmune or inflammatory disorders, rarely

8. Recurrent respiratory papillomatosis: clinical presentation, treatment, and newer options

Definition

Clinical presentation

In children

1. Progressive hoarseness - common early symptom
2. Weak cry or change in voice quality
3. Stridor:
   • Initially inspiratory
   • May become biphasic with severe obstruction
4. Dyspnea and exercise intolerance
5. Recurrent or persistent “croup” not responding as expected to usual treatment
6. Chronic cough
7. Dysphagia or choking, occasionally
8. Recurrent lower respiratory infection if distal spread occurs
9. Failure to thrive in severe, long-standing disease
10. Acute airway obstruction in advanced disease

Laryngoscopic findings

• Multiple pink, pale, or whitish exophytic lesions with a raspberry, mulberry, or cauliflower-like appearance.
• Lesions commonly arise at epithelial transition zones:
  • True vocal folds
  • Anterior commissure
  • Ventricles
  • Epiglottis
  • Subglottis

Diagnosis

1. Flexible fiberoptic laryngoscopy
2. Direct laryngoscopy and bronchoscopy under anesthesia:
   • Defines extent of disease
   • Assesses subglottic and tracheobronchial involvement
   • Permits removal of obstructing lesions
3. Biopsy for histopathological confirmation
4. HPV typing may be performed in selected cases
5. Chest imaging and bronchoscopy if there are lower-airway symptoms or concern for tracheobronchial/pulmonary disease

Treatment

Principles

• Maintain a safe airway
• Preserve voice
• Remove obstructing disease
• Reduce recurrence and surgical frequency
• Avoid scarring and laryngeal stenosis

A. Mainstay: conservative endoscopic surgery

1. Suspension microlaryngoscopy with removal of papilloma
2. Microdebrider debulking
3. KTP laser ablation
4. CO2 laser ablation
5. Cold-steel microsurgical excision for selected focal lesions

B. Tracheostomy

• Avoid if possible, because it may facilitate distal spread of papilloma to the subglottis and trachea.
• It is performed only for life-threatening airway obstruction when the airway cannot otherwise be secured.

C. Indications for adjuvant therapy

1. Frequent surgery, commonly more than 3 to 4 procedures per year
2. Rapid recurrence
3. Multilevel laryngotracheal disease
4. Distal tracheobronchial or pulmonary involvement
5. Severe airway compromise
6. Progressive disease despite appropriate surgical treatment

D. Adjuvant and newer treatment options

1. Intralesional bevacizumab
   • Anti-VEGF monoclonal antibody injected into papillomas, usually along with KTP laser treatment.
   • A current commonly used adjunct for recurrent or high-burden disease.
   • Systematic reviews support a reduction in disease burden and surgical requirement, but optimal protocols are not standardized. Walter and Atfeh systematic review 2024, PMID: 39427406; Gately et al. systematic review 2024, PMID: 39044374.
2. Systemic bevacizumab
   • Intravenous bevacizumab may be considered for severe, refractory RRP, particularly with tracheal, bronchial, or pulmonary spread.
   • Requires a multidisciplinary team including pediatric ENT, oncology, and often pulmonology.
   • Monitor blood pressure, urine protein, renal function, bleeding, thrombosis, and wound-healing issues.
   • Evidence is promising but mostly from nonrandomized studies and reviews.
3. Intralesional cidofovir
   • Antiviral agent injected into lesions.
   • May be used in selected refractory cases.
   • Its use varies between centers due to uncertainty about optimal dose and long-term safety.
4. HPV vaccination
   • Quadrivalent or nonavalent HPV vaccination should be given according to the child’s age and national immunization schedule.
   • It prevents HPV infection and may reduce recurrence or surgical frequency as an adjunct in established RRP.
   • A 2023 meta-analysis reported improved surgical outcomes after adjuvant HPV vaccination, but it does not replace endoscopic management. Ponduri et al. meta-analysis, PMID: 36651338.
5. Other less established or selective therapies
   • Interferon-alpha
   • Indole-3-carbinol or diindolylmethane
   • Photodynamic therapy
   • Immune-directed therapies in clinical trials
6. PAPZIMEOS (zopapogene imadenovec-drba)
   • A newer HPV-6/11 targeted immunotherapy approved by the US FDA in 2025 for adults with RRP.
   • It is not currently approved for pediatric RRP. Pediatric evaluation remains investigational.
   • The FDA label specifies four subcutaneous doses over 12 weeks.

