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Tubercular laryngitis: case series

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• Published: 28 January 2009
• Volume 60 , pages 331–334, ( 2008 )

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• Rajat Bhatia 1 ,
• Saurabh Varshney 1 ,
• S. S. Bist 1 ,
• Rakesh K. Singh 1 ,
• Nitin Gupta 1 &
• Pratima Gupta 1  

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Introduction

Tubercular laryngitis is a known entity since a long time but it’s presentation, diagnosis and management has undergone a drastic makeover after the advent of chemotherapy in the form of ATT (Anti tubercular treatment), modernized diagnostic aids and early detection of lesions.

Materials and methods

This prospective study was conducted on 180 patients. Each patient were subjected to detailed history and thorough ENT and head neck examination including laryngeal examination by visualization of the vocal cords, possibly using indirect laryngoscopy,. exible naso-laryngoscopy or rigid laryngoscopy Results Tubercular laryngitis was clinically diagnosed by laryngeal endoscopy and diagnosis con. rmed by laryngeal biopsy.

All patients showed remarkable improvement with anti-tubercular treatment.

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Primary Laryngeal Tuberculosis: A Series of 15 Cases

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Department of ENT and Microbiology, Himalayan Institute of Medical Sciences, Jolly Grant, Doiwala Dehradun, 248140, Uttarakhand, India

Rajat Bhatia, Saurabh Varshney, S. S. Bist, Rakesh K. Singh, Nitin Gupta & Pratima Gupta

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Correspondence to Saurabh Varshney .

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Bhatia, R., Varshney, S., Bist, S.S. et al. Tubercular laryngitis: case series. Indian J Otolaryngol Head Neck S 60 , 331–334 (2008). https://doi.org/10.1007/s12070-008-0111-0

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Published : 28 January 2009

Issue Date : December 2008

DOI : https://doi.org/10.1007/s12070-008-0111-0

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4:  Pharyngitis

Frank S. Yu; Jonathan C. Cho

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Patient presentation.

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Chief Complaint

“Mommy, my throat is on fire!”

History of Present Illness

JT is a 7-year-old Chinese American female, accompanied by her mother, who presents to the community pharmacy with complaints of sore throat and fever, looking for medications to take to relieve her symptoms. She is fussy and describes the pain when she swallows as feeling if her throat is “on fire.” Her symptoms began yesterday morning, and she has only tried drinking a pei pa koa syrup containing medicinal herbs (main active herb is elm bark) and honey to relieve the sore throat. This provided some relief but the pain has been getting worse. She did not have a temperature taken, but her forehead was hot to the touch. She was not given any medications to relieve the fever. She was dressed with additional clothing and blankets to “sweat the fever out,” but the fever still persisted. She reports that there may have been other sick classmates. She denies a prior history of sore throat.

Past Medical History

Attention-deficit disorder, recurrent otitis media (resolved)

Surgical History

Family history.

Non-contributory

Social History

Ear tubes at age 2

Amoxicillin (throat swelling, difficulty breathing)

Home Medications

Methylphenidate ER 18 mg PO daily

Physical Examination

Vital signs.

Temp 101.9°F (oral), Ht 4′4″, Wt 29.55 kg

Appears uncomfortable, tired, grimacing when swallowing

Anterior cervical lymph nodes enlarged and tender; tonsils moist, red, with white exudates

Point-of-Care GAS Rapid Antigen Detection Test

1. What is the most common pathogen responsible for acute bacterial pharyngitis in children?

A. Corynebacterium diphtheriae

B. Neisseria gonorrhoeae

C. Group C streptococcus

D. Group A streptococcus

2. What signs and symptoms in this patient definitely discriminate between GAS pharyngitis rather than viral pharyngitis?

A. Tonsils with white exudates

B. Temperature 101.9°F

C. Pain on swallowing

D. All of the above

3. If GAS is suspected, what age range is typically excluded for testing for GAS?

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Clinical Practice and Cases in Emergency Medicine

A 45-year-old Female with an Atypical Presentation of Pharyngitis

• Schander, Artur ;
• Glickman, Andrew A. ;
• Weber, Nancy ;
• Rodgers, Brian ;
• Carney, Michael B.

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Introduction: Emergency physicians are trained to treat a variety of ailments in the emergency department (ED), some of which are emergent, while others are not. A common complaint seen in the ED is a sore throat. While most sore throats are easily diagnosed and treated, less common causes are often not considered in the differential diagnoses. Therefore, the purpose of this case study was to present an atypical case of sore throat and discuss differential diagnoses.

