Research

JAMA Otolaryngology–Head & Neck Surgery | Original Investigation

Office-Based vs Traditional Operating Room Management

of Recurrent Respiratory Papillomatosis
Impact of Patient Characteristics and Disease Severity
Emel Çadallı Tatar, MD; Robbi A. Kupfer, MD; Jonnae Y. Barry, MD; Clint T. Allen, MD; Albert L. Merati, MD

IMPORTANCE Management of recurrent respiratory papillomatosis (RRP) in adults has

evolved to include office-based laser techniques.

OBJECTIVE To determine whether demographic or disease characteristics differ between

patients undergoing office-based (office group) vs traditional operating room (OR group)
surgical approaches for RRP.

DESIGN, SETTING, AND PARTICIPANTS This study was a medical record review of adult patients
with RRP treated between January 2011 and September 2013 at a tertiary care center.
Patients were divided into 2 groups according to the setting in which the patient had the
most procedures during the past 2 years.

MAIN OUTCOMES AND MEASURES Demographic and disease characteristics were compared
between patients receiving predominantly office-based vs predominantly OR management.

RESULTS Of 57 patients (47 male and 10 female, with a mean [SD] age of 53.5 [16.4] years)
treated during the 2-year period, 34 patients underwent predominantly office-based
management and 23 patients underwent predominantly OR management. Sex, age, and
weight were not statistically significantly different between the 2 groups. Patients in the OR
group had a younger age at RRP diagnosis (mean [SD], 28.7 [22.0] years in the OR group and
45.5 [20.5] years in the office group), with a mean difference of 16.8 years (95% CI, −28.3 to
−5.4 years). Patients in the OR group also had a significantly higher Derkay score (mean [SD],
15.1 [5.7] in the OR group and 10.7 [5.0] in the office group), with a mean difference of 4.4
(95% CI, 1.6-7.3). No statistically significant differences in comorbidities were observed
between the 2 groups except for type 1 or 2 diabetes, which was more common in the OR
group. There were 5 patients (22%) with diabetes in the OR group and 1 patient (3%) with
Author Affiliations: Department of
diabetes in the office group, with a mean difference of 19% (95% CI, 2.7%-35%). In a
Otolaryngology–Head and Neck
subanalysis that excluded patients with juvenile-onset RRP, Derkay score (mean [SD], 13.9 Surgery, Dışkapı Yıldırım Beyazıt
[4.5] in the OR group and 10.8 [5.1] in the office group), with a mean difference of 3.1 (95% CI, Training and Research Hospital,
0.5-6.1), and the incidence of diabetes (25% [4 of 16] in the OR group and 3% [1 of 31] in the Ankara, Turkey (Tatar); Department
of Otolaryngology–Head and Neck
office group), with a mean difference of 22% (95% CI, 3%-40%), remained significantly Surgery, University of Washington
higher in the OR group, while age at diagnosis of RRP was no longer statistically significant School of Medicine, Seattle (Kupfer,
(mean [SD], 40.2 [15.6] years in the OR group and 49.6 [16.4] years in the office group), with Merati); Department of
Otolaryngology–Head and Neck
a mean difference of 9.4 years (95% CI, −19.4 to −0.7 years).
Surgery, University of Michigan
Medical School, Ann Arbor (Kupfer);
CONCLUSIONS AND RELEVANCE There were no sex or age differences between patients with Department of Otolaryngology–Head
RRP treated in the office compared with those treated in the OR. Patients with earlier age at and Neck Surgery, College of
Medicine, University of Arizona
diagnosis of RRP and greater disease severity were more likely to be managed in the OR. Medical Center, Tucson (Barry);
Department of Otolaryngology–Head
and Neck Surgery, The Johns Hopkins
University, Bethesda, Maryland
(Allen).
Corresponding Author: Emel Çadallı
Tatar, MD, Department of
Otolaryngology–Head and Neck
Surgery, Dışkapı Yıldırım Beyazıt
Training and Research Hospital,
JAMA Otolaryngol Head Neck Surg. 2017;143(1):55-59. doi:10.1001/jamaoto.2016.2724 Dışkapı, Ankara, Turkey 06110
Published online September 22, 2016. (ectatar@gmail.com).

