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CASE REPORT
Year : 2007  |  Volume : 24  |  Issue : 3  |  Page : 87-89 Table of Contents   

Laryngeal tuberculosis clinically similar to laryngeal cancer


Department Of Pulmonary Medicine, K.G.M.U Lucknow-226003., India

Correspondence Address:
S K Verma
Department Of Pulmonary Medicine, K.G.M.U Lucknow-226003.
India
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Source of Support: None, Conflict of Interest: None


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   Abstract 

Laryngeal tuberculosis is a rare disease. The presenting features are usually hoarse­ness or dysphagia with other vague and nonspecific symptoms. Laryngoscopic fea­tures mimic malignancy in many cases. There are no noninvasive tests which can confirm a diagnosis of laryngeal tuberculosis. Biopsy of the primary growth itself is diagnostic and may show caseating granulomatous inflammation. Microbiologi­cal confirmation, though desirable, may not always be possible. The response to antitubercular treatment is good. We report a 52 year old man who presented to us with hoarseness of voice, haemoptysis and a proliferative growth in the epiglottis and was diagnosed to have laryngeal tuberculosis on histopathology. He had an excellent response to antituberculosis therapy and is now asymptomatic.


How to cite this article:
Verma S K, Verma SK, Sanjay. Laryngeal tuberculosis clinically similar to laryngeal cancer. Lung India 2007;24:87-9

How to cite this URL:
Verma S K, Verma SK, Sanjay. Laryngeal tuberculosis clinically similar to laryngeal cancer. Lung India [serial online] 2007 [cited 2018 Dec 12];24:87-9. Available from: http://www.lungindia.com/text.asp?2007/24/3/87/44221


   Introduction Top


The occurrence of tuberculosis of larynx has greatly decreased as a result of improvement in public health care and development of effective antituberculosis chemotherapy. Tuberculosis of the larynx is commonly secondary to a tuberculous lesion elsewhere in the body, or, rarely, a primary affection from inhaled tubercle bacilli directly. More recently tuberculosis of larynx have often been diagnosed by clinicians attempting to rule out carcinoma [1] . This report describes a case with a proliferative growth in the epiglottis, clinical mimicking of malignancy.


   Case Summary Top


A 52 year old male, farmer by occupation presented with a one month history of hoarseness of voice and haemoptysis. He also had cough with expectoration. There was no history of fever, chest pain, stridor, dyspnoea or contact with a case of tuberculosis. The patient was a chronic smoker (28 pack years) with no alcohol and drug abuse.

On general physical examination, he was conscious, non-febrile and well nourished. There was no cervical lymphadenopathy or clubbing. There were no scars or sinuses in the neck. Indirect laryngoscopy had shown a grayish tumor in left supraglottic region. Vocal folds were moving with no signs of infiltration. Respiratory system examination revealed bilateral coarse crepts in suprascapular region. Rests of the systems were normal.

His hematological and bio-chemical investigations were within normal limits except erythrocyte sedimentation rate was higher than normal limits (65min/hour). He tested negative for human immunodeficiency virus. A chest radiograph showed patchy opacities in both apices [Figure 1].

His PPD test showed 12mm indurations after 72 hour. After standard evaluation, patient underwent laryngoscopy under local anesthesia with taken biopsy from epiglottis.

The histopathological examination revealed fibro collagenous tissue lined by stratified squamous epithelium enclosing fair number confluent epitheliod cell granulomas, with langhans giant cells surrounded by lymphocytes and fibroblasts with a few areas of caseous necrosis suggestive of tuberculosis [Figure 2]. Sputum smear was positive for acid­fast bacilli. On the basis of the bacteriologic, radiologic and histopathologic findings, the diagnosis of pulmonary tuberculosis with larynx was established.

A standard six month treatment with a combination of isoniazid, rifampicin, pyrazinamide, and ethambutol was started for two months followed by isoniazid and rifampicin for further four months. The follow-up after treatment showed resolution of the symptoms and improvement of the mass [Figure 3].


   Discussion Top


Tuberculosis of the upper aerodigestive tract is a rare clinical entity, and recent incidence of laryngeal tuberculosis is less than 1% of all tuberculosis cases. [2],[3] Rohwedder found only 11 laryngeal cases (1.3%) in his series of 843 tuberculosis patients. [4] The pathogenesis of laryngeal involvement is either primary or secondary. [5],[6] Primary lesions occur in the absence of pulmonary disease. In the present case, the laryngeal involvement was probably secondary to pulmonary disease.

The ratio of male to female patients with epiglottic tuberculosis is 2:1 to 3:1, and according to recent series, its predominant occurrence in individuals from 40-60 years of age. [7] The age of the present case (52 years old) was in this range.