Case Presentation: The patient was a 45-year-old female who presented to the ED with a three-day history of sore throat that was exacerbated by eating and drinking. The patient was not on any prescription medications, but tried over-the-counter medications for the sore throat without any improvement in symptoms. Review of systems was positive for sore throat, fevers, and chills. Physical examination of her oropharynx revealed mildly dry mucous membranes with confluent plaques and white patchy ulcerative appearance involving the tongue, tonsils, hard palate, and soft palate. Rapid streptococcal antigen, mononucleosis spot test, and KOH test were performed and found to be negative.

Discussion: After initial testing was negative, a follow-up complete blood count with differential and complete metabolic profile were ordered. The patient was found to have decreased lymphocytes and platelets. Based upon those results, a diagnosis was made in the ED, the patient was started on medication, and further laboratory workup was ordered to confirm the diagnosis. ED providers should consider non-infectious as well as infectious causes for a sore throat, as this might lead to a diagnosis of an underlying condition.

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An international team of researchers found that heavy rains had intensified in the region, though they couldn’t say for sure how much climate change was responsible.

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By Raymond Zhong

Scenes of flood-ravaged neighborhoods in one of the planet’s driest regions stunned the world this month. Heavy rains in the United Arab Emirates and Oman submerged cars, clogged highways and killed at least 21 people. Flights out of Dubai’s airport, a major global hub, were severely disrupted.

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Oman, with its coastline on the Arabian Sea, is also vulnerable to tropical cyclones. Past storms there have brought torrential rain, powerful winds and mudslides, causing extensive damage.

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Stronger storms are a key consequence of human-caused global warming. As the atmosphere gets hotter, it can hold more moisture, which can eventually make its way down to the earth as rain or snow.

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Hot oceans are a big factor.

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Large parts of the Indian, Pacific and Atlantic Oceans have been hotter than usual recently, in part because of El Niño and other natural weather cycles, and in part because of human-induced warming .

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An official with the U.A.E.’s National Center of Meteorology, Omar Al Yazeedi, told news outlets that the agency didn’t conduct any seeding during the latest storms. His statements didn’t make clear, however, whether that was also true in the hours or days before.

Mr. Al Yazeedi didn’t respond to emailed questions from The New York Times, and Adel Kamal, a spokesman for the center, didn’t have further comment.

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Omnia Al Desoukie contributed reporting.

Raymond Zhong reports on climate and environmental issues for The Times. More about Raymond Zhong

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Navigating the Complexities of Laryngeal Tuberculosis: A Comprehensive Case Report and Literature Review

Araya gautam.

1 School of Health Sciences, Teesside University, Middlesbrough, GBR

Harendra Kumar

2 Medicine and Surgery, Dow University of Health Sciences, Karachi, PAK

Abubakar Gapizov

3 General Surgery, American University of Antigua, Coolidge, ATG

Pratik Paudel

4 Neurology, Annapurna Neuro Hospital, Kathmandu, NPL

Rakshya Gautam

5 Internal Medicine, Alka Hospital, Lalitpur, NPL

This case report and literature review presents a detailed exploration of the diagnosis and management of laryngeal tuberculosis, emphasizing the challenges encountered in dealing with rare and multifaceted medical conditions. Through a systematic analysis of the patient's clinical journey and an insightful review of pertinent literature, the study underscores the complexity inherent in diagnosing primary laryngeal tuberculosis and highlights the growing relevance of this rare extrapulmonary manifestation. The case showcases the significance of a comprehensive diagnostic approach, the collaboration of diverse medical specialists, adherence to established treatment guidelines, and the crucial role of continuous patient monitoring. The successful resolution of this intricate case serves as a compelling testament to the power of interdisciplinary coordination and precision medicine, providing valuable insights into navigating the intricate landscape of laryngeal tuberculosis.

Introduction

Laryngeal tuberculosis (TB), a rare and neglected disease, has a misdiagnosis rate of up to 80% due to the lack of specific signs or symptoms [ 1 ]. Nevertheless, it has evolved to become the most prevalent granulomatous condition in endemic countries affecting the larynx, predominantly impacting men aged 40-60 years [ 1 ].

Several risk factors contribute to the likelihood of upper respiratory tract TB infection, including HIV infection, tobacco use, diabetes, recreational drug consumption, malignancies, and immunosuppressive drug utilization. In the realm of laryngeal infection, the disease primarily affects the anterior laryngeal structures, which are the parts of the larynx that are located in the front of the neck. They include the thyroid cartilage, the epiglottis, the vocal cords, and the vestibular folds materializing as hypertrophic, exophytic, or polypoid lesions [ 1 , 2 ]. The prevalence of hypertrophic, exophytic, or polypoid lesions in upper respiratory tract TB infection is not very well documented in the literature. However, some studies have reported the occurrence of these lesions in patients with laryngeal TB, which is a rare form of extrapulmonary TB that affects the anterior laryngeal structures. These lesions can cause symptoms such as hoarseness, dysphonia, dysphagia, odynophagia, and hemoptysis [ 1 , 2 ]

Vocal cords bear the brunt in 50-70% of cases, while false cords are implicated in 40-50% of cases. These critical anatomical regions are vulnerable to inflammation during severe infections, culminating in airway obstruction. The ensuing consequence is rapid respiratory distress, which can escalate to respiratory failure if not promptly identified and managed with appropriate measures [ 2 , 3 ].

