My Experience With RRP

I am putting this on the web in the hope that it will help others with this problem.  If you have any questions you are welcome to contact me at:

There are two web sites containing information on rrp.  See:
RRP Foundation
The RRP Web Site

I first noticed a problem with my voice late spring 2001.  It gradually grew worse and I went to see my primary care doctor who referred me to a local ENT.  The ENT said that I had polyps and that they might be due to acid reflux.  He put me on Prilosec for a month.  This did not help.  He then scheduled me for surgery.  At this point I knew nothing about rrp and the ENT said that sometimes these polyps just happen.  I had my first surgery 1/3/2002.  I do not know what he used to remove the polyps.  I was only told to rest my voice for a few days.  My voice got somewhat better and then quickly back to where it was.  I went back for a checkup after 2 weeks.  The doctor told me that he had not been able to remove all of the polyps without risking damage to my vocal cords.  He had left a thin layer.  He referred me to Dr Zeitels at Mass Eye & Ear Infirmary in Boston.  I had a fight with my insurance company to get an out of network referral.  Eventually I did get it.  I will have different insurance starting January.

This is an image from my first examination with Dr Zeitels on 3/20/2002.  Note the papilloma on my left vocal fold.  Also note that it is spreading down towards where the vocal folds join.  Dr Zeitels said that he was almost certain it was rrp.  He explained the disease and referred me to the RRP Foundation at  He recommended surgery.  After another insurance fight I got it scheduled.
Tony's Papilloma 3/20/02

The next image was taken during my surgery on 6/10/2002, 3 months after the one above.  This was taken through a microscope.  Note that the papilloma appears to have spread down to where the vocal folds joined.  I have seen other pictures taken during surgery of other parts of the papilloma.  All of it grew a great deal during the 3 months.  He used a combination of cold steel and a Tuned Pulse Dye Laser (PDL).  (There is a description of the PDL further on.)
Surgeries Under General Anesthesia: 2
Surgeries Under Local Anesthesia: 0
Interval Since Last Surgery: 22 Weeks
Tony's Papilloma 6/10/02

The next image was taken about 2 weeks after surgery on 6/26/2002.  The left vocal fold is still somewhat red and swollen but the surface looks good except for the lump towards the center.  The doctor said that this was almost certainly a granuloma but there was some possibility that the papilloma was growing back.  He said that it might or might not shrink.
Tony's Papilloma 6/26/02

The next image was taken 1 month after surgery on 7/10/2002.  As you can see the lump did not go away.  The doctor said that this was clearly a granuloma.  It was firm which was easier to see in the video when it came into contact with the other vocal fold.  He said that papilloma is softer.  This will cause problems with my speech.  He was also concerned that it would damage the other vocal fold.  I will have to have surgery in about 2 weeks to get it removed.  More pictures when I get them.
Tony's Papilloma 7/10/02

I had surgery again on 7/25/2002.  I did not get any photos from the surgery this time.  He removed the granuloma and a small amount of papilloma that grew back.
Surgeries Under General Anesthesia: 3
Surgeries Under Local Anesthesia: 0
Interval Since Last Surgery: 7 Weeks

I had a checkup about two weeks later and was told that I was completely clear of papilloma.  This exam was done with a flexible scope through the nose and no pictures were taken.  I had several sessions with a speech therapist and my voice ended sounding the same as it did before this whole thing started!  The only difference I noticed was that I could not yell as loud as I used to.  Of course I was told that yelling was not a good thing to do.  I am sometimes in situations where I have to communicate with someone when there is high background noise.

I went for a checkup on 11/6/2002.  This was somewhat later than planned due to Dr Zeitels schedule.  He told me that the papilloma had returned and that I needed to have it removed again.  This was about 15 weeks since the last surgery.

This time Dr Zeitels recommended that I have the papilloma removed using just the Tuned Pulse Dye Laser (PDL) under local anesthesia.  He referred me to Dr Franco to have this done.  Dr Franco works with Dr Zeitels at Mass Eye & Ear Infirmary and has been doing this procedure for 2-3 years.  I went in to see Dr Franco on 11/19/2002.  He explained that the PDL was tuned to a wavelength that is preferentially absorbed by blood.  It is used to coagulate the blood supply to the papilloma.  They then slough off of the vocal cords.  It cannot be used if the papilloma is too large because it can only penetrate so far.  Here is the before image on 11/19/2002.  The resolution is not as good as the previous images because this one was taken with a flexible scope through the nose rather than a rigid one through the mouth.