(Reprinted) 55

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 Research Original Investigation
R
ecurrent respiratory papillomatosis (RRP) is a challeng-
ing chronic disease caused by human papillomavirus
infection. Sequelae of RRP range from voice changes
that have a significant effect on quality of life to life-
threatening airway compromise. The propensity for frequent
recurrences requires numerous successive surgical proce-
dures and further affects quality of life.1,2
Management of RRP involves removal of obstructing
lesions to preserve normal tissue and function. While tradi-
tional management includes surgical excision under general
anesthesia in the operating room (OR), 1,3 availability of
pulsed-dye laser and pulsed potassium-titanyl-phosphate
laser, which can be delivered through a flexible fiber, has
expanded management options to include office-based
techniques.4,5
With availability of both office-based and surgical
options, clinicians are faced with considering multiple fac-
tors in selecting the best management for each patient. An
understanding of the clinical and demographic data behind
prior decisions will guide the surgeon to determine which
technique may be more appropriate for an individual
patient. The objective of this study was to determine
whether demographic or disease characteristics differ
between patients undergoing primarily office-based (office
group) vs traditional OR (OR group) surgical approaches for
RRP at a tertiary care center (University of Washington
School of Medicine, Department of Otolaryngology–Head
and Neck Surgery) where both techniques are readily avail-
able.
Methods
The study was approved by the University of Washington
Internal Review Board, which waived the requirement for
informed consent of participants. Medical record review of
adult patients with RRP treated at the University of Wash-
ington School of Medicine Department of Otolaryngology–
Head and Neck Surgery between January 2011 and Septem-
ber 2013 was performed. Patients were divided into 2
groups according to predominant management of the dis-
ease during the past 2 years, which was determined for this
study by the setting in which the patient had the most pro-
cedures (office group vs OR group). In the office group,
pulsed-dye laser or pulsed potassium-titanyl-phosphate
laser was used via flexible fiber delivery (Figure).
Patients with a recent diagnosis of RRP and patients new
to the Department of Otolaryngology–Head and Neck Sur-
gery routinely undergo microdirect laryngoscopy under gen-
eral anesthesia for thorough examination and biopsy as their
initial procedure. Therefore, each patient’s first procedure in
the department was excluded from the analysis to avoid bias
toward placing patients in the OR group. Also, we excluded pa-
tients who had no procedure performed during the past 2 years.
A subanalysis was performed that excluded all patients with
juvenile-onset RRP.
Anatomic Derkay scores at the time of each procedure were
calculated for each patient. According to the anatomic por-
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Office-Based vs OR Management of Recurrent Respiratory Papillomatosis
Key Points
Question Do demographic or disease characteristics differ
between patients with recurrent respiratory papillomatosis (RRP)
undergoing office-based (office group) vs traditional operating
room (OR group) surgical approaches?
Findings In this medical record review of 57 adult patients with
RRP treated between 2011 and 2013 at a tertiary care center, sex,
age, and weight were not statistically significantly different
between the 2 study groups, but patients in the OR group had
earlier diagnosis of the disease and a significantly higher mean
Derkay score. There were no statistically significant differences in
comorbidities between the 2 groups except for type 1 or 2
diabetes, which was more common in the OR group.
Meaning Patients with earlier age at diagnosis of RRP and greater
disease severity are more likely to be managed in the OR.
tion of the staging system by Derkay et al,6 the aerodigestive
tract is divided into 25 subsites, each of which is given a score
of 0 to 3 (0 is no lesion, 1 is a surface lesion, 2 is a raised le-
sion, and 3 is a bulky lesion). The scores at each involved
subsite were summed to generate a composite anatomic score.
Sex, age, weight, and age at diagnosis of RRP were compared
between the 2 groups using a 2-tailed t test. The mean Derkay
scores were compared using the Mann-Whitney test, and preva-
lences of comorbidities were compared using the Fisher ex-
act test. Data were analyzed using a software program (SPSS,
version 15.0; SPSS Inc).
Results
Of 57 patients (47 male and 10 female, with a mean [SD] age
of 53.5 [16.4] years) meeting the inclusion criteria, 34 under-
went predominantly office-based management and 23 under-
went predominantly OR management. A total of 237 proce-
dures were performed, including 144 office-based procedures
and 93 OR procedures. Demographic and RRP disease charac-
teristics are listed in Table 1.
Sex distribution was similar in both groups (83% male [28
of 34 in the office group and 19 of 23 in the OR group]), and
there were no statistically significant differences in age or
weight between the groups. Patients in the OR group had ear-
lier diagnosis of the disease and a significantly higher mean
Derkay score. The mean difference between the OR group and
the office group in the time of diagnosis was 16.8 years (95%
CI, −28.3 to −5.4 years), and the mean difference in Derkay score
was 4.4 (95% CI, 1.6-7.3) (Table 1). Reasons for choosing OR vs
office-based treatment were stated in the medical record for
58% (33 of 57) of patients. When available, the most common
one for recommending OR treatment was the extent of dis-
ease, cited for 26% (15 of 57) of all patients. Other reasons for
OR treatment were intolerance of office laser procedures in 9%
(5 of 57), unfavorable location of disease in 9% (5 of 57), need
for biopsy in 7% (4 of 57), airway concerns in 5% (3 of 57), and
comorbidity in 2% (1 of 57).
Medical comorbidities were cited as the reason for OR
management in only 1 patient who had a history of cardiac
jamaotolaryngology.com
 Office-Based vs OR Management of Recurrent Respiratory Papillomatosis Original Investigation Research

