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Laryngeal tuberculosis: A diagnosis not to be overlooked
G Model ANORL-356; No. of Pages 2
ARTICLE IN PRESS European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2014) xxx–xxx
Available online at
ScienceDirect www.sciencedirect.com
Letter to the editor Laryngeal tuberculosis: A diagnosis not to be overlooked 1. Case report A 50-year-old female, pathology clinic physician, presented with 2 months of persistent hoarseness with no associated symptoms of fever, night sweats, weight loss, cough or dysphagia. There was no history of smoking or use of irritants, or of tuberculosis. She was using long-term inhaled corticosteroids for asthma. Laryngoscopic examination revealed a granulomatous lesion of the posterior two-thirds of the right vocal fold, with conserved laryngeal mobility (Fig. 1). No palpable cervical lymphadenopathy. Head and neck computed tomography scan found focal regular thickening of the right vocal fold without cervical lymphadenopathy. The laryngeal microsurgical biopsy of the lesion revealed granulomas with caseating necrotic centers and Langhans-type giant cells. There was no evidence of malignancy. Acid-fast bacilli were found in the specimen by Ziehl-Neelsen stain, confirming the diagnosis of laryngeal tuberculosis. Chest X-ray was normal. Sputum smear was positive for acidfast bacilli and culture yielded Mycobacterium tuberculosis. A standard six-month course of anti-tuberculosis chemotherapy was given. This included rifampicin, isoniazid, pyrazinamide and ethambutol for 2 months followed by rifampicin and isoniazid continued for 4 months. After treatment, the patient’s symptoms had resolved and laryngoscopy was normal. The case was declared as an occupational disease by the National Center of Protection Against Occupational Hazards. 2. Discussion Laryngeal tuberculosis (LT) is due to Mycobacterium tuberculosis and represents the most frequent granulomatous disease of the larynx. It is, however, a rare disease and currently accounts for less than 1% of all cases of tuberculosis [1–4]. It is almost always associated with pulmonary tuberculosis (PT) [1], but patients without history of PT may still contract LT [2]. It occurs mostly in male adults aged between 40 and 50 years, without BCG vaccination and with malnutrition, or in cases of acquired immunodeficiency syndrome (AIDS), immunosuppression and smoking [1,2]. Hoarseness is the most common laryngeal symptom, but odynophagia and dyspnea can be present too [2,4]. Primary LT is very uncommon. It often simulates malignancy on imaging and laryngoscopy, and the final diagnosis is invariably based on biopsy [1,2]. On laryngoscopy, the visual appearance of the larynx is variable and lesions may appear as ulcerative, ulcerofungative, non-specific
Fig. 1. Appearance on flexible nasoendoscopy. A thickened, irregular lesion is seen on the right vocal fold.
inflammatory or polypoid [4]. The appearance may also mimic leukoplakia, chronic laryngitis or laryngeal candidiasis [2,4]. Lesion location is extremely variable. The vocal folds represent the most frequent site, followed by the vestibular folds, epiglottis, subglottic region and posterior commissure [2]. LT is bilateral in 75% of cases [1]. The classic microscopic appearance comprises granulomas with caseating necrotic centers and Langhans-type giant cells. If acid-fast bacilli are found in the specimen, the diagnosis can be confirmed [2]. Treatment should start as soon as possible after diagnosis, and is based on anti-tuberculosis chemotherapy [1]. Extensive laser resection before diagnosis should be avoided because prognosis is usually good after adequate anti-tuberculosis treatment and vocal fold immobility may be reversible [2]. Resolution of lesions and improvement of symptoms usually occurs within several weeks of medical therapy. LT is a diagnosis to be borne in mind in evaluating laryngeal lesions; the medical profession is at risk, being exposed to contagious diseases, especially tuberculosis, and it is important never to neglect protective measures. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. References [1] El Kettani NE, El Hassani M, Chakir N, et al. Primary laryngeal tuberculosis mimicking laryngeal carcinoma: CT scan features. Indian J Radiol Imaging 2010;20(1):11–2.
http://dx.doi.org/10.1016/j.anorl.2013.11.011 1879-7296/© 2014 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Cruz S, et al. Laryngeal tuberculosis: A diagnosis not to be overlooked. European Annals of Otorhinolaryngology, Head and Neck diseases (2014), http://dx.doi.org/10.1016/j.anorl.2013.11.011
G Model ANORL-356; No. of Pages 2 2
ARTICLE IN PRESS Letter to the editor / European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2014) xxx–xxx
[2] Wang CC, Lin CC, Wang CP, et al. Laryngeal tuberculosis: a review of 26 cases. Otolaryngol Head Neck Surg 2007;137(4):582–8. ˜ JL, et al. Dysphonia and [3] Rodríguez Barrientos R, Rodríguez Blanco A, Vidal Munoz laryngeal tuberculosis: presentation of two cases and review of the literature. Aten Primaria 2002;30(8):530–2. [4] Chen H, Thornley P. Laryngeal tuberculosis: a case of a non-healing laryngeal lesion. Australas Med J 2012;5(3):175–7.
