Scientific Letter
Early infantile dysphonia as an alert symptom of juvenile laryngeal papillomatosis
Disfonía infantil precoz como síntoma de alerta de la papilomatosis laríngea juvenil
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Fita, J.A. Díaz Manzano, S.B. Reyes Domínguez, P. Pastor Costa, A. Navarro Mingorance" "autores" => array:5 [ 0 => array:4 [ "nombre" => "A.M." "apellidos" => "Fita" "email" => array:1 [ 0 => "fitaanamaria@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "J.A." "apellidos" => "Díaz Manzano" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "S.B." "apellidos" => "Reyes Domínguez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "P." "apellidos" => "Pastor Costa" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "A." "apellidos" => "Navarro Mingorance" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Unidad de Cuidados Intensivos Pediátricos, Servicio de Pediatría, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Otorrinolaringología, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Disfonía infantil precoz como síntoma de alerta de la papilomatosis laríngea juvenil" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 746 "Ancho" => 995 "Tamanyo" => 85639 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Fibre-optic laryngoscopy: lesion of papillomatous appearance, occupying the anterior third of the vocal cords and partially obstructing the glottic lumen.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Juvenile laryngeal papillomatosis (JLP) is the second most common cause of dysphonia in children, after true vocal cord nodules. The most frequent causative agent is human papillomavirus (HPV) serotypes 6 and 11. The most widely accepted mode of transmission is vertical, through the birth canal of a mother with an active or latent genital infection.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> The prevalence is 1.11–2.59 per 100,000 children.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> We present 6 cases of JLP, a recurrent disease with non-specific clinical symptoms, which should be taken into account in cases of persistent dysphonia.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We conducted a retrospective study of diagnosed cases of JLP during the period from 1 January 2000 to 31 December 2013. We analysed epidemiological data (age at diagnosis, sex), treatment received, sequelae and number of surgical interventions (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). The male–female ratio found was 1:1. The median age at diagnosis was 18 months, with an interquartile range (IQR) of 26.5 months. The common symptoms were dysphonia, nocturnal breathing difficulty and inspiratory stridor. Patient 1 was an uncontrolled pregnancy with maternal serology compatible with a resolved syphilis and hepatitis B infection, premature at 25 weeks gestation, with a birth weight of 1000<span class="elsevierStyleHsp" style=""></span>g. She had associated malnutrition and laryngomalacia. She needed tracheostomy from 14 to 20 months of age (because of respiratory failure secondary to papillomatosis). Patient 2 was the product of an adolescent pregnancy of a mother vaccinated against HPV (Cervarix<span class="elsevierStyleSup">®</span> 3 doses) at the age of 14. He was diagnosed with recurrent laryngitis. Patient 3 had been an uncontrolled pregnancy. Patient 4 had a maternal history of papillomas on the hands, and was diagnosed with adenoidal hypertrophy and bronchitis. The mother of patient 5 had had previous genital papillomatosis and patient 6 had language acquisition difficulties.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The laryngeal papillomas were detected by fibre-optic laryngoscopy, and an excision was performed (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) by endolaryngeal microsurgery. In 4 of the 6 cases they received intraoperative adjuvant treatment with intralesional cidofovir on at least one occasion. Case 2 also received oral propranolol daily for a year. The histological findings were consistent with papillomatosis, and serotype HPV-11 was identified in cases 2 and 3 and HPV-6 in case 6.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The vocal cords are the most frequent site of JLP. Distal spread has been associated with poorer prognosis and with HPV-11 infection.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> The classic presentation is persistent dysphonia with weak crying between 2 and 4 years of age. The second most common symptom is stridor, first inspiratory and then biphasic. Less common presenting symptoms include chronic cough, recurrent pneumonia, failure to thrive, dyspnoea, dysphagia and acute respiratory distress, especially in infants with an upper respiratory tract infection.