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Summary: A case of tuberculosis of larynx in a 45-year-old male patient has been described here. Usually, the signs and
symptoms of laryngeal tuberculosis resemble with malignant diseases of larynx. The diagnosis was made here by the
microscopic examination of sputum smear for Acid Fast Bacilli, chest x-ray, direct laryngoscopy and biopsy from the
laryngeal lesion. [Indian J Tuberc 2012; 59: 231-234]
1. Assistant Professor (ENT, Head & Neck Surgery) 2. Assistant Professor (Community Medicine)
Alluri Sitarama Raju Academy of Medical Sciences, Eluru, West Godavari District (Andhra Pradesh)
Correspondence: Dr Prabir Ranjan Moharana, Assistant Professor (Community Medicine), Alluri Sitarama Raju Academy of Medical Sciences,
Eluru, West Godavari District (Andhra Pradesh) - 534 005; E-mail: drprabir2007@rediffmail.com; Mob-8985221941.
On examination, the nose, ear, head and epiglottis and inter arytenoid region. The specimen
neck were found to be normal. All the cranial nerves was sent for histopathological examination.
were functionally intact.
The histopathological examination revealed
His laboratory investigations revealed normal fibro-collagenous tissue lined by stratified squamous
haemoglobin level(13gm%), normal differential count epithelium enclosing fair number of confluent
(Neutrophils-65%, Lymphocytes-30%, Eosinophils- epithelioid cell granulomas with Langhans type giant
5%, Basophills-0%, Monocytes-0%), normal total cells surrounded by lymphocytes and fibroblasts with
leucocytes count (8500 cells/mm3) and a raised a few areas of caseous necrosis suggestive of
Erythrocyte Sedimentation Rate (50 mm in first hour). tuberculosis.
Mantoux test revealed an induration of 12 mm after
72 hours. A chest radiograph showed patchy opacities On the basis of bacteriological, radiological
in both the lung apices. Sputum smear was found and histopathological findings, diagnosis of laryngeal
positive for Acid Fast Bacilli. Tests for Human tuberculosis secondary to pulmonary tuberculosis
Immunodeficiency Virus(HIV) status and Hepatitis-B was established.
Virus(HBV) Surface Antigen were found to be negative.
Liver function tests, renal function tests and fasting Then standard Category-I regimen of Revised
blood sugar were found to be within normal limits. National Tuberculosis Control Program (RNTCP) was
given to the patient for six months. Follow-up
Direct laryngoscopy was done under short examination after one month of treatment showed
general anaesthesia and biopsy was taken from resolution of the signs and symptoms. Larynx appeared
normal under video laryngoscopy and there was In laryngeal tuberculosis, anterior part of
significant gain in weight of the patient after two larynx is more commonly involved than posterior part
months of treatment. and the most common site of involvement is inter
arytenoid region.9 But according to Clery and Batsakis,
DISCUSSION involvement of anterior half of larynx now occurs twice
as often as the posterior half of larynx. The vocal cords
During the last 10 years, mortality from are the most commonly affected sites(50-70%) which
tuberculosis has decreased by 43% in India.1 Now the are followed by false cords(40-50%), epiglottis,
disease is changing its manifestation with increase in aryepiglottic folds, arytenoid, posterior commissure
the incidence of extra-pulmonary cases. However, and sub-glottis (10-15%).10 In this case, the involved
the cause of this change is not clearly known.2 On sites were epiglottis, arytenoids, inter arytenoid fold
the other hand, it might be due to an increased and ventricular bands.
number of cases of extra-pulmonary tuberculosis
which are being diagnosed by newer techniques. The findings of laryngeal tuberculosis can be
categorized into four groups i.e. (a) whitish ulcerative
Laryngeal tuberculosis is a rare clinical lesions (40.9%) (b) non-specific inflammatory lesions
entity and recent incidence of laryngeal tuberculosis (27.3%), (c) polypoid lesions (22.7%) and (d) ulcero
is less than 1% of all tuberculosis cases.3 In a series fungative mass lesions (9.1%).11 The present case showed
of 843 tuberculosis cases, only 11 cases showed whitish ulcerative lesion over the arytenoids, inter
laryngeal involvement (1.3%).4 But India is an arytenoid region and epiglottis with purulent exudations.
endemic zone for tuberculosis. In a study of 500
patients with pulmonary tuberculosis from India, Direct laryngoscopy and biopsy are
laryngeal involvement was observed in 4% of them.5 mandatory to establish the confirmative diagnosis.
It can be done under local or general anaesthesia.
Laryngeal tuberculosis may be primary or Characteristic features which are found in
secondary to pulmonary tuberculosis. Primary tuberculosis are epitheloid granulomas with
laryngeal tuberculosis occurs without any evidence of Langhans type of giant cells and caseating
pathology in lungs or in any other site. Present case was granuloma formation.
thought to be secondary to pulmonary tuberculosis.
It should be kept in mind that tuberculosis
Male predominance is found in laryngeal and malignancy of larynx may co-exist. 12 So,
tuberculosis i.e. 2-3:1 and the commonest age group biopsy not only diagnoses tuberculosis, but also
is 40-60 years.6 excludes malignancy as early as possible. Anti-
tubercular therapy offers a good prognosis. This
Tuberculosis in head and neck region is patient became asymptomatic after one month of
commonly associated with HIV infection. In any HIV chemotherapy.
positive patient with head and neck lesion, tubercular
infection is to be excluded first.7 Now the incidence CONCLUSION
of tuberculosis is increasing because of co-existing
HIV infection. In this case, the patient was negative Laryngeal tuberculosis is no more a rare
for HIV infection. condition with incidence of 4% among all cases of
tuberculosis. In most of the cases, it is secondary
Alonso et al, in their report of 11 laryngeal to pulmonary tuberculosis. Direct laryngoscopy
tuberculosis cases, found isolated dysphonia or and biopsy are mandatory to establish
dysphonia with odynophagia to be the most common confirmatory diagnosis and to exclude malignant
presenting symptom(s).8 In our case, the presenting diseases which often co-exist. Anti-tubercular
symptoms were hoarseness of voice, pain in the therapy is the treatment of choice and prognosis
throat, odynophagia and productive cough. is very good if it is treated early.