The current case demonstrates the complicated diagnostic challenges presented by seemingly disparate symptoms and medical histories. The medical team successfully navigated these problems with a deliberate approach, interdisciplinary collaboration, and a commitment to evidence-based principles.

Case presentation

A 24-year-old Filipino male presented with a chief complaint of difficulty breathing. Past medical history includes bronchial asthma. Family history reveals bronchial asthma in his mother and brother; his mother also had Pott's disease but had been refusing anti-TB treatment. The patient was a driver and egg dealer, residing in a bungalow-type dwelling with his wife, with a history of smoking (nine pack-years) and occasional alcohol consumption (one to two sessions per month). He did not chew betel nuts and used liquefied petroleum gas for cooking at home.

Two years prior to the presentation, he had experienced sudden onset epigastric discomfort with burning pain, which reached an intensity of 5/10 and ascended to his throat. This pain worsened during fasting but was relieved by food intake. He occasionally vomited non-bilious, non-bloody contents after meals. After a visit to a rural health center, he was diagnosed with "hyperacidity" and received unspecified medications that provided temporary relief. Over the following months, he endured persistent epigastric pain but did not seek medical attention. Seven months prior, he developed intermittent, rough, breathy hoarseness that worsened with exertion but improved with voice rest. A private ENT physician diagnosed laryngopharyngeal reflux, and treatment with omeprazole and an unrecalled nasal spray offered temporary relief. As the hoarseness persisted, it led to another ENT consultation, which revealed a suspicious laryngeal mass.

Despite a recommended laryngeal CT scan, the patient's symptoms improved, but he continued to experience hoarseness. Additionally, he began to experience episodes of noisy, wheezy breathing without apparent triggers, requiring salbutamol nebulization at a local hospital. Three weeks prior to presentation, the frequency of hoarseness and breathing difficulties increased, prompting a visit to a district hospital, where he was evaluated as a probable pulmonary (PTB) suspect, with negative direct sputum smear microscopy (DSSM) results and no initiation of anti-TB medications. Shortly before admission, he developed sudden dyspnea, leading to initial evaluation by the Internal Medicine service, which attempted but failed emergency intubation. Subsequently, he was referred to anesthesiology for a challenging intubation and to the ENT service for possible emergency tracheostomy, resulting in his admission.

In pursuit of an accurate diagnosis, a systematic approach was adopted. Traumatic causes, inhalation injury, neoplasms, and oropharyngeal obstruction were ruled out through detailed clinical examination and laryngoscopic findings. Table ​ Table1 1 shows the complete blood count and differential count results. The initial chest X-ray as shown in Figure ​ Figure1 1 revealed bilateral hilar lymphadenopathy and normal lung parenchyma. Comprehensive imaging, including chest and neck CT, displayed extensive mediastinal lymphadenopathy encasing the trachea, suggesting impending upper airway obstruction.

MCV: mean corpuscular volume; MCH: mean corpuscular hemoglobin; MCHC: mean corpuscular hemoglobin concentration

Laryngoscopy as shown in Figure ​ Figure2 2 revealed diffuse edema, erythema, ulcers, and immobility of vocal cords, consistent with TB laryngitis, a type of extrapulmonary TB affecting the larynx. The pathophysiology of laryngeal TB was discussed, focusing on Mycobacterium tuberculosis transmission through inhalation and subsequent inflammation causing edema, ulcers, and vocal cord immobility. Mediastinal lymphadenopathy's impact on the recurrent laryngeal nerve and cricoarytenoid joint's implications were emphasized.

Airway security was paramount due to potential complications of laryngeal TB. Immediate measures, including tracheal intubation, were taken to ensure respiratory support in case of airway obstruction. A multidisciplinary team, comprising pulmonologists and infectious disease specialists, collaborated in patient care. Following the National TB Program guidelines for extrapulmonary TB, the patient received a four-drug regimen: isoniazid, rifampicin, pyrazinamide, and ethambutol. Liver function and side effects were closely monitored. During hospitalization, the patient's laryngeal edema and respiratory symptoms improved significantly. After two months of anti-TB treatment, repeat laryngoscopy demonstrated regression of ulcerations and improved vocal cord mobility. The patient completed the six-month anti-TB treatment without adverse effects. Six-month and one-year follow-up appointments post-treatment revealed sustained improvement, and the patient remained asymptomatic throughout this period.