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The differential diagnosis with this disease must be made with other causes of airway obstruction, primarily at the pharyngo-laryngeal level (laryngomalacia, vocal cord paralysis, glottic or subglottic granulomas or cysts, laryngitis, congenital or acquired subglottic stenosis, haemangiomas and traumas) and at the tracheal level (tracheal stenosis, tracheomalacia, extrinsic compression by abnormal vascular structures). Less commonly it will be confused with abnormalities at the nasal level (choanal atresia/stenosis, pyriform aperture stenosis, adenoid hypertrophy, tumours, rhinitis and foreign bodies), as well as at the pharyngeal level (nasopharyngeal stenosis, tonsillar hypertrophy, macroglossia and craniofacial abnormalities).</p><p id="par0030" class="elsevierStylePara elsevierViewall">It is not unusual in JLP for an erroneous initial diagnosis to be made, given the range of non-specific symptoms it shares with other common respiratory diseases. In the series of cases described by Zacharisen and Conley,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> croup, laryngomalacia and asthma were the most common misdiagnoses before reaching a definitive diagnosis. One must remain alert to recurrent or progressive respiratory symptoms that do not follow the natural course of the most common diseases and do not improve with conventional treatment.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Delay in diagnosis could lead to obstruction of the upper airway with the risk of acute respiratory failure. Coope and Connett<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> report the case of a five-year-old child with persistent dysphonia diagnosed with asthma, who died as a result of airway collapse. The post mortem showed obstruction of the upper airway by papillomatosis.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The natural course of the condition can be unpredictable: it may remit spontaneously, remain stable or show aggressive growth, although the most common outcome is spontaneous remission with increasing age, and after numerous surgical interventions to excise the lesions.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> In the presence of persistent dysphonia with or without stridor, laryngoscopic examination may offer early diagnosis and thereby avoid the development of associated complications.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Please cite this article as: Fita AM, Díaz Manzano JA, Reyes Domínguez SB, Pastor Costa P, Navarro Mingorance A. Disfonía infantil precoz como síntoma de alerta de la papilomatosis laríngea juvenil. An Pediatr (Barc). 2015;83:211–212.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 746 "Ancho" => 995 "Tamanyo" => 85639 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Fibre-optic laryngoscopy: lesion of papillomatous appearance, occupying the anterior third of the vocal cords and partially obstructing the glottic lumen.</p>" ] ] 1 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">ELMS: endolaryngeal microsurgery; F: female; HPV: human papillomavirus; M: male.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Cases \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sex \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Treatment \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Adjuvant treatment \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Complications \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Qx<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">HPV \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CO<span class="elsevierStyleInf">2</span> laser ELMS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cidofovir \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Tracheotomy, synechiae, dysphonia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Diode laser microdibrider ELMS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cidofovirpropranolol \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CO<span class="elsevierStyleInf">2</span> laser ELMS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cidofovir \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Synechiae, dysphonia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CO<span class="elsevierStyleInf">2</span> laser ELMS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Synechiae, dysphonia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Diode laser ELMS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">36 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CO<span class="elsevierStyleInf">2</span> laser ELMS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cidofovir \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Dysphonia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab940516.