PDL Procedure

-I was seated in an exam chair.

-First he sprayed an anesthetic and decongestant through my right nostril.  He also sprayed the same anesthetic that is used for the rigid scope down my throat.  This was followed by spraying lidocane down my throat while I was told to pant quickly.  I have a very active gag reflex and I kept gagging as the lidocane was sprayed.  This probably led to some later problems.

-A thin tube connected to suction was run down my other nostril.  I was given goggles to protect my eyes.

-A flexible scope was run down my right nostril.  It was somewhat thicker then the ones normally used for exams.  It had an opening down the middle.  A suction tube was connected near the part the doctor held, with a valve that he controlled.  A thin, clear optical fiber was also run into the handle area of the scope.  He pushed it into the scope and could control the amount that extended beyond the end of the scope.

-He would then manipulate the scope and fiber to aim it at the papillomas.  When in place he used, I believe, a foot pedal to turn it on.  I could hear it pulse between 1-2 times per second and I could see the pulses in the fiber.  The light appeared to be a pinkish color.  During this I was told to breath in and out.  There was some smell of burning but it was not too bad.

-At times I did have some problems with pain, at one point bad enough that he had to stop and spray more lidocane in.  Even after that I had some significant pain.  After the procedure we "discussed" this.  If I have to have this done again I will probably get a lot more of the initial spray down the throat and then wait a while before trying the lidocane.  This helped with the rigid scope in the past.  The gagging probably prevented the lidocane from getting everywhere it needed to.

-He needed to use about 725 pulses.  He had told me before he started that the length of voice rest would depend on how many pulses were used.  The laser causes bruising in the vocal cords.  I was told not to speak at all for 7 days.  If I had had less papilloma and only about 100 pulses were required the voice rest would have been 2-3 days.

After the procedure he showed me parts of the video on the computer.  If you look at the upper part of the left vocal cord in the image above (the one to the right in the image) you will see a distinct lump.  After using the laser on the base of it he was able to use the scope to push it off.  He then had me cough it up so I could swallow.

The picture below was taken at the end of the procedure.  As you can see the lump mentioned above is gone.  There is a white area where it was.  However the more spread out papilloma is a bruised mess that is still attached.  It is hard to imagine that the result will be a clean vocal cord but that is what is supposed to happen.  I will go back in 2-3 weeks and will see how it turned out.

The reason for doing this under local is because of the risk of repeated general anesthesia.  Also the entire procedure took around 15 minutes after things were setup.  Afterwards I just left and got a ride home.  All I had was a sore throat that almost entirely went away by the next day.  If this works well and my voice comes back it will be a great improvement over surgery.
Surgeries Under General Anesthesia: 3
Surgeries Under Local Anesthesia: 1
Interval Since Last Surgery: 17 Weeks

I went back for a checkup on 12/13/02, after the PDL treatment.  My voice had not come back as well as I had hoped.  I also had a bit of a sore throat almost up to the date of my checkup.  Dr Franco said that the PDL treatment causes some blood vessel damage in the vocal fold.  If I am rough on the vocal fold it is more likely that there will be bleeding inside of the vocal fold that will cause swelling.  The day after the 7 days of voice rest I was visiting with friends over Thanksgiving.  Over the 4-5 days I was probably taking much more than I should have.  In large groups I was trying to speak louder than I should.  This may have delayed the healing.  Dr Franco said that the lump at the upper right in the photo appears to be a granuloma that may be caused by irritation that resulted from overusing my voice.  He also said that in the future it would be better to get me in for the PDL treatment before there was as much re-growth.  When there are fewer laser pulses used the recovery is quicker and there is less chance of problems such as this.

He also commented that the fold was redder and more swollen than he expected.  I then told him that I had inhaled a bit of food that morning and had to cough repeatedly and vigorously to get it up.  He said that could have been the cause.  I am supposed to not speak any louder than I can comfortably.  I will have another checkup in about 6 weeks.

