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Indian Journal of Tuberculosis

231

(Received on 16.6.2011; Accepted after revision on 19.7.2012)

Case Report

Manas Ranjan Rout1 and Prabir Ranjan Moharana2

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: [email protected]; Mob-8985221941.

TUBERCULOSIS OF LARYNX: A CASE REPORT

INTRODUCTION

Involvement of larynx in tuberculosisoccurs as secondary to pulmonary tuberculosis.Primary involvement of larynx is rare. Exact modeof transmission from the lungs is not known. It isbelieved that contact with sputum containing tuberclebacilli plays an important role. The occurrence oftuberculosis of larynx has greatly decreased as a resultof improvement in public health care and developmentof effective antitubercular chemotherapy. Thesepatients usually present with the symptoms of cough,hoarseness of voice, pain in throat, dysphagia,haemoptysis which simulate malignancy and othergranulomatous infections of larynx.

This report describes a 45-year-old malepatient with laryngeal tuberculosis who presented tous with symptoms of hoarseness of voice, productivecough, mild pain in throat and odynophagia.

CASE REPORT

A 45-year-old male patient came to our OutPatients Department with complaints of hoarsenessof voice and mild pain in throat since one month andpain during swallowing since ten days. During clinicalhistory-taking, he revealed that he had cough withexpectoration since four months. During this period,

he had low grade of fever associated with gradualdeterioration in health.

There was no previous history of similarillness and tubercular infection in the family. Patientwas not an alcoholic but he was a known-smoker forthe last 20 years consuming around 10 cigarettes perday.

Since the last four months, he had takenseveral courses of antibiotics and analgesics withoutany relief of symptoms.

On physical examination, he was found tohave thin body built. There was no pallor andlymphadenopathy. Findings of systemic examinationwere normal. On local examination, the oral cavity andposterior pharyngeal wall were found to be normal. Onindirect laryngoscopy, the epiglottis was so muchcongested and edematous (Fig.) that other parts ofthe larynx could not be visualized. On videolaryngoscopy, the epiglottis, arytenoids, interarytenoid region and ventricular bands were foundto be congested and edematous. Small multiple ulcerswere found over the arytenoids, inter-arytenoidregion and epiglottis with purulent exudation. Truevocal cord was poorly visualized. Movement of thevocal cords and arytenoids appeared to be normalwith glottic chink due to edema of the arytenoids.

[Indian J Tuberc 2012; 59: 231-234]

Summary: A case of tuberculosis of larynx in a 45-year-old male patient has been described here. Usually, the signs andsymptoms of laryngeal tuberculosis resemble with malignant diseases of larynx. The diagnosis was made here by themicroscopic examination of sputum smear for Acid Fast Bacilli, chest x-ray, direct laryngoscopy and biopsy from thelaryngeal lesion.

Key words: Laryngeal Tuberculosis, Extra-pulmonary Tuberculosis, Odynophagia, Laryngoscopy.


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On examination, the nose, ear, head andneck were found to be normal. All the cranial nerveswere functionally intact.

His laboratory investigations revealed normalhaemoglobin level(13gm%), normal differential count(Neutrophils-65%, Lymphocytes-30%, Eosinophils-5%, Basophills-0%, Monocytes-0%), normal totalleucocytes count (8500 cells/mm3) and a raisedErythrocyte Sedimentation Rate (50 mm in first hour).Mantoux test revealed an induration of 12 mm after72 hours. A chest radiograph showed patchy opacitiesin both the lung apices. Sputum smear was foundpositive for Acid Fast Bacilli. Tests for HumanImmunodeficiency Virus(HIV) status and Hepatitis-BVirus(HBV) Surface Antigen were found to be negative.Liver function tests, renal function tests and fastingblood sugar were found to be within normal limits.

Direct laryngoscopy was done under shortgeneral anaesthesia and biopsy was taken from

epiglottis and inter arytenoid region. The specimenwas sent for histopathological examination.

The histopathological examination revealedfibro-collagenous tissue lined by stratified squamousepithelium enclosing fair number of confluentepithelioid cell granulomas with Langhans type giantcells surrounded by lymphocytes and fibroblasts witha few areas of caseous necrosis suggestive oftuberculosis.

On the basis of bacteriological, radiologicaland histopathological findings, diagnosis of laryngealtuberculosis secondary to pulmonary tuberculosiswas established.

Then standard Category-I regimen of RevisedNational Tuberculosis Control Program (RNTCP) wasgiven to the patient for six months. Follow-upexamination after one month of treatment showedresolution of the signs and symptoms. Larynx appeared

Figure: Congested and edematous epiglottis with multiple ulcers.

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normal under video laryngoscopy and there wassignificant gain in weight of the patient after twomonths of treatment.

DISCUSSION

During the last 10 years, mortality fromtuberculosis has decreased by 43% in India.1 Now thedisease is changing its manifestation with increase inthe incidence of extra-pulmonary cases. However,the cause of this change is not clearly known.2 Onthe other hand, it might be due to an increasednumber of cases of extra-pulmonary tuberculosiswhich are being diagnosed by newer techniques.

