• Secure the airway and perform urgent suspension microlaryngoscopy with endoscopic debulking/excision of the papillomas, usually with a microdebrider or laser, while preserving normal vocal-fold mucosa.
• The purpose is to relieve obstruction, not to eradicate HPV. Repeated procedures are commonly needed because this is recurrent respiratory papillomatosis.
• Tracheostomy is not the preferred first-line treatment. It is a life-saving rescue only if ventilation/intubation and urgent endoscopic clearance cannot safely maintain the airway, or obstruction is too severe to permit endoscopic management.

Complications

Of the disease

• Recurrent airway obstruction, stridor, respiratory failure
• Extension into the trachea, bronchi, and rarely lungs
• Hoarseness/dysphonia
• Rare dysplasia or malignant transformation, especially with aggressive disease and risk cofactors

Of repeated endoscopic surgery

• Vocal-fold scarring and persistent poor voice
• Anterior commissure synechia/web
• Anterior or posterior glottic stenosis
• Granuloma formation
• Laryngeal edema and postoperative airway compromise
• Laryngotracheomalacia or, rarely, airway collapse after extubation following repeated procedures

Specific concern with tracheostomy

• Possible distal seeding/spread of papilloma into the trachea and lower airways
• Tube blockage, infection, bleeding, accidental decannulation, tracheal granulations/stenosis
• Dependence on tracheostomy

Precautions

1. Treat as a difficult pediatric airway
   • ENT surgeon, experienced pediatric anesthetist, rigid bronchoscopy equipment, and tracheostomy setup must be immediately available.
   • Maintain spontaneous ventilation until the airway is secured when feasible.
   • Avoid repeated traumatic intubation attempts, which can precipitate complete obstruction/bleeding.
2. Avoid tracheostomy whenever safely possible
   • Use it only for a non-negotiable airway emergency or when endoscopic surgery is impossible immediately.
   • If performed, aim for early decannulation once the laryngeal airway is adequate.
3. Use tissue-sparing technique
   • Debulk only obstructing disease.
   • Do not aggressively strip papilloma from the anterior commissure or deep vocal-fold layers, as this promotes webs, scarring, and stenosis.
4. Laser safety, if laser is used
   • Use the lowest practical inspired oxygen concentration.
   • Avoid nitrous oxide.
   • Use laser-safe airway precautions, wet protective material around the tube, smoke evacuation, and an airway-fire plan. Laser treatment in papillomatosis carries an airway-fire risk at high oxygen concentrations. Miller's Anesthesia, p. 9800.
5. Postoperative monitoring
   • Observe closely for edema, stridor, bronchospasm, and extubation failure.
   • PICU monitoring may be appropriate after severe obstruction or extensive surgery.