Professional Documents
Culture Documents
Myron W. Yencha, MD, * Ronald Linfesty, MD, and Ana Blackmon, MD~
(Editorial Comment: Laryngeal tuberculosis is patients infected with TB, and the mortality
decidedly unusual in North America. The authors rate decreased to less than 2%. 1,2 However,
speculate, however, that the incidence of laryngeal because the incidence of TB is on the rise
tuberculosis is on the rise; therefore, it behooves
otolaryngologists to consider this in the differential worldwide (mainly caused by the emergence
diagnosis of laryngeal lesions.) of the acquired immunodeficiency syndrome
[AIDS] epidemic) the incidence of laryngeal
Tuberculosis is an infectious disease caused involvement may also be increasing. We re-
by Mycobacterium tuberculosis. Typically, pa- port a case of laryngeal TB in a human immu-
tients present with fever, chills, night sweats, nodeficiency virus (HIV)-negative patient and
weight loss, and cough. This disease mainly review the literature.
affects the pulmonary system but can also
involve extrapulmonary sites such as the
CASE REPORT
larynx.
In the preantibiotic era, laryngeal TB was A 58-year-old white male presented to the
considered the most common disease of the internal medicine clinic with a 1-month his-
larynx, affecting 35% to 83% of patients with tory of cough, dysphonia, dysphagia, and
TB, and the mortality rate was 45% to 90%.1,2 odynophagia. This patient was the health care
Involvement of the larynx was considered a provider on a sea-going vessel and had self-
preterminal event. With the development of treated with amoxicillin without resolution of
antituberculous medications, isolation proto- his symptoms. He denied weight loss, fever,
cols, and early detection methods, laryngeal chills, hemoptysis, or decrease in appetite. He
involvement decreased to less than 1% of also denied any allergies and was not on any
medications. His past medical history was
significant for a positive purified protein de-
From the *Department of Otolaryngology--Head and
Neck Medicine, US Naval Hospital, Pensacola, FL, and rivative (PPD) test, for which he received
the Departments of tPathology and :~lnternal Medicine, treatment, and an abnormal chest radiograph
US Naval Hospital, Yokosuka, Japan. (CXR). Neither old films or radiological re-
The opinions or assertions expressed herein are those
of the authors and are not to be construed as official or as ports were available for review. His social
reflecting the views of the Department of the Navy or the history included one pack of cigarettes per day
Department of Defense. for 50 years and a history of alcohol abuse.
Address reprint requests to Myron W. Yencha, MD,
Department of Otolaryngology-Head and Neck Surgery, This patient lives in the Philippines and re-
US Naval Hospital-Pensacola, 6000 West Highway 98, cently traveled to Thailand and Singapore.
Pensacola, FL 32512. Physical examination showed an ill-appearing
This is a US government work. There are no restric-
tions on its use. male in no apparent distress. Head and neck
0196-0709/00/2102-001050.00/0 examination revealed a 2.5-cm, soft, mobile
122 American Journal of Otolaryngology, Vo121, No 2 (March-April), 2000: pp 122-126
LARYNGEAL TUBERCULOSIS 123
Fig 1. Intraoperative photograph shows an edema- Fig 3. Photomicrograph shows numerous acid-fast
tous (turban-shaped) epiglottis with nodularity and ulcer- bacilli (arrows). (Kinyoun acid-fast stain; original magni-
ations. fication x 1000).
124 YENCHA, LINFESTY,AND BLACKMON
copy because it allows direct visualization of diagnosed with TB, PPD testing was per-
the endolarynx and a means of obtaining formed on all members of that ship. The
tissue for diagnosis. The diagnosis of laryngeal results showed that 12 members, who were
TB is established with the identification of known to have had a recent negative PPD test,
granulomatous inflammation, caseating granu- tested positive although none had active pul-
lomas, and AFB on histopathologic examina- monary TB. Subsequently, all were treated
tion. However, the presence of psuedoepithe- with isoniazid for 6 months.
liomatous hyperplasia, which mimics SCCA, Finally, dysphonia is a complaint heard
can make the diagnosis difficult; thus, the frequently by the otolaryngologist and has
pathologist should be informed that TB is part many etiologies. In the HIV-infected popula-
of the differential diagnosis. Also, laryngeal tion, where TB is on the rise, dysphonia could
TB and laryngeal SCCA can coexist in the be the presenting symptom of laryngeal TB;
same patient, and laryngoscopy findings are thus, precautions should be taken to ensure
often indistinguishable; thus, biopsies should safety of the otolaryngologist and their staff.
