Vivienne Weil was an unusually quiet baby.
“She never cried loudly enough to bother us,” recalled Natalia Weil of her daughter, who was born in 2011.
Although Vivienne babbled energetically in her early months, her vocalizing diminished about the time of her first birthday. So did the quality of her voice, which dwindled from normal to raspy to little more than a whisper. Vivienne also was a late talker: She didn’t begin speaking until she was 2.
Her suburban Maryland pediatrician initially suspected that a respiratory infection was to blame for the toddler’s hoarseness.
At first, Natalia, a statistician, and her husband, Jason, a photographer, were reassured by the pediatrician. Her explanation sounded logical: Toddlers get an average of seven or eight colds annually.
Weil, now 33, said the couple assumed Vivienne’s voice would return to normal — and didn’t want to overreact.
“We were first-time parents and we were worried,” Weil said, “but thought maybe we worried too much and should wait. We decided to give it time. We didn’t know how much children were supposed to talk at the age of 1 or 2. ... We just did what the doctors told us.”
But Vivienne’s paternal grandmother grew increasingly concerned. Because Vivienne was slow to talk, her grandmother wondered whether she might have a developmental delay or a speech problem and suggested an evaluation by a speech pathologist.
During a visit in September 2013, Vivienne’s pediatrician diagnosed acid reflux and prescribed a liquid antacid for the 2-year-old. The doctor also approved a referral to an ear, nose and throat specialist.
An ENT who saw Vivienne soon afterward diagnosed her with dysphonia — an impaired voice that can result from a problem with the vocal cords. He sent her to a pediatric otolaryngologist for a more complete evaluation.
The pediatric specialist listened to her breathe and talk and then scheduled a laryngoscopy. The test involves a visual inspection of the back of the throat. In some cases, doctors use a thin, flexible tube attached to a tiny fiber-optic camera that is threaded up the nose and down the throat.
The procedure, Weil recalled, was traumatic for Vivienne and her parents. The little girl, terrified by what was happening, began screaming and had to be held down by several nurses so the doctor could perform the test.
But its results were definitive — and explained the reason for Vivienne’s prolonged voicelessness.
She was suffering from a rare disease called recurrent respiratory papillomatosis (RRP), which is caused by two strains of the human papilloma virus (HPV), a sexually transmitted infection that can be acquired at or before birth. The disease is incurable; it can be treated by surgery to remove the tumors which temporarily restores the voice. The goal of treatment is to lengthen the interval between surgeries while preventing permanent damage to the delicate vocal cords.
HPV is ubiquitous; nearly all sexually active adults have been exposed to it. Most people clear the infection from their bodies without ever knowing they had it. But in some cases two strains, HPV 6 and 11, can cause genital warts: benign, sometimes cauliflower-shaped tumors known as papillomas. These warts can occur months or sometimes years after exposure.
In some cases, mothers with genital warts can pass the virus during childbirth, resulting in the development of papillomas in the child’s respiratory tract, particularly the larynx. (Two other strains considered “high risk” — HPV 16 and 18 — can cause cervical cancer.)
The Centers for Disease Control and Prevention estimates that two in every 100,000 children have RRP, which can be prevented by a vaccine called Gardasil. Federal health officials recommend administering the vaccine, first licensed in 2006, to children at 11 or 12 before they are sexually active.
The pediatric ENT told the Weils it was a good thing they hadn’t waited longer to seek treatment. Vivienne’s tumors had grown so large that they were threatening her airway.
“I was speechless,” recalled Weil, who at the time was pregnant with her second daughter. “I thought, ‘I gave this to my baby.’”
Weil said that she had no idea she ever had genital warts or had been exposed to HPV.
Shortly before Vivienne’s first surgery in November 2013, Weil sought answers from her obstetrician. How, she asked, could HPV have been missed?
The doctor replied that Pap smears performed in 2009 and 2011 were normal.
“It is possible that you had the virus and then your immune system cleared it so your test was negative in Dec. 2011” — 10 months after Vivienne’s birth, the doctor wrote.
Nor is it clear that a Caesarean delivery would have prevented the disease. Experts say that some cases appear to have been contracted in utero.
Because of her age, Weil was not included in the initial targeting efforts for the vaccine, which focused on preteen girls. (Federal health officials recently approved the latest version of the vaccine, Gardasil 9, which protects against nine strains of HPV, for adults up to age 45.)
Vivienne’s first surgery, performed under general anesthesia, involved debridement, a procedure that essentially shaves off the tumors.
Weil said she remembers walking into the recovery room with her husband to hear Vivienne “crying loudly,” she recalled. “For us it was the best sound in the world.”
But as is almost always the case, Vivienne’s voice faded to a whisper after a few months as the tumors grew back. For the next few years she underwent simultaneous debridement of both vocal cords every four to six months.
In March 2018 after her 11th operation, her voice did not return. No physical explanation could be found, and doctors suggested the cause might stem from psychological factors. For the next six months, Vivienne underwent hypnosis and saw speech therapists to no avail.
In desperation Weil posted a video of her daughter on Instagram. She hoped that someone — possibly another parent — might have some advice.
Within days, a California woman whose daughter has the disease suggested trying a different treatment. Instead of debridement, she recommended finding a doctor who uses a potassium titanyl phosphate (KTP) laser. Some specialists believe that use of the laser is superior, because it removes more tumor while minimizing damage to the vocal cords.
Weil found Simon Best, an otolaryngologist and researcher at Johns Hopkins who studies the disease and is an expert in laser treatment. He agreed to see Vivienne.
Best estimates that in his 13-year career he has treated about 100 people, mostly adults, who have RRP. Some developed the disease as children. In others, it arose in their 30s and 40s, a decade or so after HPV exposure.
“It has a horrible propensity to just keep coming back,” Best said. One of his patients had endured 300 operations by the time he was 20.
Best treats only one vocal cord at a time to prevent webbing, which occurs when the vocal cords grow together and can harm the voice.
“I was pleasantly surprised that there wasn’t a huge amount of scarring,” said Best of Vivienne, whom he first saw in September 2018.
The first laser surgery on the second grader’s right vocal cord was performed in November 2018; her voice returned, but remained raspy. A second operation on the left vocal cord in January 2019 has had excellent results. In March, Vivienne underwent a successful repeat procedure on her right side.
In the last few months, Weil said, Vivienne has blossomed, eagerly making new friends and becoming a “happy, babbly little girl.”
“She says that having a voice is even better than she thought it would be,” Weil said. A year ago, she had told her mother that several classmates had excluded her from their game of “cheerleader.”
Best recommends that a voice problem that lasts longer than a month should prompt an examination by “someone who can visualize the larynx.”
It’s difficult to predict how many surgeries Vivienne might need, he said. It’s unlikely to be just three because recurrence is the rule.