9. Glottic carcinoma: presentation, confirmation of diagnosis, and treatment modalities

Definition

Clinical presentation

Early symptoms

1. Persistent progressive hoarseness - earliest and most important symptom
2. Change in voice quality, vocal fatigue, reduced voice projection
3. Throat discomfort or foreign-body sensation
4. Persistent cough or throat clearing

Late symptoms

1. Dyspnea and stridor due to airway narrowing
2. Dysphagia or odynophagia if tumor extends beyond glottis
3. Hemoptysis
4. Referred otalgia
5. Weight loss and anorexia
6. Neck mass due to cervical lymph-node metastasis
7. Aspiration in advanced disease
8. Fixation of vocal cord or hemilarynx

Diagnosis and confirmation

1. History
   • Duration of hoarseness
   • Tobacco use
   • Alcohol intake
   • Occupational exposure
   • Previous irradiation
   • Dysphagia, stridor, weight loss, hemoptysis, otalgia
2. Clinical examination
   • Oral cavity and oropharynx
   • Neck palpation for lymph nodes
   • Cranial nerve examination
   • Nutritional and pulmonary assessment
3. Indirect laryngoscopy or flexible fiberoptic laryngoscopy
   • Identifies the lesion
   • Assesses cord mobility, tumor site, subglottic extension, and airway
4. Direct laryngoscopy or microlaryngoscopy under anesthesia
   • Assesses exact site and extent
   • Allows biopsy
   • Examines anterior commissure, ventricle, subglottis, and opposite cord
5. Biopsy
   • Histopathology confirms squamous cell carcinoma.
6. Imaging for staging
   • Contrast-enhanced CT neck or MRI neck:
     • Paraglottic space involvement
     • Cartilage invasion
     • Extralaryngeal extension
     • Cervical nodes
   • Chest CT or chest radiograph for pulmonary metastasis or second primary
   • PET-CT in advanced disease, nodal disease, or suspected distant metastasis
   • Baseline blood tests, liver and renal function, and anesthetic assessment

Treatment modalities

A. Carcinoma in situ and T1 glottic carcinoma

1. Transoral laser microsurgery or endoscopic cordectomy
2. Definitive radiotherapy

B. T2 glottic carcinoma

1. Definitive radiotherapy
2. Transoral laser surgery in selected lesions
3. Open partial laryngectomy in selected cases

C. T3 glottic carcinoma

1. Concurrent chemoradiotherapy for larynx preservation in suitable patients
2. Total laryngectomy, especially with poor laryngeal function, extensive cartilage involvement, significant aspiration, or bulky disease
3. Radiotherapy alone if chemotherapy is unsuitable
4. Salvage total laryngectomy for persistent or recurrent cancer after chemoradiotherapy

D. T4a glottic carcinoma

• Total laryngectomy with appropriate neck dissection, followed by postoperative radiotherapy or chemoradiotherapy according to pathology.
• Selected patients may receive nonsurgical organ-preservation protocols, but primary surgery is often preferred when there is major cartilage destruction or extralaryngeal extension.

E. Nodal disease

• Therapeutic neck dissection and/or radiotherapy or chemoradiotherapy, based on stage and treatment plan.

F. Recurrent or metastatic disease

1. Salvage laryngectomy for localized recurrence after radiotherapy
2. Systemic therapy:
   • Platinum-based chemotherapy
   • Immunotherapy in appropriate recurrent/metastatic disease
3. Palliative radiotherapy, airway care, nutritional support, and symptom control when cure is not feasible

10. Case: 50-year-old man with progressive hoarseness, right vocal-cord growth, and fixation of right hemilarynx, with no nodes or metastases

Diagnosis

• T3 N0 M0 glottic squamous cell carcinoma
• Stage III laryngeal carcinoma

Investigations for confirmation

1. Flexible fiberoptic laryngoscopy
   • Defines site, size, surface, anterior commissure involvement, subglottic extension, and cord mobility.
2. Direct laryngoscopy and microlaryngoscopy under general anesthesia
   • Careful mapping of tumor
   • Assessment of the opposite vocal cord, ventricle, anterior commissure, subglottis, and piriform fossae
   • Biopsy from representative viable tumor tissue
3. Histopathological examination
   • Usually reveals squamous cell carcinoma.
   • Report should include differentiation and any relevant pathological findings.

Investigations for staging

1. Contrast-enhanced CT scan of neck
   • Defines paraglottic-space invasion
   • Detects cartilage erosion/invasion
   • Assesses extralaryngeal extension and cervical nodes
2. MRI neck
   • Useful when the extent of soft-tissue or cartilage invasion is uncertain.
3. Chest imaging
   • Chest CT, especially in a smoker, to exclude lung metastasis or synchronous lung primary.
4. PET-CT
   • Consider in locally advanced disease, suspicious lymph nodes, or suspected distant disease.
5. Panendoscopy
   • Direct laryngoscopy with examination of upper aerodigestive tract for synchronous primary lesions when indicated.
6. Pre-treatment assessment
   • Complete blood count
   • Renal and liver function
   • ECG and anesthetic evaluation
   • Dental review before radiotherapy
   • Nutritional and speech/swallow evaluation