Tuberculosis isolated to the head and neck region is common in patients with HIV infection and should be considered in differential diagnosis of all head and neck lesions in patients infected with HIV, even in the absence of pulmonary involvement. [8] In our presented case, there was no suspicion on HIV infection and there were no immunosuppressant applied. Alonso et al. in their report of 11 cases found the dominant symptom dysphonia in 82% of cases, either in isolation or accompanied by odinophagia or dyspnoea. [9]

In present case, the main symptoms were hoarseness of voice and haemoptysis. Difficulty in swallowing, hoarseness, and chronic cough are main symptoms in patients suspicious to laryngeal carcinoma. Classically, laryngeal involvement is mainly in the posterior half of the larynx. [10] However, according to Clery and Batsakis, localization in the anterior half of the larynx now occurs twice as often as in the posterior half, and vocal cords are the most commonly affected site (50-70%), followed by false cords (40-50%), and epiglottis, aryepiglottic folds, arytenoids, posterior commisure and/or subglottis (10-15%). [11] In the present case, epiglottis was involved.

According to Shin et al., the findings of laryngeal tuberculosis may be categorized into four groups: (a) whitish ulcerative lesions (40.9%), (b) nonspecific inflammatory lesions (27.3%), (c) polypoid lesions (22.7%), and (d) ulcerofungative mass lesions (9.1%). [12] In present case, ulcerofungative mass lesion was present on the epiglottis. Although the CT appearances may not be specific, the possibility of tuberculosis should be raised when a bilateral and diffuse laryngeal lesion is seen without destruction of the laryngeal architecture in patients with pulmonary tuberculosis.

Direct laryngoscopy and biopsy are mandatory to establish a definitive diagnosis. [13] Epitheloid granuloma with Langhans type giant cell, granulomatous inflammation and caseating granuloma formation are characteristic features of this form of tuberculosis. [3] It should be kept in mind that both tuberculosis and malignancy may coexist in the same patient. [6] Therefore, the diagnostic challenge is, as in our case, first to exclude a laryngeal cancer. An antituberculous therapy offers a good prognosis, generally curing the disease without any sequel. Most lesions disappear over a 2-month period, as in the present case.

Today, clinicians should be aware of a tuberculotic lesion in the differential diagnosis of the various neck and head pathologies. The incidence of tuberculosis is increasing worldwide, and the disease has changed its behavior in several ways. Tuberculosis of the larynx and hypopharynx should be suspected in cases presenting with dysphagia and odynophagia mimicking a laryngo-pharyngeal carcinoma. [14]

 
   References Top

1.Harold P, 111, Sasaki C. Granulomatous diseases of the larynx. Otol Clinics of N Am 1982; 15(3): 539-51.  Back to cited text no. 1    
2.Egeli E, Oghan F, Alper M, et al. Epiglottic tuberculosis in a patient treated with steroids for Addison's disease. Tohoku J Exp Med 2003; 201: 119-125.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.Unal M, Dusmez D, Gorur K, et al. Nasopharyngeal tuberculosis with massive cervical lymphadenopathy. J Otolaryngo12002; 31: 186-188.  Back to cited text no. 3    
4.Rohwedder Jj. Upper respiratory tract tuberculosis. Sixteen cases in a general hospital. Ann Intern Med 1974;80:708-713.  Back to cited text no. 4    
5.Ramadan HH, Tarazi AE, Baroody FM. Laryngeal tuberculosis: presentation of 16cases and review of the literature6 J Otolaryngol 1993; 22: 39-41.  Back to cited text no. 5    
6.Richter B, FradisM. Kohler G, Ridder GJ. Epiglottic tuberculosis: differential diagnosis and treatment. Case report and review of literature. Ann Otol Rhinol Laryngol 2001; 110:197-201.  Back to cited text no. 6    
7.Galli J, Nardi C, Contucci AM, et al. Atypical isolated epiglottic tuberculosis: a case report and a review of the literature. Am J Otolaryngol 2002; 23: 237-240.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]
8.Singh B, Balwally AN, Har-El G, Lucente FF. Isolated cervical tuberculosis in patients with HIV infection. Otolaryngol Head Neck Surg 1998 Jun; 118: 766-770.  Back to cited text no. 8    
9.Alonso PE, Mateos AM, Perez-Requena j, Serrano EA. Laryngeal tuberculosis. Rev Laryngol Otol Rhinol. 2002; 14: 352-356.  Back to cited text no. 9    
10.Kandiloros DC, Nikolopoulos TP, Ferekidis EA, et al. Laryngeal tuberculosis at the end of the 20th century. J laryngol Otol 1997;111: 619-621.  Back to cited text no. 10  [PUBMED]  
11.Cleary KR, Batsakis, JG. Mycobacterial disease of the head and neck: current, perspective. Ann Otol Rhinol Laryngol 1995; 104:830-833.  Back to cited text no. 11    
12.Shin JE, Nam SY, Yoo Sj, Kim SY. Changing trends in clinical manifestations of laryngeal tuberculosis. Laryngoscope 2000; 110.­1950-1953v.  Back to cited text no. 12    
13.Moon WK, Han MH, Chang KH, Kim Hj, Im JG, Yeon KM, Han MC. Laryngeal tuberculosis: CT findings. AJR 1996; 166: 445­-449.  Back to cited text no. 13  [PUBMED]  [FULLTEXT]
14.Unal M, Vayisoglu Y, Guner N, Karabacak T. Tuberculosis of the aryepiglottic fold and sinus pyriformis: Mt Sinai J.Med. 2006 Sep; 73: 806-809.  Back to cited text no. 14    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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