Mycobacterium tuberculosis causes TB, an infectious disease characterized by granulomas [ 1 , 2 , 4 ]. While it mostly affects the lungs, resulting in PTB, it can also affect extrapulmonary areas such as the larynx [ 5 ]. This disease is a significant public health concern in developing countries, particularly in the lungs, which account for 80% of cases [ 4 , 6 ]. Nonetheless, it can cause damage to any part of the body.

Primary laryngeal TB is an uncommon kind of extrapulmonary TB that accounts for fewer than 1% of all TB cases [ 4 , 6 , 7 ]. However, due to a rise in the number of immunocompromised individuals and the prevalence of multidrug-resistant TB, cases of laryngeal TB have become increasingly common [ 7 ]. Extrapulmonary TB accounts for around 30-40% of cases and may affect a variety of organs including eyes, ears, heart, and adrenal glands [ 4 , 6 , 7 ]. TB may affect the larynx, despite the fact that it is seldom addressed. Due to laryngeal inflammation and granulations, laryngeal TB may cause a range of symptoms, from slight voice hoarseness to severe discomfort while swallowing (odynophagia) and difficulty breathing (dyspnea) [ 8 , 9 ]. Given the global resurgence of TB, which is being fueled in part by the spread of HIV, healthcare practitioners and ENT specialists should be aware of the possibility of TB in the larynx [ 9 - 11 ].

While laryngeal TB is rare, it presents a difficult diagnostic challenge due to symptoms that are similar to those of many other respiratory disorders. Early symptoms such as inspiratory stridor, dyspnea, and hoarseness might have been readily attributed to more common illnesses such as vocal cord dysfunction, laryngopharyngeal reflux, or even obstructive sleep apnea [ 7 , 9 , 12 ]. His medical history, however, painted a more convoluted picture, with a history of bronchial asthma, a family history of Pott’s disease, and smoking habits.

The presence of constitutional symptoms such as fatigue, weight loss, and nocturnal sweats complicated the diagnosis even further. A focused technique proved critical in traversing this thick maze of symptoms. After ruling out traumatic causes, inhalation injuries, neoplasms, and oropharyngeal obstructions, the diagnostic range was narrowed to TB-related disease. The presence of bilateral hilar lymphadenopathy on the initial chest X-ray served as a significant clue, shifting the focus of the diagnosis to possible mediastinal involvement. Following extensive imaging, including chest and neck CT scans, substantial mediastinal lymphadenopathy encasing the trachea was seen, raising concerns about imminent upper airway obstruction. Laryngoscopy confirmed the diagnosis, revealing typical TB laryngitis symptoms such as widespread edema, erythema, ulceration, and vocal cord immobility.

With the possibility of an impending airway obstruction, maintaining the patient’s airway security became a top concern. Swift and urgent actions, such as tracheal intubation and standby surgical airway management, were critical in preventing respiratory distress. The collaborative efforts of pulmonologists and infectious disease specialists were critical in developing a comprehensive and effective treatment approach. This regimen, which included isoniazid, rifampicin, pyrazinamide, and ethambutol, not only targeted the causative agent Mycobacterium tuberculosis but also aimed to reduce the development of drug resistance. As the foundation of the treatment plan, rigorous and consistent monitoring of liver function and potential side effects was devised, ensuring patient safety and drug adherence.

Investigating the pathophysiology of laryngeal TB unveils the intricate interplay of the immune system's reactions. Inhaling Mycobacterium tuberculosis causes an inflammatory cascade that results in vocal cord swelling, ulceration, and eventual paralysis [ 3 , 11 , 12 ]. The addition of mediastinal lymphadenopathy adds another layer of complexity, potentially jeopardizing critical structures including the recurrent laryngeal nerve and the cricoarytenoid joint.

The trajectory of the patient's clinical growth throughout the treatment journey attests to the management technique's efficacy. There were noticeable reductions in laryngeal edema and respiratory symptoms two months after starting the anti-TB regimen. A second laryngoscopy revealed ulcer regression and significant improvement in vocal cord mobility, confirming the effectiveness of the chosen treatment approach.

Conclusions

This report provides a comprehensive examination of the diagnosis and treatment of laryngeal TB, shedding insight into the complexities associated with unusual and different medical conditions. The current case exemplifies the difficulties in diagnosing primary laryngeal TB and demonstrates the growing relevance of this uncommon extrapulmonary presentation. It emphasizes the need for a thorough diagnostic approach, collaboration among many medical specialists, adherence to established treatment procedures, and the critical significance of continued patient monitoring. The successful resolution of this tough case is a dramatic testament to the efficacy of multidisciplinary collaboration and precision medicine, providing critical insights for negotiating the complex environment of laryngeal TB. The case highlights the need to take a logical and collaborative approach when dealing with such complex medical concerns, which finally leads to a positive outcome for the patient.

The authors have declared that no competing interests exist.

Human Ethics

Consent was obtained or waived by all participants in this study