O R I G I N A L A R T I C L E

Treatment of nasopharyngeal papillomatosis with coblation: a case seriesGeoffrey Peters, MD, Kevin McLaughlin, MD, Daniel W. Nuss, MD

Background: Nasopharyngeal papillomatosis is uncommon.Access and visualization make excision difficult, increasingthe risk for recurrence. We present a novel technique forexcision of nasopharyngeal papillomatosis.

Methods: A case series of 3 patients with recurrent pa-pilloma of the nasopharynx (NP) were treated with endo-scopic transnasal coblation. We used an Arthrocare EVac70 Coblator (se�ing: coblation-9, coagulation-5).

Results: Using transnasal endoscopic coblation, we per-formed complete excision in 3 patients with recurrent pa-pilloma of the NP (4 total procedures). There were no com-plications. One patient had a minor recurrence, which wassuccessfully re-excised with the same technique.

Conclusion: Nasopharyngeal papillomas can be difficult toexcise. Multiple techniques have been described using atransoral approach, with no reported complications. How-

ever, surgical access to the entire NP is more challengingwith a transoral approach. Also, bleeding and poor visu-alization secondary to bleeding can be encountered withthese techniques. These problems were not encounteredwith transnasal coblation. The absence of eschar and de-creased collateral thermal damage make coblation prefer-able to cauterization or laser excision. This proposed tech-nique enables more complete visualization and removal ofdisease, which may reduce recurrence rates. C© 2011 ARS-AAOA, LLC.

Key Words:nasopharynx; papilloma; coblation; treatment; nasopharyn-geal; papillomatosis

How to Cite this Article:Peters G, McLaughlin K, Nuss DW. Treatment of nasopha-ryngeal papillomatosis with coblation: a case series. IntForum Allergy Rhinol, 2011; 1:405–408

R ecurrent respiratory papillomatosis (RRP) is a histo-logically benign neoplasm that most commonly in-

volves the larynx. It is a disease of viral etiology, mostcommonly caused by human papillomavirus (HPV) types6 and 11. HPV DNA has been demonstrated in clinicallynormal epithelium of patients with active RRP and alsoin patients during clinical remission.1 This indicates a po-tential for recurrent lesions, as well as formation of newlesions.

Location and extent of papilloma involvement can bevariable, and can occur anywhere in the respiratory tract.Involvement of the nasopharynx (NP) is uncommon, witha rate of 3%.2 It has been shown that papillomas occur atmucosal sites with a squamous-ciliary junction. In the NP,

Department of Otolaryngology Head and Neck Surgery, LouisianaState University (LSU) Health Sciences Center, New Orleans, LA

Correspondence to: Kevin McLaughlin, MD, Assistant Clinical Professor,Dept. of Otolaryngology Head and Neck Surgery, LSU Health SciencesCenter, 533 Bolivar Street, 5th floor, New Orleans, LA 70112; e-mail:kevinmclau@gmail.com

Potential conflict of interest: None reported.

Received: 16 August 2010; Revised: 23 September 2010; Accepted: 30September 2010DOI: 10.1002/alr.20016View this article online at wileyonlinelibrary.com.

ciliated epithelium of the nasal cavity continues onto thesuperior (nasopharyngeal) surface of the soft palate, whereit meets the squamous epithelium lining the lower portionof the palatal NP. During velopharyngeal closure the softpalate approximates the posterior wall of the NP. Epithe-lium on the NP surface of the palate is subject to abra-sive trauma against the posterior wall, and a squamociliaryjunction results.2

Nasopharyngeal papillomas can be isolated, or be in con-junction with lesions at other sites. Interestingly, of thereported cases of NP papilloma, there was no concurrentinvolvement of the larynx. Some cases did have concurrentoral cavity and oropharyngeal lesions.3,4 Patients with NPpapillomatosis can present with snoring, nasal obstruction,sleep apnea, chronic sinusitis, globus/foreign body sensa-tion, throat irritation, epistaxis, and/or hemoptysis.

Surgical removal of NP lesions presents unique treatmentchallenges. Access and visualization make treatment diffi-cult, which is increased in the context of intraoperativebleeding. This can prevent complete excision and result inrecurrent disease. We present a novel technique for surgicaltreatment of NP papillomatosis. A case series of 3 patientswith recurrent papilloma of the NP were treated with endo-scopic transnasal coblation. We used an ArthroCare EVac70 Coblator (setting of coblation-9, coagulation-5; Arthro-Care Corp., Austin, TX).

