|LETTER TO EDITOR
|Year : 2015 | Volume
| Issue : 2 | Page : 49-50
Primary tuberculosis of larynx: An uncommon presentation
V Rakshith1, SM Azeem Mohiyuddin2, K Vidyavathi1, A Sagayaraj2
1 Department of Pathology, Sri Devaraj Urs Medical College, Tamaka, Kolar, Karnataka, India
2 Department of ENT, Sri Devaraj Urs Medical College, Tamaka, Kolar, Karnataka, India
|Date of Web Publication||13-Jun-2016|
Dr. V Rakshith
Department of Pathology, Sri Devaraj Urs Medical College, NH 4, Tamaka, Kolar - 563 101, Karnataka
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Rakshith V, Azeem Mohiyuddin S M, Vidyavathi K, Sagayaraj A. Primary tuberculosis of larynx: An uncommon presentation. J Laryngol Voice 2015;5:49-50
The larynx is a rare extra-pulmonary site for presentation of tuberculosis. The incidence of laryngeal tuberculosis is <1% of all tuberculosis cases.  Tuberculosis of the larynx can be a primary or secondary lesion. It develops primarily due to direct spread of the mycobacterium tuberculosis to the larynx present in the sputum, or secondarily due to pulmonary tuberculosis. This condition is often diagnosed by clinicians attempting to rule out carcinoma. This case report describes primary laryngeal tuberculosis in a patient with a clinical diagnosis of laryngeal papillomatosis. An 18-year-old girl presented to the Department of Otolaryngology, with complaints of hoarseness of voice associated with dry cough and decreased appetite since 5-6 months, which was gradually progressive. There was no history of fever, cough with expectoration, throat pain, dysphagia, odynophagia, difficulty in breathing, or family history of tuberculosis. The patient did not have any other comorbidities. On general physical examination, she was moderately built and nourished. There were no signs of pallor, edema, clubbing, and lymphadenopathy. Examination of the neck was normal. The oral cavity and pharynx was normal. Indirect laryngoscopy showed normal epiglottis and polypoidal (warty) lesions on the true vocal cords, anterior commissure, and false cords. Routine hematological and biochemical investigations were normal. Serological tests for HIV and hepatitis B surface antigen were negative. Chest X-ray was normal. Examination of the respiratory system and other systems was normal. A clinical diagnosis of laryngeal papillomatosis was made. Microlaryngeal surgery was done, and the papillomatous (warty) lesions were excised and sent for histopathological examination. Microscopy revealed fragments lined by stratified squamous epithelium with areas of ulceration. Sub-epithelium showed dense infiltration by lymphocytes and plasma cells along with ill-defined epithelioid granulomas and multinucleated giant cells [Figure 1]. ZN stain for tubercle Bacilli was positive. As there was no evidence of pulmonary involvement, a diagnosis of primary laryngeal tuberculosis was made. The patient was started on anti-tubercular treatment for 6 months, after the surgery. Now, the patient is better and voice has improved. There was no clinical evidence of recurrence. Tuberculosis of larynx is a rare occurrence with an incidence of <1% of all extra-pulmonary tuberculosis.  Pathogenesis of laryngeal tuberculosis is either primary or secondary and is considered to be the most common cause of granulomatous disease of the larynx.  The route of invasion is either direct contact of sputum containing tubercle Bacilli or blood and lymph-borne Bacilli deposited locally.  Primary lesions occur in the absence of pulmonary involvement. Secondary tuberculosis is usually a complication of active pulmonary tuberculosis. Clinically, laryngeal tuberculosis presents as hoarseness of voice, which may mimic malignancy on indirect laryngoscopy. In a study done in 2002 on 11 cases, hoarseness of voice was found as the dominant symptom in 82% of cases either in isolation or accompanied by odynophagia or dyspnea.  In the present case, the patient presented with hoarseness of voice of a 5-6 months duration. The age of presentation in various studies ranged from 41 to 50 years.  Our patient was an 18-year-old girl. Review of literature showed only a few case reports in young patients.  Earlier studies have shown that tuberculosis of larynx mainly involves the posterior half of larynx.  However, recent studies have shown that in the larynx, the most common parts involved are the vocal cords (50-70%), followed by the false cords (40-50%) and epiglottis, aryepiglottic folds, arytenoids, posterior commissure, and/or subglottis (10-15%).  In the present case, the vocal cords were involved. Grossly, the laryngeal tuberculosis may be categorized into four groups: (1) Whitish ulcerative lesions (40.9%), (2) nonspecific ulcerative lesions (27.3%), (3) polypoidal lesions (22.7%), and (4) ulcerofungative mass lesions (9.1%).  In the present study, multiple polypoidal lesions were present on the vocal cords, leading to a clinical diagnosis of laryngeal papillomatosis. Direct laryngoscopy and biopsy under anesthesia are mandatory for definitive diagnosis.  Epithelioid granulomas with Langhans type giant cell, granulomatous inflammation, and caseating granuloma formation are characteristic features of tuberculosis. Tuberculosis and malignancy may coexist in the same patients also. Tuberculosis isolated to the head and neck region is common in patients with HIV infection and should be considered in the differential diagnosis of head and neck lesions, even in the absence of pulmonary involvement.  Our patient had a negative HIV status and no evidence of clinical or radiological findings of pulmonary tuberculosis. The present case showed multiple polypoidal (warty) lesions in the vocal cords, anterior commissure, and false cords, leading to a clinical diagnosis of laryngeal papillomatosis. However, histopathological examination confirmed laryngeal tuberculosis. In conclusion, tuberculosis of the larynx and hypopharynx should be suspected in cases presenting with hoarseness, dysphagia, and odynophagia. As the prevalence of tuberculosis is increasing worldwide, awareness in the changing patterns of the disease and a high index of suspicion are needed for the diagnosis.
|Figure 1: Histopathology showing ill-defined granulomas and giant cells (black arrows) beneath the lining epithelium (green arrow) (H and E, ×400). Inset: Tubercle Bacilli (ZN, ×1000)|
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