Towards the end of December 2002 my voice almost returned to normal.  I was pleasantly surprised.  After seeing the pictures during surgery and after my slow recovery I was somewhat skeptical about my voice recovering.  The pulsed dye laser works!

I went in for another checkup on 1/27/03.  The picture below was taken at that visit.  I had significant re-growth of the papilloma.  Much of my left vocal fold, on the right in the picture, is completely covered with a smooth layer of papilloma.  There is a small lump towards the bottom and larger ones near the top.

I was also disturbed to see a small pap on my right vocal fold.  It showed up better on the screen than in this scan of the photo.  This is the first time that the right one has been involved.

At this point the effect on my voice was minor.  The part of the vocal fold furthest away from where the folds join has less effect on the voice.  The other parts have a fairly smooth layer.

I am scheduled to go back on 2/6/03.  Dr Franco plans to do Cidofovir injections in all of the places where I have papillomas.  He will then use the pulse dye laser to remove the papillomas.  This will all be done under local anesthesia.

On 2/6/03 I went in again for treatment.  No pictures this time.  First under local anesthesia I was given Cidofovir injections.  This was done with a large curved needle through my mouth guided by a flexible scope through my nose.  These injections were done through the papillomas into my vocal folds.  After this the papilloma were treated with the Pulse Dye Laser.  I am on voice rest till 2/12 and I have a checkup schedule for 2/28.

I still had difficulties with the effectiveness of the local anesthetic.  During some of the injections and some portions of the laser treatment I experienced significant pain.  The problem was not just the pain but my inability to control my gag reflex when experiencing it.  I will discuss how to deal with this in the future with the doctor when I have the checkup.
Surgeries Under General Anesthesia: 3
Surgeries Under Local Anesthesia: 2
Interval Since Last Surgery: 11 Weeks

On 2/28/03 I went back in for a checkup.  This was about 3 weeks after I was treated with Cidofovir injections and with the PDL.  As you can see, my left vocal fold is covered with papilloma.  The doctor said that this is new growth since the treatment!  We discussed what to do about this.  One option would be to go in for surgery with general anesthesia.  This would allow the doctor to do a better job of cleaning all of the papilloma off.  The other option would be to go in again for another series of Cidofovir injections and another treatment with the PDL under local anesthesia.  His recommendation was to try the PDL again.  He said that sometimes it takes a few treatments before the rate of reoccurrence goes down when using the PDL.  He did not know why that was.  I decided to try the PDL with local anesthesia and I am scheduled for that treatment on 3/6/03.

I also discussed the problems I had with the local anesthesia not working.  He said that part of the problem is that the area where the large lump is, near the wide opening, does not get good coverage when the Lidocane is inhaled.  He offered two options.  The first would be to take some Valium an hour before the treatment.  He said that along with the usual local anesthesia it would help me control the gagging.  The second option would be to get an injection in the neck which would completely eliminate all feeling.  That would last for 2-3 hours.  I will try the Valium for the next treatment.

On 3/6/03 I went back in for treatment.  The papilloma were injected with Cidofovir and the PDL was used on them.  I still had problems with the local anesthesia.  The Valium was completely useless.  If anything it made it a little more difficult to intentionally relax and ignore what was going on.  I took 4 mg and I weigh about 245#.  The doctor was able to inject all of the papilloma, including the large lump at the top of my left vocal fold with Cidofovir.  The injections in the lump were painful but I was able to control it.  However, any attempt to use the laser on the lump caused enough pain that I gagged uncontrollably.  The doctor expressed the hope that because he was able to thoroughly inject it the Cidofovir may help.  The problem seems to be that panting while lidocane is being sprayed down my throat does not get to the upper area of the vocal folds.  I am on voice rest for 5 days and I will have a checkup in about 2 weeks.
Surgeries Under General Anesthesia: 3
Surgeries Under Local Anesthesia: 3
Interval Since Last Surgery: 4 Weeks

On 3/21 I went back for a checkup.  The doctor said that the material on my left vocal fold is probably papilloma which is dead but has not yet sloughed off.  It is white and papilloma normally redder because it has lots of capillaries in it.  I have a checkup in another 3 weeks.  My voice is reasonably close to normal.