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Case reports and operative techniqueCase 1

The patient is a 55-year-old male with a history of humanimmunodeficiency virus (HIV) (active acquired immune de-ficiency syndrome [AIDS]) and recurrent papillomatosis.He previously underwent multiple excisions of papillomasinvolving the lip, oral cavity, and oropharynx. The patientwas referred to our clinic for recurrent disease. He had com-plaints of chronic nasal obstruction and occasional globussensation. Endoscopic exam revealed nasopharyngeal mul-tifocal papillomas: posterior portion of inferior turbinates;lateral/posterior walls (with extension into fossa of Rosen-muller) of NP; roof of NP; and a sessile lesion involvingapproximately 60% NP surface of the soft palate.

The patient underwent transnasal excision of the nasalcavity and NP lesions using a 0-degree endoscope andcoblation. Dissection was carried down to the underly-ing fascia/muscle to ensure complete excision. The endo-scope provided excellent visualization, and bleeding wascontrolled with the coagulation setting. Access to the NPsurface of the soft palate was facilitated by digital manip-ulation of the soft palate through the oral cavity. Woundswere left to heal by secondary intention. There were nocomplications. The pathology report showed benign squa-mous papilloma with HPV effect.

Postoperatively, the patient did very well and deniedany dysphagia or symptoms of velopharyngeal insufficiency(VPI). He was followed very closely on an outpatient ba-sis with repeat endoscopic exams. About 4 months later, hewas found to have a small recurrent lesion of the right fossaof Rosenmuller (3 mm). The patient underwent repeat ex-cision with the same technique. Repeat exams for 2 monthsshowed no evidence of recurrent disease. Unfortunately, thepatient later expired due to an unrelated cause.

Case 2The patient is a 66-year-old female previously treated by anotolaryngologist for a 3-cm papilloma on the NP surface ofthe soft palate. The surgery consisted of transoral subtotalexcision using cold/sharp dissection. Complete excision wasnot performed due to difficulty accessing the entire lesion.The pathology report showed squamous papilloma withmoderate dysplasia and extensive koilocytosis (HPV effect).The patient developed a recurrent lesion within 6 weeks,and was referred to our clinic.

The patient was seen in our clinic with complaints ofglobus sensation. Endoscopic exam revealed a 3-cm ses-sile papilloma of the NP surface of the soft palate only(Fig. 1A, B). No other lesions were noted.

Initial treatment included transnasal ablation with a goldlaser under local anesthesia. However, a recurrent 3-cmlesion developed within 4 weeks.

The patient subsequently underwent transnasal excisionwith coblation. A 70-degree endoscopic was used. Com-plete access to the lesion was facilitated with transoral ele-vation of the palate with a curved suction. Dissection was

FIGURE 1. Case 2. (A) Preoperative image of papilloma on NP surface ofsoft palate. (B) Preoperative view of papilloma with epiglottis in the distance.NP = nasopharynx.

carried down to the muscular layer. There was minimalbleeding, and tissue planes were easily visualized. The le-sion was completely excised, and cidofovir was injected intothe wound bed. The wound was left to heal by secondaryintent. There were no complications.

Postoperatively, the patient had no complaints. She de-nied any dysphagia, NP reflux, or globus. Repeat endo-scopic exams revealed no evidence of recurrent papillomaat 15 months (Fig. 2A, B).

Case 3The patient is an otherwise healthy 52-year-old male with ahistory of foreign body sensation in the back of the throat,snoring, and sleep-disordered breathing. Physical exam re-vealed a significantly enlarged uvula. Flexible endoscopicexam revealed a 2-cm papilloma on the NP surface of thesoft palate near the midline. No other lesions were noted.The patient underwent transoral sharp excision. Uvulec-tomy was also performed. There were no complications.Pathology was consistent with papilloma.

About 3 months postoperation, the patient was found tohave a recurrent lesion (2 cm) at the same site. Repeat exci-sion was performed with transnasal endoscopic coblation.A 0-degree endoscope was used with transoral elevation ofthe soft palate. The lesion was completely excised downto the muscular layer, and the wound was left to heal bysecondary intent. There were no complications.