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">In months at diagnosis</p>" ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Number of interventions.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Juvenile laryngeal papillomatosis at the Hospital Clínico Universitario Virgen de la Arrixaca between January 2000 and December 2013.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Condyloma in pregnancy is strongly predictive of juvenile-onset recurrent respiratory papillomatosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M.J. 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Simpson" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/lary.20901" "Revista" => array:6 [ "tituloSerie" => "Laryngoscope" "fecha" => "2010" "volumen" => "120" "paginaInicial" => "1233" "paginaFinal" => "1245" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20513045" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0045" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lower airway papillomatosis in children" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "L. Zawadzka-Glos" 1 => "A. Jakubowska" 2 => "M. Chmielik" 3 => "A. Bielicka" 4 => "M. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 14 | 10 | 24 |
| 2024 October | 53 | 33 | 86 |
| 2024 September | 72 | 30 | 102 |
| 2024 August | 98 | 50 | 148 |
| 2024 July | 118 | 29 | 147 |
| 2024 June | 127 | 17 | 144 |
| 2024 May | 81 | 52 | 133 |
| 2024 April | 75 | 34 | 109 |
| 2024 March | 93 | 28 | 121 |
| 2024 February | 93 | 24 | 117 |
| 2024 January | 70 | 26 | 96 |
| 2023 December | 120 | 19 | 139 |
| 2023 November | 78 | 35 | 113 |
| 2023 October | 84 | 34 | 118 |
| 2023 September | 65 | 33 | 98 |
| 2023 August | 50 | 21 | 71 |
| 2023 July | 91 | 38 | 129 |
| 2023 June | 48 | 27 | 75 |
| 2023 May | 106 | 25 | 131 |
| 2023 April | 76 | 23 | 99 |
| 2023 March | 118 | 30 | 148 |
| 2023 February | 85 | 12 | 97 |
| 2023 January | 70 | 27 | 97 |
| 2022 December | 75 | 24 | 99 |
| 2022 November | 112 | 30 | 142 |
| 2022 October | 95 | 45 | 140 |
| 2022 September | 149 | 26 | 175 |
| 2022 August | 173 | 61 | 234 |
| 2022 July | 167 | 44 | 211 |
| 2022 June | 143 | 36 | 179 |
| 2022 May | 131 | 43 | 174 |
| 2022 April | 121 | 37 | 158 |
| 2022 March | 136 | 55 | 191 |
| 2022 February | 106 | 36 | 142 |
| 2022 January | 121 | 40 | 161 |
| 2021 December | 87 | 35 | 122 |
| 2021 November | 103 | 50 | 153 |
| 2021 October | 166 | 67 | 233 |
| 2021 September | 120 | 45 | 165 |
| 2021 August | 110 | 51 | 161 |
| 2021 July | 78 | 38 | 116 |
| 2021 June | 96 | 34 | 130 |
| 2021 May | 104 | 30 | 134 |
| 2021 April | 225 | 96 | 321 |
| 2021 March | 142 | 30 | 172 |
| 2021 February | 98 | 20 | 118 |
| 2021 January | 130 | 18 | 148 |
| 2020 December | 114 | 26 | 140 |
| 2020 November | 85 | 26 | 111 |
| 2020 October | 57 | 21 | 78 |
| 2020 September | 67 | 17 | 84 |
| 2020 August | 61 | 12 | 73 |
| 2020 July | 73 | 17 | 90 |
| 2020 June | 79 | 15 | 94 |
| 2020 May | 92 | 18 | 110 |
| 2020 April | 86 | 15 | 101 |
| 2020 March | 74 | 19 | 93 |
| 2020 February | 89 | 13 | 102 |
| 2020 January | 64 | 12 | 76 |
| 2019 December | 56 | 22 | 78 |
| 2019 November | 57 | 16 | 73 |
| 2019 October | 562 | 16 | 578 |
| 2019 September | 52 | 7 | 59 |
| 2019 August | 53 | 19 | 72 |
| 2019 July | 43 | 18 | 61 |
| 2019 June | 65 | 15 | 80 |
| 2019 May | 67 | 12 | 79 |
| 2019 April | 133 | 38 | 171 |
| 2019 March | 56 | 12 | 68 |
| 2019 February | 45 | 9 | 54 |
| 2019 January | 53 | 34 | 87 |
| 2018 December | 54 | 23 | 77 |
| 2018 November | 71 | 27 | 98 |
| 2018 October | 120 | 59 | 179 |
| 2018 September | 70 | 15 | 85 |
| 2018 August | 2 | 0 | 2 |
| 2018 June | 2 | 0 | 2 |
| 2018 May | 10 | 0 | 10 |
| 2018 April | 30 | 0 | 30 |
| 2018 March | 51 | 0 | 51 |
| 2018 February | 51 | 0 | 51 |
| 2018 January | 55 | 0 | 55 |
| 2017 December | 13 | 0 | 13 |
| 2017 November | 19 | 0 | 19 |
| 2017 October | 15 | 0 | 15 |
| 2017 September | 12 | 0 | 12 |
| 2017 August | 17 | 0 | 17 |
| 2017 July | 13 | 0 | 13 |
| 2017 June | 21 | 21 | 42 |
| 2017 May | 18 | 7 | 25 |
| 2017 April | 21 | 33 | 54 |
| 2017 March | 15 | 10 | 25 |
| 2017 February | 5 | 3 | 8 |
| 2017 January | 6 | 5 | 11 |
| 2016 December | 26 | 6 | 32 |
| 2016 November | 35 | 5 | 40 |
| 2016 October | 36 | 12 | 48 |
| 2016 September | 33 | 4 | 37 |
| 2016 August | 23 | 4 | 27 |
| 2016 July | 11 | 2 | 13 |
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