A subtype of the human papillomavirus (HPV) which, along with subtype 11, is one of the more common subtypes seen in the airway. HPV 6 is associated with a lesser risk of cancer formation, as is HPV 11.
Papillomas: HPV Subtype 6 (1 of 4)
Papilloma, left vocal cord (right of image), standard light. Voice is grossly hoarse. This patient has HPV subtype 6.
Papillomas, removed: HPV Subtype 6 (3 of 4)
After removal and cidofovir injection, normalized larynx. Voice is normal.
Subtle papillomas, HPV subtype 6 (1 of 3)
After achieving a normal voice through several procedures, the patient came in for reexamination due to the return of mild huskiness. This distant panoramic view with standard illumination does not reveal any obvious papillomas.
Subtle papillomas, HPV subtype 6 (2 of 3)
At close range, using narrow band illumination, a subtle but definite HPV effect is seen. Notice the stippled vascular markings and the faintly increased pinkness at the margins of the cords, indicated by dotted lines.
Subtle papillomas, HPV subtype 6 (3 of 3)
With the vocal cords now at the pre-phonatory instant, these low-profile HPV-related papillomas are again seen, indicated by dotted lines.
Standard light, HPV-6 infection (1 of 4)
Breathing position, standard light in a young woman with longstanding HPV-6 infection. Voice remains quite good, many months after her last microsurgery with cidofovir injection. The only obvious “lesion” is posterior right cord (left of image) but the characteristic punctate vascular marks are not seen. The black lines are purely for use to orient photo 4.
Stobe light, vocal cord margin irregularity (2 of 4)
With such a clear voice, this prephonatory instant under strobe light reveals a surprising degree of vocal cord margin “serpentine” irregularity. Black lines again support orientation with photo 4.
Narrow band light, vascular marks seen (3 of 4)
At very close range and also using narrow band light, the tiny punctate vascular marks are seen in the lesion first seen in photo 1. Faint vascularity like that demonstrated here can be a correlate of relatively stable, inactive disease, which has clinically been the case here.
Narrow band light, papilloma formation (4 of 4)
This narrow band view includes only the anterior half of the vocal cords from the black lines of photos 1 and 2 to the anterior commissure (at x). Inside the faint circles, note the vascular markings that suggest papilloma formation to explain the serpentine margin.
Two papillomas (1 of 3)
Approximately one month after removal of papillomas and Avastin injection in a man who has battled aggressively-recurring disease caused by HPV, type 6. In this view using narrow band light, only two small papillomas are visible.
Stippled vascularity (2 of 3)
At closer range, careful inspection shows no papilloma (yet), but only the stippled vascularity typical of HPV infection.
Stippled vascularity not seen (1 of 4)
Diffuse involvement of true and false cords with papilloma caused by HPV 6. After hundreds of procedures from childhood through early adulthood, the stippled vascularity is not extremely evident in this standard-light view.
HPV vascular effect (2 of 4)
At closer range, still under standard light, the characteristic vascularity—what we term “HPV vascular effect”—is only beginning to be evident (arrows).
Vascularity clearly seen (3 of 4)
At still closer range, and now under narrow-band light, stippled vascularity is clearly seen (arrows).
Under narrow-band light (4 of 4)
Even closer view still under narrow-band light: the stippled vascularity is now unmistakable.
“Curative mode” plan (1 of 7)
Known HPV 6-induced laryngeal papillomas, with resulting gross hoarseness. The plan is “curative mode” defined as 3 or more successive, surgical cleanouts with adjuvant injection to see if the disease can be put into remission or at the least “tamed” to less rapid recurrence.
Closer view (2 of 7)
At closer range. Still, the full extent of disease becomes more obvious at the anterior right vocal cord (left of photo at arrow) in the next photo, when viewed under narrow band illumination (NBI).
Narrow-band illumination (3 of 7)
Now under NBI, the right anterior vocal cord (left of photo) involvement is seen clearly.
Post surgery (4 of 7)
A few days after surgical removal using the usual “basement membrane peel” technique of removal and in this case cidofovir injection. Voice is already dramatically improved, the right cord (left of photo) retains vibratory ability, and the grey wound base is seen clearly.
Towards “management mode” (5 of 6)
Voice had been “normal” until recent weeks, and so the patient therefore waited longer than intended for followup surgery, to the point that we are drifting out of “curative mode” and over into “management mode.” Here, under standard light, the disease is not that obvious.
Same view under NBI (6 of 7)
Under NBI at closer range, the carpet of HPV upper surface and one actual papilloma are more evident, but it is still not quite clear why the patient says voice has been getting slightly hoarse.
Stippled vascularity seen (7 of 7)
At closer range, faint HPV-induced vascular stippling is seen along the margin of the right vocal cord (left of photo) within the dotted line, and this explains his subtle and increasing hoarseness. Another surgical cleanout with adjuvant medication is scheduled.