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Coblation treatment of nasopharyngeal papillomatosis

FIGURE 2. Case 2. (A) Postoperative view of soft palate and posterior wall.(B) Postoperative view of soft palate with epiglottis in the distance.

Postoperatively, the patient remained asymptomatic. Re-peat exams have shown no evidence of recurrence at17 months.

DiscussionA review of the literature on NP papilloma shows onlycase reports with vague descriptions of surgical treatment.Operative techniques include sharp dissection, cauteriza-tion, excision with a microdebrider, and curette adenoidec-tomy. All reported cases were treated with a transoralapproach.3–7 One study used a uvulopalatopharyngoplastyapproach in 2 adult patients to remove papilloma of the NPsurface of the soft palate. The lesions were sharply excised,along with partial excision of the soft palate with primaryclosure.3

Of the reported cases, 3 involved the posterior wall ofNP. They were treated with a microdebrider or curet-tage through a transoral approach. There were no re-

ported complications and only 1 mild recurrence requiringobservation.4,5,7 In our experience, this technique has lim-ited access and visualization. It cannot treat lesions on thelateral wall or within the fossa of Rosenmuller, or lesionsabutting/involving the Eustachian tube orifice. Performingcurettage is a somewhat “blind” technique, which increasesthe likelihood of incomplete excision. Treatment with amicrodebrider or curettage can have significant bleeding,which can distort visualization.

There were 5 reported cases with involvement of the NPsurface of the soft palate. These were treated transorallyusing sharp or cautery excision, with or without partialexcision of the soft palate. There were no reported compli-cations and no recurrences.3–6 Lesions on the NP surfaceof the soft palate are difficult to access through a transoralapproach. Sharp dissection can cause significant bleeding,and cautery creates an eschar. This can distort visualizationof tissue planes. Partial excision of the soft palate can leadto VPI. Treatment of recurrent disease with this techniquewould pose an even greater risk for VPI.

Using transnasal endoscopic coblation, we performedcomplete excision in 3 patients with recurrent papillomaof the NP (4 total procedures). There was minimal bloodloss, and no intraoperative or postoperative complications.Case 1 had florid circumferential nasopharyngeal papil-lomatosis. He developed a minor recurrence in the fossaof Rosenmuller. This was successfully re-excised with thesame technique, and no recurrence was noted at 2 monthspostoperation. Case 2 had recurrent papilloma after ini-tial treatment with transoral sharp excision and transnasalgold laser ablation. Repeat excision was performed usingthe proposed technique. As recommended by the task forceon RRP,8 cidofovir was used due to the refractory na-ture of the disease. There is no evidence of recurrence at15 months. Case 3 was initially treated with transoralsharp excision. Repeat excision was performed using theproposed technique. There is no evidence of recurrence at17 months.

Transnasal endoscopy provides a magnified, clear imageof the entire NP. This is superior to using the naked eyethrough a transoral approach. Angled scopes can be usedfor visualization of the NP surface of the soft palate. En-doscopy also allows for photo and video documentation.

The coblation device has advantages of suction andhemostasis capabilities, absence of an eschar, and decreasedcollateral thermal damage compared to cauterization andlaser.9,10 These advantages preserve visualization of tissueplanes. Also, the malleable nature of the coblation deviceprovides access to all surfaces of the NP.

ConclusionPapillomatosis involving the NP presents unique treatmentchallenges. Access and visualization make surgical treat-ment difficult. Multiple techniques have been describedusing a transoral approach, with no reported complica-tions. However, surgical access to the entire NP is more

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challenging with a transoral approach. Also, bleeding andpoor visualization secondary to bleeding can be encoun-tered with these techniques. These problems were not en-countered with transnasal endoscopic coblation. The supe-rior image quality of today’s endoscopes provides excellent

visualization. The entire NP can be accessed with transnasalendoscopy. The coblation device also has distinct advan-tages as previously described. This technique enables morecomplete visualization and removal of disease, which mayreduce recurrence rates.

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9. Magdy EA, Elwany S, el-Daly AS, Abdel-Hadi M, Morshedy MA. Coblation tonsillectomy:a prospective, double-blind, randomised, clinicaland histopathological comparison with dissection-ligation, monopolar electrocautery and laser tonsil-lectomies. J Laryngol Otol. 2008;122:282–290.

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