Dr Franco also said that he met with Dr Rosen and Dr Rosen may be getting PDL equipment for treating rrp.

On 4/18/03 I went back in for a checkup.  As you can see there is still material on my left vocal fold.  Dr Franco said that the lump near the top should not effect my voice much.  He was unable to treat it much with the laser because the local anesthesia did not get to that area well enough.  I am writing this on 5/14 and so far my voice, while not perfect, is doing reasonably well.  I go back for a checkup on 5/30.

On 5/30/03 I went back for a checkup.  Except for the large lump at the top of my left vocal fold there has been little if any change.  The lump has become smaller.  My voice is not perfect but it is quite usable.  I will continue to take 750 mg DIM per day and I have a checkup on 8/4.
Tony Papillomas 7/14/03
My voice started to deteriorate by late June.  I was able to schedule an appointment for a checkup on 7/14/03.  The image above is from that exam.  The two lumps on my right vocal fold (left above) have come back and there has been considerable regrowth on the left fold.  I was given two options; PDL treatment without general anesthesia and surgery using steel and the PDL under general.  In both cases I would be injected with Cidofovir, the third time for me.

The obvious advantage of PDL only is there is no general anesthesia.  This is what I have done for the last three treatments.  After the PDL treatments my voice is very good but not quite as good as before rrp.  The advantage of surgery under general is that the doctor can do a much better job of cleaning off the vocal folds.  This is due both to the nature of the PDL only treatment and to the problems I have with the local anesthesia.  Because more of the papilloma will be removed this might result in a longer time before I need treatment again.  Given how erratic this disease is it will be hard to tell unless it comes back soon.  My voice may also be better after surgery.

I decided on surgery under general anesthesia and I am scheduled for 8/13/03.  The last time I had surgery under general they used a different mix and/or timing.  I came out without vomiting and feeling much better.  I hope the results will be the same this time.

I had surgery on 8/13/03 and then a follow-up exam on 8/29/03.  The image above is from that exam.  (The pattern in the lower part is on the photo I scanned.)  The doctor used cold steel along with the 585-nm Pulsed Dye Laser to remove the papilloma.  Again I had no problem with the anesthesia this time.  Prior to surgery I discussed my experience with the anesthesiologist.  He said that the difference between the prior two times was the use of morphine.  When I had morphine I was violently nauseous after surgery.
Surgeries Under General Anesthesia: 4
Surgeries Under Local Anesthesia: 3
Interval Since Last Surgery: 23 Weeks

I was on voice rest for two weeks after the surgery.  The first day or so my voice was somewhat rough and tired easily.  It is now 9/6/03 and my voice varies from sounding basically normal to breaking up if I use it too much.  My vocal "stamina" is still not what it was.  If I speak more or less continuously for an extended period of time my voice starts breaking up intermittently and gets a little sore.  I try to avoid this but I have had some extended meetings at work.  I'll take it easy for the next week or so.

There is a medical paper on the use of the PDL laser under general anesthesia.  It is:

585-nm Pulsed Dye Laser Treatment of Glottal Papillomatosis
Ramone A. Franco, Jr. MD, Steven M. Zeitels, MD, William A. Farinelli, R. Rox Anderson, MD
Annals of Otology, Rhinology & Laryngology June 2002 Volume 111 Number 6

A quote from this paper:

"It is readily apparent that PDL treatment offers relief of tumor burden and minimizes the attendant long-term consequences of vocal fold scarring that results from repeated surgical ablative procedures (CO2 laser or cold instruments) required by dissection within the superficial lamina propria.  Because the epithelium is not fully removed, bilateral treatment of disease is possible.  Anterior commissure disease (medial or internal surface), which is usually treated with staged operations, can be treated simultaneously, and thus the number of general anesthetic procedures, with their attendant morbidity and cost, is minimized.

Clinical observation at the time of PDL therapy revealed that there were interesting and useful responses of the vocal folds' layered microstructure to the laser energy.  A cleave plane developed at the epithelial basement membrane in those areas in which the PDL was used, facilitating an ultraprecise cold instrument resection if that therapeutic pathway was chosen.  This phenomenon has not been identified in PDL-treated skin,  It may be attributable to denaturation of basement membrane linking proteins that anchor the epithelium to the superficial lamina propria.  In addition there was enhanced microsurgical precision due to improved hemostasis.  Because the microvasculature was photocoagulated, there was optimal visualization of the highly magnified tissue planes of the superficial lamina propria."