Laryngeal tuberculosis is a rare clinicalentity and recent incidence of laryngeal tuberculosisis less than 1% of all tuberculosis cases.3 In a seriesof 843 tuberculosis cases, only 11 cases showedlaryngeal involvement (1.3%).4 But India is anendemic zone for tuberculosis. In a study of 500patients with pulmonary tuberculosis from India,laryngeal involvement was observed in 4% of them.5

Laryngeal tuberculosis may be primary orsecondary to pulmonary tuberculosis. Primarylaryngeal tuberculosis occurs without any evidence ofpathology in lungs or in any other site. Present case wasthought to be secondary to pulmonary tuberculosis.

Male predominance is found in laryngealtuberculosis i.e. 2-3:1 and the commonest age groupis 40-60 years.6

Tuberculosis in head and neck region iscommonly associated with HIV infection. In any HIVpositive patient with head and neck lesion, tubercularinfection is to be excluded first.7 Now the incidenceof tuberculosis is increasing because of co-existingHIV infection. In this case, the patient was negativefor HIV infection.

Alonso et al, in their report of 11 laryngealtuberculosis cases, found isolated dysphonia ordysphonia with odynophagia to be the most commonpresenting symptom(s).8 In our case, the presentingsymptoms were hoarseness of voice, pain in thethroat, odynophagia and productive cough.

In laryngeal tuberculosis, anterior part oflarynx is more commonly involved than posterior partand the most common site of involvement is interarytenoid region.9 But according to Clery and Batsakis,involvement of anterior half of larynx now occurs twiceas often as the posterior half of larynx. The vocal cordsare the most commonly affected sites(50-70%) whichare followed by false cords(40-50%), epiglottis,aryepiglottic folds, arytenoid, posterior commissureand sub-glottis (10-15%).10 In this case, the involvedsites were epiglottis, arytenoids, inter arytenoid foldand ventricular bands.

The findings of laryngeal tuberculosis can becategorized into four groups i.e. (a) whitish ulcerativelesions (40.9%) (b) non-specific inflammatory lesions(27.3%), (c) polypoid lesions (22.7%) and (d) ulcerofungative mass lesions (9.1%).11 The present case showedwhitish ulcerative lesion over the arytenoids, interarytenoid region and epiglottis with purulent exudations.

Direct laryngoscopy and biopsy aremandatory to establish the confirmative diagnosis.It can be done under local or general anaesthesia.Characteristic features which are found intuberculosis are epitheloid granulomas withLanghans type of giant cells and caseatinggranuloma formation.

It should be kept in mind that tuberculosisand malignancy of larynx may co-exist.12 So,biopsy not only diagnoses tuberculosis, but alsoexcludes malignancy as early as possible. Anti-tubercular therapy offers a good prognosis. Thispatient became asymptomatic after one month ofchemotherapy.

CONCLUSION

Laryngeal tuberculosis is no more a rarecondition with incidence of 4% among all cases oftuberculosis. In most of the cases, it is secondaryto pulmonary tuberculosis. Direct laryngoscopyand biopsy are mandatory to establishconfirmatory diagnosis and to exclude malignantdiseases which often co-exist. Anti-tuberculartherapy is the treatment of choice and prognosisis very good if it is treated early.


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REFERENCES

1. Central TB Division, Ministry of Health & Welfare,Govt. of India, TB India 2010, RNTCP Status Report.

2. Lee KC, Schecter G . Tuberculosis infection of head andneck. Ear, Nose, Throat Journal 1995; 74: 395-9.

3. Egeli E et al. Epiglottic tuberculosis in a patient treatedwith steroid for Addisons disease. Tohoku J Exp Med2003; 20:119-25.

4. Rohwedder JJ. Upper respiratory tract tuberculosis,sixteen cases in a general hospital. Ann Intern Med 1974;80:708-13.

5. Sode A et al. Tuberculosis of larynx: clinical aspects in19 patients. Laryngoscope 1989; 99: 1147-50.

6. Galli J et al. Atypical isolated epiglottic tuberculosis, acase report and review of literature. Am J Otolaryngol2002; 23: 237-40.

7. Sing B et al. Isolated cervical tuberculosis in patientswith HIV infection. Otolaryngol Head Neck Surgery 1998Jun; 118: 766-70.

8. Alonso PE et al. Laryngeal tuberculosis. Rev laryngolotol rhinol 2002; 14: 352-6.

9. Dhingra PL, Disease of Ear, Nose and Throat, ElsevierPublishers, 3rd edn, 351-2.

10. Cleary KR, Batsakis JG. Mycobacterial disease of headand neck, current perspective. Ann otol rhinol laryngol1995; 104: 830-3.

11. Shin JE et al. Changing trends in clinical manifestationsof laryngeal tuberculosis. Laryngoscope 2000; 110:1950-3.

12. Richter B et al. Epiglottic tuberculosis, differentialdiagnosis and treatment, case report and review ofliterature. Ann otol rhinol laryngol 2001; 110: 197-201.

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