Figure. Office-Based Ablation of a Papilloma With Pulsed Potassium-Titanyl-Phosphate Laser

A Preprocedural laryngoscopy B Papilloma beginning to blanch

C Bulky papilloma fully devascularized D Posttreatment appearance

A, Shown are a small bulky lesion of

the right anterior vocal fold, a
small-surface papilloma on the right
superior vocal fold, and a small
surface papilloma on the left anterior
vocal fold. B and C, Application of the
laser. D, Most of the devascularized
papilloma was debrided using the
laser fiber. Remnants will slough off
after several days.

Table 1. Patient Demographics and Disease Characteristics by Management Group

OR Group Office Group
Characteristic (n = 23) (n = 34) P Value
Female-male ratio 4:19 6:28 >.99
Age, mean (SD), y 48.9 (15.6) 56.5 (16.5) .09
Age at RRP diagnosis, mean (SD), y 28.7 (22.0) 45.5 (20.5) .005
Derkay score, mean (SD) 15.1 (5.7) 10.7 (5.0) .002 Abbreviations: OR, operating room;
RRP, recurrent respiratory
Weight, mean (SD), kg 92.1 (21.2) 85.4 (16.0) .20
papillomatosis.

transplantation. In another patient, a history of difficult intu-
bation led to office-based treatment.
Type 1 or 2 diabetes was significantly more common in
the OR group (Table 2). No other statistically significant dif-
ferences in comorbidities were observed between the 2
groups, although there was a trend toward a higher preva-
lence of substantial cardiac disease in patients treated in
the OR.
The exclusion of patients with juvenile-onset RRP from the
analysis resulted in 16 patients in the OR group and 31 pa-
tients in the office group. In this subanalysis, the Derkay score
remained significantly higher in the OR group (mean [SD], 13.9
[4.5] in the OR group and 10.8 [5.1] in the office group), with a
mean difference of 3.1 (95% CI, 0.5-6.1). Similarly, the inci-
dence of diabetes remained significantly higher in the OR group
(25% [4 of 16] in the OR group and 3% [1 of 31] in the office
group), with a mean difference of 22% (95% CI, 3%-40%). Age
at disease diagnosis was no longer statistically significant in
the subanalysis (mean [SD], 40.2 [15.6] years in the OR group
and 49.6 [16.4] years in the office group), with a mean differ-
ence of 9.4 years (95% CI, −19.4 to −0.7 years).
Discussion
Recurrent respiratory papillomatosis is the most common
benign neoplasm of the larynx, with an estimated incidence
of 1.8 cases per 100 000 adults.7 The recurrent nature of

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 Research Original Investigation Office-Based vs OR Management of Recurrent Respiratory Papillomatosis

Table 2. Comorbidities by Management Group

No. (%)
OR Group Office Group
Variable (n = 23) (n = 34) P Value
Type 1 or 2 diabetes 5 (22) 1 (3) .03
Cardiac disease 3 (13) 0 .06
Immunodeficiency 1 (4) 0 .40
Autoimmune disease 0 2 (6) .51
Asthma 1 (4) 2 (6) >.99
Other lung disease 4 (17) 2 (6) .21
Acid reflux 11 (48) 15 (44) >.99
Difficult airway 1 (4) 2 (6) >.99
Anxiety 1 (4) 2 (6) >.99
Abbreviation: OR, operating room.