In rough translation this says that the use of the PDL in conjunction with cold steel has a number of advantages:

-It reduces the amount of damage caused by repeated surgeries
-Both vocal folds, even where they join, can be treated at the same time without causing webbing
-The doctor can be more precise because the PDL coagulates blood and reduces bleeding which would interfere with the doctor's view.
-The PDL tends to cause the papilloma to separate from the vocal fold making it easier to accurately remove the papilloma with cold steel

I have found that I need, what I call, my secret decoder ring to read medical journal articles.  I use Taber's Cyclopedic Medical Dictionary
. Or you can get Tabers Electronic Medical Dictionary.

Note that this paper discusses the use of the PDL under general anesthesia.  It does not discuss the use under local anesthesia.

Some time ago I had a couple of visits with a speech therapist.  Unfortunately, shortly after I had a couple of appointments, the papilloma came back to the point that I needed treatment again.  She lent me a book which includes a CD.  Since I could not speak after surgery I could not use it and I returned it.  However I picked up a copy and I have started to work through it.  I may then make another appointment with her to make sure that I am doing things correctly, assuming the papilloma is not back and causing trouble by then.  The book she recommended is Is Your Voice Telling On You?

I have a follow-up exam scheduled for 9/29/03.

My voice returned almost to normal.  The differences are subtle.  My voice does deteriorate more quickly than it did.

The picture above is from a checkup on 9/23/03.  As you can see papilloma has regrown on my left vocal fold and now it has also shown up on my left false vocal fold.  I am scheduled for treatment under local anesthesia on 10/21 using just the PDL.  This time I plan to get a nerve block in my neck so that the doctor can treat anywhere that needs it without worrying about pain or gagging.  I'll see how that works.  I will also get a Cidofovir injection.  Because my voice is not too bad I could wait longer for the treatment.  However I have been told that the awake PDL works better if the coverage is not too extensive.  Also, the more the laser is used the more the vocal folds are bruised and the longer the voice rest must be.  I would rather have more frequent 1 week or less voice rests than less frequent 2 week ones.  It disrupts life and work less.

I had surgery again on 10/21/03.  This was done under local anesthesia using the Pulse Dye Laser (PDL).  The image above is from after the treatment.  Most of the right vocal fold had papilloma on it and was treated.  I was told to not speak for 5 days.
Surgeries Under General Anesthesia: 4
Surgeries Under Local Anesthesia: 4
Interval Since Last Surgery: 10 Weeks

Because I have had a problem in the past with the inhaled Lidocane spray anesthesia not working well enough I had a nerve block to do a better job of numbing me up.  The nerve block allowed the doctor to use the PDL as much as was needed.  In some spots I still had some minor pain but I was able to avoid gagging so the treatment could continue.

I was also injected with Cidofovir.  The doctor was not able to inject as much as he wanted.  The nerve block numbed my vocal folds enough that the injection pain was not a problem.  However the position the scope needed to be held in touched, probably, my soft palate in such a way that I was unable to avoid gagging.  I have had Cidofovir injected while awake before without this problem.  I am not sure what caused the problem this time.  Either the other doctor who was manipulating the scope held it in a different manner or the nerve block somehow made other areas more sensitive.  I'll have to discuss this with Dr Franco, Jr. when I have my checkup in about 3 weeks.

I'll also explain how the nerve block was done.  A syringe with a long thin needle is filled with Lidocane.  Injections are done in 4 places, 2 on each side into the neck under the jaw.  The needle is inserted until it hits air in the larynx to get the location and then it is partially withdrawn while the injections are done.  Several times for each needle it is also wiggled around and pushed in somewhat, presumably to get a different location.  This was somewhat distressing at the time.  Partially due to pain and partially due to psychological reasons.  Getting needles stuck through your neck just does not seem right!  Also, my neck is quite sore where the injections were done.  (I was treated earlier today.)  I am hoping that this will pass soon.

