|Year : 2020 | Volume
| Issue : 1 | Page : 15-17
Laryngeal verruca vulgaris: An unusual presentation
MV Anoopa1, AM Anithakumari2, Ria Emmanuel2
1 Department of ENT, Manipal Hospitals, Bengaluru, Karnataka, India
2 NABH Accredited Hospital, Bengaluru, Karnataka, India
|Date of Submission||28-May-2020|
|Date of Acceptance||22-Jun-2020|
|Date of Web Publication||4-Nov-2020|
M V Anoopa
Department of ENT, Manipal Hospitals, Old Airport Road, Bengaluru - 560 017, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Laryngeal verruca vulgaris (LVV) is a rare benign condition. To date, only limited cases of the same have been reported in the literature. This article reveals an unusual presentation of LVV-simulating laryngeal malignancy.
Keywords: Dysplasia, laryngeal verruca vulgaris, verrucous carcinoma
|How to cite this article:|
Anoopa M V, Anithakumari A M, Emmanuel R. Laryngeal verruca vulgaris: An unusual presentation. J Laryngol Voice 2020;10:15-7
| Introduction|| |
Verruca vulgaris of the skin is the most common clinical form of human papillomavirus (HPV) in humans presenting as one or more small, firm, elevated, and non-tender growths. Apart from skin, verruca vulgaris can also be seen on mucosal surfaces, particularly on the lips and in the oral cavity. The clinical occurrence of laryngeal verruca vulgaris (LVV) is rare. The case discussed is in stark contrast to the previous presentations in terms of the widespread nature of the lesion and histopathological evidence of dysplasia.
| Case Report|| |
A 49-year-old male presented to the outpatient department with progressive difficulty in the breathing of 6 months duration. He noticed the change in voice for 3 years, which had worsened over time. He had no comorbidities. He gave a history of smoking (15 packyear) for the past 30 years and consumed alcohol occasionally. Although the rest of the general examination was normal at presentation, he had stridor even at rest. The laryngoscopic evaluation revealed a proliferative lesion involving the entire length of right false cord, true cord, and extending onto anterior two-third of the left vocal cord with areas of keratotic patches. The vocal cords were mobile. Clinical examination aroused the suspicion of malignancy. Contrast-enhanced computed tomography scan was reported as mass lesion involving glottis (more on the right side), false cords, and anterior commissure without cartilage erosion or paraglottic involvement [Figure 1].
|Figure 1: Axial and coronal section of contrast-enhanced computed tomography of the neck showing extensive proliferative laryngeal lesion occluding the airway. Preservation of the paraglottic fat and laryngeal framework without lymphadenopathy favours benign nature of the lesion|
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Under general anesthesia, the patient underwent direct laryngoscopy and biopsy of the lesion from the right side. The extent of the lesion was confirmed. Tracheostomy was performed in view of impending airway compromise.
Histopathology was reported as hyperplastic stratified squamous epithelium with focal hyperkeratosis, papillomatosis, prominent granular cell layer with many coarse keratohyalin granules, and koilocytes in the superficial layer [Figure 2]. Inward turning of the elongated rete ridges was noted and diagnosed with verruca vulgaris with mild-to-moderate dysplasia. Under general anesthesia, the lesion was excised using cold steel and coblation as a second sitting.
|Figure 2: Squamous proliferation with papillomatosis, hyperkeratosis and parakeratosis; Magnified view showing keratohyalin granules and koilocytic changes (H and E, ×10), (H and E, ×40)|
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Follow-up after 6 weeks showed few residual lesions on the right false cord and arytenoids, which were excised. Histopathology still revealed LVV with mild-to-moderate dysplasia [Figure 3]. In view of the benign nature of the disease and at the same time considering the dysplastic histologic changes, he was sent home tracheostomised and is due for follow-up in 3 months for reassessment and decannulation if clinically clear. Due to the current pandemic and being a resident of a remote village, the follow-up visit is postponed. However, video consultation at 3 months shows that he is stable, has a good voice and carrying out a daily routine with a corked tracheostomy tube.
|Figure 3: Dysplastic changes in the epithelium depicted by irregular stratification, nuclear pleomorphism, and hyperchromatism (H and E, ×40)|
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| Discussion|| |
Cutaneous verruca vulgaris (warts) is one of the most common clinical manifestations of HPV infection in humans. Several variants of the infection occur, depending primarily on the HPV subtype and anatomical features of the region such as verruca vulgaris, verruca plantaris, verruca plana, condyloma accuminatum and is routinely encountered by the dermatologist., Other rare sites of predilection include oral mucosal surfaces such as lips, buccal mucosa, tongue, the floor of the mouth. Rarest of all is the LVV, which was first described when the histopathological features of the lesions were observed to be similar to those of cutaneous verruca vulgaris.