Treatment options

Option 1: Concurrent chemoradiotherapy for larynx preservation

• Definitive radiotherapy with concurrent cisplatin is a common organ-preservation approach in a fit patient.
• Advantages:
  • Possibility of preserving the larynx
  • Avoids immediate permanent tracheostoma
• Limitations:
  • Acute mucositis, dysphagia, dermatitis, and late edema/fibrosis
  • Persistent laryngeal dysfunction can occur
  • Failure may require salvage total laryngectomy

Option 2: Total laryngectomy

• Total laryngectomy, with appropriate neck management, is preferred when there is:
  • Bulky T3 disease
  • Major cartilage involvement
  • Severe airway compromise
  • Poor pretreatment voice/swallow function
  • Aspiration
  • Contraindication to chemoradiotherapy
  • Patient preference for surgical treatment
• Postoperative radiotherapy or chemoradiotherapy is given if pathological risk factors are present, such as close/positive margins, nodal disease, extranodal extension, or advanced local extension.

Option 3: Definitive radiotherapy alone

• Consider if the patient cannot tolerate cisplatin or declines surgery.
• Local control may be lower than with concurrent chemoradiotherapy in suitable advanced-stage patients.

Option 4: Salvage surgery

• If chemoradiotherapy fails, the usual curative salvage option is total laryngectomy.

Neck management

• For a clinically N0 glottic lesion, elective neck treatment is not always required.
• In T3 disease, the decision is individualized according to subsite extension, imaging, and institutional protocol.

Rehabilitation after total laryngectomy

1. Tracheoesophageal puncture with voice prosthesis
2. Electrolarynx
3. Esophageal speech
4. Speech and swallowing rehabilitation
5. Stoma care and psychosocial support

11. Vocal nodules: causes, development, and treatment

Definition

Causes

A. Primary cause: chronic phonotrauma

1. Excessive shouting or screaming
2. Loud speaking
3. Excessive talking
4. Improper singing technique
5. Speaking over background noise
6. Frequent use of a hard glottal attack
7. Persistent crying in children

B. Predisposing occupations and activities

1. Teachers
2. Singers
3. Actors
4. Salespersons
5. Call-center workers
6. Sports coaches
7. Children who are habitually loud or “vocally exuberant”

C. Predisposing medical factors

1. Upper respiratory infection with repeated coughing or throat clearing
2. Laryngopharyngeal reflux
3. Allergy and postnasal drip
4. Chronic nasal obstruction leading to mouth breathing
5. Smoking and environmental irritants
6. Hearing loss, causing the patient to speak loudly
7. Stress, anxiety, and poor voice technique

Development and pathogenesis

1. Repeated excessive collision of the vocal folds occurs during phonation.
2. The maximum vibratory and collision force occurs at the junction of the anterior one-third and posterior two-thirds of each vocal fold.
3. Initial changes are edema and congestion of the superficial lamina propria.
4. Repeated phonotrauma leads to localized inflammation and thickening.
5. Early lesions are soft, red, edematous, and reversible.
6. With chronic trauma, fibrosis and hyalinization occur, producing firm, pale, bilateral nodules.
7. Nodules prevent complete glottic closure during phonation, causing an hourglass glottic chink.
8. The patient compensates by increasing muscular effort, which worsens phonotrauma and maintains the lesion.

Clinical features

1. Gradual onset of hoarseness
2. Vocal fatigue
3. Breathiness or rough voice
4. Reduced volume and vocal range
5. Voice breaks, especially during singing
6. Need for frequent throat clearing
7. Symptoms worsen after prolonged voice use and improve with voice rest

Examination

• Small, symmetrical bilateral lesions
• Located at the junction of anterior one-third and posterior two-thirds of vocal folds
• Usually subepithelial with normal overlying mucosa
• Mucosal wave is commonly preserved on stroboscopy

Treatment

A. Conservative treatment: first-line

1. Voice therapy by a speech-language therapist
   • Corrects abusive phonatory behavior
   • Teaches breath support, resonance, pitch control, and reduced laryngeal strain
2. Voice hygiene
   • Avoid shouting and screaming
   • Avoid speaking over noise
   • Use amplification when needed
   • Ensure adequate hydration
   • Schedule vocal rest periods
   • Avoid whispering forcefully
3. Treatment of contributing conditions
   • Treat reflux when clinically present
   • Treat allergic rhinitis and postnasal drip
   • Manage chronic cough
   • Correct hearing impairment
   • Address nasal obstruction
4. Counseling
   • Explain that improvement takes weeks to months.
   • Family and school involvement is particularly important in children.

B. Surgery

1. Persistent symptomatic lesion remains despite well-supervised, compliant, prolonged voice therapy
2. The diagnosis is uncertain and biopsy is needed
3. The lesion is actually a polyp, cyst, fibrous mass, or another lesion rather than a true nodule
4. The patient has persistent disabling dysphonia with clear structural pathology