I asked about options to get more effective coverage for the Cidofovir in the future, other than general anesthesia.  One option would be to inject Cidofovir through the front of the neck into the larynx.  The problem with this is that it would be difficult to apply it near the surface where it is needed.  The second option would be an additional nerve block going in through somewhere in the face to numb the soft palate.  I would need to think about that one!  The nerve block I had today was considerably worse than I had expected.

I had a checkup on 11/14/03.  I do not have pictures.  While my vocal folds were not back to their "normal" state they looked OK and I could speak well.

I had a checkup on 12/22/03.  The picture quality above makes it hard to see but my left vocal fold, right above, is larger than the right and there are two small bumps of regrowth towards the top.  This is a location which has tended to have growth.  This is two months since my last treatment, there is little regrowth, and my voice works well.  The growth seems to have slowed.  I don't know if this is due to the Cidofovir injections, to taking I3C, or luck.  In any case I am glad to be able to speak!

I had a checkup on 2/9/04.  The doctor said that the large white lump on my left vocal fold is a granuloma.  It is too white to be papilloma.  He said that it was probably caused by irritation at a site where papilloma was removed.  The more or less even layer of papilloma on the left vocal fold is not significantly changed from last time.  It appears that the papilloma is growing little if at all.

My voice is working pretty well.  I only have problems if I have to speak for a long time.  Even then I can manage it by sipping water and taking it a little easy.  As long as it is not significantly interfering with my voice I'll wait to do anything about the granuloma.  The papilloma will almost certainly come back sometime and the granuloma can be dealt with then.

I had a checkup on 4/9/04.  No pictures were taken.  There appears to be no papilloma growth and the granuloma seen above has come off.  My left vocal fold, right above, is still thicker than it used to be but my voice is quite functional.  I can't sing as will as I could before this all started but I couldn't sing very well in any case so it is not a real loss.  I have a checkup in July.

I had a checkup  on 7/9/04.  There still appears to be no papilloma growth.  The granuloma is still gone.  My voice is fine.  I have a checkup scheduled in January.

I had a checkup on 1/16/05.  There still appears to be no papilloma growth.  I have a new granuloma above the right vocal fold.  This is in an area that does not interfere significantly with my voice.  At this time we will leave this alone.  I have another checkup scheduled in about 6 months.

I had a checkup on 9/19/05.  The granuloma that was above the right vocal fold is gone.  There appears to be some papilloma on my left vocal fold but there does not appear to have been any additional growth since my last checkup.  My voice has not changed.  I have another checkup scheduled in about 9 months.

I have had a bit of a sore throat on and off for the last 6 weeks.  I asked Dr Franco about this.  I suggested that it might be due to post nasal drip caused by seasonal allergies.  He said that might be the case and that it might also be due either to some irritation from the papilloma I have or from acid reflux.  He suggested that I take Prilosec OTC.  If it is going to help he said that I should see a noticeable improvement within 4-6 weeks.

I plan to wait till a month or so after we get our first good hard frost.  I live in NH and that should stop the plants that cause me some problems.  If that does not help I'll try the Prilosec OTC.

On the rrpf group someone asked me about the amount of Cidofovir I received.  Questions were also raised about side effects from Cidofovir.  I asked the doctor about that.

He uses a concentration of 25mg/cc of Cidofovir.  He injects it into the papillomas.  The total amount injected depends on the amount of papilloma and how much he can get in.  When done under local it also depended on how well the local worked and how much I could tolerate.  The total amounts injected for my 5 treatments varied from 5-25mg of Cidofovir.

He also said that although he has never had any of his patients experience side effects from Cidofovir it is possible, although extremely rare, to get them even with injections limited to the papillomas.  The side effects typically effect the kidneys.

A quick search turned up the following info from the NIH on Cidofovir  Note that this is about the drug delivered in an IV drip which, as I understand it, is much more likely to cause problems than injection in the papillomas.

Given the risks involved in having repeated surgeries and the problems rrp causes I have decided that taking Cidofovir is the lesser risk and is worth it.  Everyone has to make their own decision based on the limited amount of information available.


I have been getting questions about my current status.  I am still in remission.  I have had no further checkups.  I may go sometime soon just to make sure there has been no growth that is not effecting my voice.

Note I am not a doctor and I am not giving medical advice.  I am just describing the experiences and thoughts I have had.