LVV is caused by HPV, a member of the papilloma viridae family. These are envelope-free viruses with icosahedral nucleocapsid, 50–55 nm in diameter and contain a double-stranded and protein-encapsulated DNA genome. More than 200 HPV types have been described. Only a few among them such as HPV 2, 4, 6, 11, 16, 18, 33, and 35 are of interest to human infection. A clinical study by Barnes et al. revealed HPV 6 and 11 as the causative factor for LVV.
The exact incidence of this pathology is unknown due to misdiagnosis in the past. To date, only six articles are published with a total of 14 cases.,,,,, The first case was reported by Fechner and Mills which was misdiagnosed to be verrucous carcinoma and underwent hemilaryngectomy. It can be assumed that the lesion is seen more frequently in men (only one female patient reported so far), and our case also involved a male. Smoking increases the risk for the development of verruca vulgaris, as evident from the studies.
Histologic characteristics of these lesions are hyperplastic stratified squamous epithelium with focal hyperkeratosis, papillomatosis, and prominent granular cell layer with many coarse keratohyalin granules. Alternating with granular cells are vacuolated superficial keratinocytes known as koilocytes. Narrow columns of rete ridges with considerable lamina propria between them are seen without any evidence of dysplasia.
The differential diagnosis includes verrucous carcinoma, papillary keratosis, squamous papilloma, and verrucous hyperplasia., Although these entities have overlapping clinical characteristics, histopathology helps in the diagnosis. LVV and papillary keratosis are seen in adult age and confined to vocal cords. The histopathological difference is that papillary keratosis has a thin granular layer, varying degree of atypia and dysplasia of epithelium, and the absence of koilocyte which help discriminate it from verruca vulgaris.
Papillomas appear pink on laryngoscopic examination, whereas verruca vulgaris appears keratotic. Sites of predilection include vocal cords, ventricular bands, other laryngeal structures and tracheobronchial airway, with frequent recurrence, but LVV is limited to vocal cords. Neither keratinization nor keratohyalin granules are seen in papilloma. Koilocytosis is observed in both lesions but is more common in LVV.
LVV, verrucous hyperplasia and verrucous carcinoma occur in adults in the fifth decade and show male predominance. Verrucous hyperplasia is distinguished from verrucous carcinoma solely based on depth of invasion. The verrucous proliferation confined above the plane of surrounding normal epithelium is verrucous hyperplasia, extension below the plane constitute verrucous carcinoma. There are no significant granular cells and keratohyalin granules in verrucous carcinoma or verrucous hyperplasia. Koilocytes in the spinous layer are much less common compared to LVV. Large rete with no lamina propria among them is seen in verrucous carcinoma and verrucous hyperplasia in contrast to elongated rete with considerable lamina propria in LVV. More intense lymphocytic infiltration and inflammation are found in the stroma of verrucous carcinoma.
In contrast to the previous studies, the case we discussed has a wide extension of the lesion beyond the vocal cords with a broad-based attachment and features of dysplasia, which makes it peculiar and prompts us to publish this case.
Literature reveals that the total excision of the lesion is sufficient for LVV. None of the reported cases showed recurrence after total excision. While the longest follow-up period is 17 years for one case, the results of 6–12-month follow-up on average have been reported. The patient is due for follow-up with no clinical features of disease recurrence in this 6-month period.
As a conclusion, LVV has rarely been reported in the literature. In verrucous lesions of the larynx, verruca vulgaris should be considered as one of the differential diagnosis. In this case report, the clinical features and histopathology of LVV are discussed by comparing with those reported in the literature, and we aimed to bring forth an unusual clinical presentation of LVV. We emphasize the features that should be considered in the differential diagnosis through histopathological findings. To comment on the clinical behaviour of LVV, more cases and long-term follow-up results are needed.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]