RRP necessitates successive surgical procedures to control a m e n a b l e t o p u l s e d p o t a s s i u m - t i t a ny l - p h o s p h a t e

the disease, maintain the airway, and improve voice quality.
Approximately 9284 such procedures were performed dur-
ing a 13-month period from 1993 to 1994, accounting for $42
million in health care costs.7 However, office-based laser
management of RRP allows for decreased cost per proce-
dure. Furthermore, office-based laser procedures have
epithelium-sparing properties, as well as the substantial
benefit of avoiding general anesthesia.8,9
While many features of office-based management
of RRP appear attractive to both patients and clinicians, sur-
gical management using general anesthesia remains a viable
approach in the management of RRP. Our study aimed to
elucidate patient factors that may have a role in the decision
for a surgical approach.
When we rev iewed our cohort of adult patients
with RRP treated at a tertiary care center where both
office-based and OR techniques are regularly used,
we noted that office-based laser approaches were chosen
more often than OR procedures. In cases in which a reason
for choosing an OR approach was stated in the medical rec-
ord, the main one cited was the extent of disease. Likewise,
we found that patients who underwent OR management
had a statistically significantly higher anatomic burden of
disease. These findings are not surprising, but they may be
important for understanding which patients are more
appropriate for the OR vs the office setting. The difference
in the mean Derkay scores between the 2 groups was only
4.4, but the standard deviations were large. Therefore, we
did not identify a Derkay score cutoff at which office-based
management is not feasible because the location and
nature of disease may be more important than the overall
burden. For instance, a large, bulky lesion may be less
laser treatment but may have the same Derkay score as 3
small-surface lesions that would be easily treatable in the
office.
We found that a younger age at diagnosis of RRP was
more common in the OR group. When patients with
juvenile-onset RRP were excluded, age at diagnosis of the
disease was no longer significantly different between
the office-based and OR groups. This finding suggests
that the age difference is driven by the juvenile-onset
patients who may prefer OR management because of their
familiarity with it.
Demographics were similar between the 2 groups, sug-
gesting that sex and age do not appear to have a significant
role in patient or surgeon preference for treatment setting.
When we compared comorbidities, diabetes was the only
comorbidity that differed between the 2 groups. Diabetes
has not been shown to be correlated with increased RRP
severity,10 suggesting that the observed association is inde-
pendent of the anatomic burden of disease. It is possible
that a larger study would detect differences in the preva-
lence of other medical comorbidities, such as cardiac dis-
ease, that we did not find in this cohort.
Conclusions
In this cohort of adult patients with RRP, no sex or age dif-
ferences were detected between patients who were treated
in the office compared with those who were treated in the
OR. Patients with earlier age at diagnosis of RRP, greater
disease severity, and diabetes were more often managed in
the OR.

ARTICLE INFORMATION
Accepted for Publication: July 24, 2016.
Published Online: September 22, 2016.
doi:10.1001/jamaoto.2016.2724
Author Contributions: Dr Tatar had full access to
all the data in the study and takes responsibility for
the integrity of the data and the accuracy of the
data analysis.
Study concept and design: Tatar, Kupfer, Allen,
Merati.
Acquisition, analysis, or interpretation of data:
Kupfer, Barry.
Drafting of the manuscript: Tatar, Kupfer.
Critical revision of the manuscript for important
intellectual content: All authors.
Statistical analysis: Kupfer.
Administrative, technical, or material support: Tatar,
Kupfer, Barry, Allen.
Study supervision: Kupfer, Allen.

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 Office-Based vs OR Management of Recurrent Respiratory Papillomatosis Original Investigation Research

Conflict of Interest Disclosures: All authors have
completed and submitted the ICMJE Form for
Disclosure of Potential Conflicts of Interest, and
none were reported.
Previous Presentation: This study was presented
as a poster at The Fall Voice Conference; October
23-25, 2014; San Antonio, Texas.
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