be taken from all suspicious lesions and at
multiple sites. 9,1~Furthermore, the typical pa- SUMMARY
tient with laryngeal TB has similar risk factors
(tobacco and alcohol abuse) as those for laryn- Since the introduction of antituberculous
geal SCCA. medications, the incidence of laryngeal TB
In one study of HIV-infected patients with has declined and remains stable. As a result,
laryngeal TB, SCCA was the initial impression many physicians do not consider TB in the
on laryngoscopy (even though systemic symp- differential diagnosis of laryngeal lesions.
toms were present but attributed to their HIV However, with the incidence of TB increasing,
status). 12 This resulted in a delay of diagnosis the overall incidence of laryngeal involvement
in all of these patients, thereby putting the may be on the rise. The main presenting
examining physician at risk for aquiring TB. symptom is dysphonia, and the diagnosis is
Thus, HIV-infected patients with laryngeal confirmed by histopathologic examination of
lesions should be considered infectious, and biopsied tissue showing granulomatous inflam-
appropriate precautions should be taken until mation, caseating granulomas, and AFB. Possi-
proven otherwise. bilities that may make the diagnosis difficult
The differential diagnosis of laryngeal TB include the presence of psuedoepithelioma-
includes neoplasms (mainly SCCA), sarcoid- tous hyperplasia, which mimics SCCA. Treat-
osis, Wegener's granulomatosis, mycotic infec- ment primarily consists of antituberculous
tions, syphilis, and chronic nonspecific laryn- medications with surgery reserved for those
gitis.7,13,14 cases of airway compromise. Finally, laryn-
Treatment consists of culture-sensitive anti- geal complications can occur; thus, long-term
tuberculous medications and respiratory isola- follow-up is recommended.
tion. Surgical intervention (tracheostomy) is
reserved for those cases of airway compro-
REFERENCES
mise.
After therapy, the patient's symptoms should 1. Lindell MM, Jing BS, Wallace S: Laryngeal tuberculo-
resolve. However, in those cases of persistent sis. Am J Roentgenol 129:677-680, 1 9 7 7
2. Brodovsky DM: Laryngeal tuberculosis in an age of
dysphonia, further investigation is warranted. chemotherapy. Can J Otolaryngol 4:161-176, 1975
As the larynx heals, fibrosis of laryngeal tis- 3. Ellner JJ: Tuberculosis in the time of AIDS: The
sues can occur resulting in the following se- factors and the message. Chest 98:1051-1052, 1990
4. Beck K: Mycobacterial disease associated with HIV
quelae: cricoarytenoid joint fixation, posterior infection. J Gen Intern Med 6:$19-$23, 1991 (suppl)
glottic stenosis, subglottic stenosis, or persis- 5. Ramadan HH, Tarazi AE, Baroudy FM: Laryngeal
tent dysphonia. 6nLls tuberculosis: Presentation of 16 cases and review of the
literature. J Otolaryngo122:39-41, 1993
From an epidemiological standpoint, our 6. Soda A, Rubio H, Salazar M, et al: Tuberculosis of the
patient was a health care provider who was larynx: Clinical aspects in 19 patients. Laryngoscope
actively seeing patients despite being symp- 99:1147-1150, 1989
7. Smallman LA, Clark DR, Raine CH, et al: The presen-
tomatic (for 2 months) and infected with TB, tation of laryngeal tuberculosis. Clin Otolaryngol 12:221-
although undiagnosed. After the patient was 225, 1987
126 YENCHA, LINFESTY, AND BLACKMON
8. Chodosh PL, Willis W: Tuberculosis of the upper 12. Singh B, Balwally AN, Nash M, et al: Laryngeal
respiratory tract. Laryngoscope 80:679-696, 1970 tuberculosis in HIV-infected patients: a difficult diagno-
9. Leveson MJ, Ingerman M, Grimes C, et al: Laryngeal sis. Laryngoscope 106:1238-1240, 1996
Tuberculosis: Review of twenty cases. Laryngoscope 94: 13. Couldery AD: Tuberculosis of the upper respiratory
1094-1097, 1984 tract misdiagnosed as Wegener's granulomatosis--an im-
10. Galietti F, Giorgis GE, Gandol FG, et al: Examina- portant distinction. J Laryngol Otol 104:255-258, 1990
tion of 41 cases of laryngeal tuberculosis observed be- 14. Riley EC, A m u n d s o n DE: Laryngeal Tuberculosis
tween 1975-1985. Eur Respir J 2:731-732, 1989 revisited. A m Fam Physician 49:759-762, 1992
11. Rupa V, Bhanu TS: Laryngeal tuberculosis in the 15. Park SS, Streitz JM, Rebeiz EE, et ah Idiopathic
eighties--an Indian experience. J Laryngo] Otol 103:864- Subglottic Stenosis. Arch Otolaryngol Head Neck Surg
868, 1989 121:894-897, 1995