S. Cruz ∗ A. Ribeiro N. Trigueiros M. Rodrigues e Rodrigues
Department of Otolaryngology, Hospital Pedro Hispano, Local Health Unit of Matosinhos E.P.E, Rua Dr. Eduardo Torres, 4464-513 Senhora da Hora, Portugal ∗ Corresponding
author. Tel.: +351 917 780 662. E-mail address: [email protected] (S. Cruz)
Please cite this article in press as: Cruz S, et al. Laryngeal tuberculosis: A diagnosis not to be overlooked. European Annals of Otorhinolaryngology, Head and Neck diseases (2014), http://dx.doi.org/10.1016/j.anorl.2013.11.011
ARTICLE IN PRESS European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2014) xxx–xxx
Available online at
ScienceDirect www.sciencedirect.com
Letter to the editor Laryngeal tuberculosis: A diagnosis not to be overlooked 1. Case report A 50-year-old female, pathology clinic physician, presented with 2 months of persistent hoarseness with no associated symptoms of fever, night sweats, weight loss, cough or dysphagia. There was no history of smoking or use of irritants, or of tuberculosis. She was using long-term inhaled corticosteroids for asthma. Laryngoscopic examination revealed a granulomatous lesion of the posterior two-thirds of the right vocal fold, with conserved laryngeal mobility (Fig. 1). No palpable cervical lymphadenopathy. Head and neck computed tomography scan found focal regular thickening of the right vocal fold without cervical lymphadenopathy. The laryngeal microsurgical biopsy of the lesion revealed granulomas with caseating necrotic centers and Langhans-type giant cells. There was no evidence of malignancy. Acid-fast bacilli were found in the specimen by Ziehl-Neelsen stain, confirming the diagnosis of laryngeal tuberculosis. Chest X-ray was normal. Sputum smear was positive for acidfast bacilli and culture yielded Mycobacterium tuberculosis. A standard six-month course of anti-tuberculosis chemotherapy was given. This included rifampicin, isoniazid, pyrazinamide and ethambutol for 2 months followed by rifampicin and isoniazid continued for 4 months. After treatment, the patient’s symptoms had resolved and laryngoscopy was normal. The case was declared as an occupational disease by the National Center of Protection Against Occupational Hazards. 2. Discussion Laryngeal tuberculosis (LT) is due to Mycobacterium tuberculosis and represents the most frequent granulomatous disease of the larynx. It is, however, a rare disease and currently accounts for less than 1% of all cases of tuberculosis [1–4]. It is almost always associated with pulmonary tuberculosis (PT) [1], but patients without history of PT may still contract LT [2]. It occurs mostly in male adults aged between 40 and 50 years, without BCG vaccination and with malnutrition, or in cases of acquired immunodeficiency syndrome (AIDS), immunosuppression and smoking [1,2]. Hoarseness is the most common laryngeal symptom, but odynophagia and dyspnea can be present too [2,4]. Primary LT is very uncommon. It often simulates malignancy on imaging and laryngoscopy, and the final diagnosis is invariably based on biopsy [1,2]. On laryngoscopy, the visual appearance of the larynx is variable and lesions may appear as ulcerative, ulcerofungative, non-specific
Fig. 1. Appearance on flexible nasoendoscopy. A thickened, irregular lesion is seen on the right vocal fold.
inflammatory or polypoid [4]. The appearance may also mimic leukoplakia, chronic laryngitis or laryngeal candidiasis [2,4]. Lesion location is extremely variable. The vocal folds represent the most frequent site, followed by the vestibular folds, epiglottis, subglottic region and posterior commissure [2]. LT is bilateral in 75% of cases [1]. The classic microscopic appearance comprises granulomas with caseating necrotic centers and Langhans-type giant cells. If acid-fast bacilli are found in the specimen, the diagnosis can be confirmed [2]. Treatment should start as soon as possible after diagnosis, and is based on anti-tuberculosis chemotherapy [1]. Extensive laser resection before diagnosis should be avoided because prognosis is usually good after adequate anti-tuberculosis treatment and vocal fold immobility may be reversible [2]. Resolution of lesions and improvement of symptoms usually occurs within several weeks of medical therapy. LT is a diagnosis to be borne in mind in evaluating laryngeal lesions; the medical profession is at risk, being exposed to contagious diseases, especially tuberculosis, and it is important never to neglect protective measures. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. References [1] El Kettani NE, El Hassani M, Chakir N, et al. Primary laryngeal tuberculosis mimicking laryngeal carcinoma: CT scan features. Indian J Radiol Imaging 2010;20(1):11–2.
http://dx.doi.org/10.1016/j.anorl.2013.11.011 1879-7296/© 2014 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Cruz S, et al. Laryngeal tuberculosis: A diagnosis not to be overlooked. European Annals of Otorhinolaryngology, Head and Neck diseases (2014), http://dx.doi.org/10.1016/j.anorl.2013.11.011
G Model ANORL-356; No. of Pages 2 2
ARTICLE IN PRESS Letter to the editor / European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2014) xxx–xxx
[2] Wang CC, Lin CC, Wang CP, et al. Laryngeal tuberculosis: a review of 26 cases. Otolaryngol Head Neck Surg 2007;137(4):582–8. ˜ JL, et al. Dysphonia and [3] Rodríguez Barrientos R, Rodríguez Blanco A, Vidal Munoz laryngeal tuberculosis: presentation of two cases and review of the literature. Aten Primaria 2002;30(8):530–2. [4] Chen H, Thornley P. Laryngeal tuberculosis: a case of a non-healing laryngeal lesion. Australas Med J 2012;5(3):175–7.
S. Cruz ∗ A. Ribeiro N. Trigueiros M. Rodrigues e Rodrigues
Department of Otolaryngology, Hospital Pedro Hispano, Local Health Unit of Matosinhos E.P.E, Rua Dr. Eduardo Torres, 4464-513 Senhora da Hora, Portugal ∗ Corresponding
author. Tel.: +351 917 780 662. E-mail address: [email protected] (S. Cruz)
Please cite this article in press as: Cruz S, et al. Laryngeal tuberculosis: A diagnosis not to be overlooked. European Annals of Otorhinolaryngology, Head and Neck diseases (2014), http://dx.doi.org/10.1016/j.anorl.2013.11.011