A case report of difficult diagnosis in the patient with advanced laryngeal tuberculosis

Leukoplakia or LPR: The Misdiagnosis of Laryngeal Tuberculosis

OBJECTIVE

The objective is to reduce the rates of misdiagnosis and inappropriate treatment of laryngeal tuberculosis (LTB).

STUDY DESIGN

Retrospective case series.

MATERIALS AND METHODS

Medical records of 3 histopathology-confirmed cases at a tertiary medical center from 2000 to 2018.

RESULTS

Seventeen patients with LTB included in this study. Of the 17 patients, 16 patients were male and 1 was female; 11 patients had a history of smoking. Odynophagia was the chief complaint in 6 cases, and 11 patients complained of hoarseness. The appearance of the affected larynx was ranged from diffuse swelling (n = 7, 41.2%), mucosa white lesion (n = 5,29.4%), and granulomatous tumors (n = 2, 11.76%), and these features presented together (n = 2, 11.76%). Seventeen patients with LTB were misdiagnosed as acute epiglottitis in 4 (23.5%) patients, acute laryngitis in 1 (5.9%) patient, leukoplakia in 5 (29.4%) patients, laryngopharyngeal reflux (LPR) in 6 (35.3%) patients, and laryngocarcinoma in 1 (5.9%) patient. Chest computed tomography reported old pulmonary tuberculosis in 2 (11.7%) patients, active pulmonary tuberculosis in 7 (41.2%) patients, and normal lung status in 8 (47.1%) patients. Histopathological examination reported Mycobacterium tuberculosis infection by revealing epithelioid cell granulomas with Langhans-type giant cells in 14 (82.4%) patients and epithelioid cell granulomas with caseous necrosis and Langhans-type giant cells in 3 (17.6%) patients.

CONCLUSIONS

Laryngeal tuberculosis was easily misdiagnosed as acute epiglottitis or leukoplakia because of diffuse swelling of the epiglottis or white lesions over the true vocal cord, especially patients with increasing LTB were misdiagnosed as LPR with the enhancement of LPR awareness among otolaryngologist. Clinicians should be aware of the possibility of LTB for chronic intractable laryngitis with failure treatment of proton pump inhibitor and recurrent acute epiglottitis with foreign body injury.

Upper Respiratory Tract Tuberculosis

Upper respiratory tract involvement in cases of tuberculosis (TB) of the head and neck continues to be described in the most recent reports from several different regions, including some from developed countries. Laryngeal TB is the most common of all forms of upper respiratory tract TB (URT-TB). Pulmonary lesions in URT-TB are present in about 20% of adults and about 50 to 60% of children. Systemic manifestations are uncommon. URT-TB is especially seen in patients with a variety of risk factors, such as the presence of human immunodeficiency virus (HIV) infection, diabetes, smoking, alcoholism, drug abuse, malignancies, and use of immunosuppressive drugs. Nodules or ulcerative lesions are seen on morphological examination. Endoscopic examination is required for mucosal lesions. Diagnosis of TB is suspected on an epidemiological basis in high-prevalence countries or from the failure of a patient to respond to routine treatment. Smear and/or histopathological examinations help in establishing the final etiological diagnosis. Treatment includes standard anti-TB chemotherapy for at least 6 months with four primary drugs during the initial intensive phase of 2 months and two or three primary drugs during the remaining maintenance phase of 4 months. Treatment is modified on the basis of culture and sensitivity reports in cases of suspected drug resistance. Surgical intervention may be required for some patients with abscess formation and progressive disease unresponsive to medical therapy. Airway obstruction, although rare, even in fulminant cases may require tracheostomy for relief.

Association of laryngeal and nasopharyngeal tuberculosis: a case report

Introduction

To the best of our knowledge, the association of nasopharyngeal and laryngeal tuberculosis has never been described before in the literature. We report here a first observation.

Case presentation

We report the case of a 38-year-old Arab man who presented with an isolated hoarseness. Radiological and endoscopic examinations showed a thickening of the left lateral wall of his nasopharynx and the left vocal cord. Pathology revealed the diagnosis of tuberculosis of both localizations. He received a 6-month antituberculous chemotherapy with a satisfying uneventful evolution.

Conclusions

Tuberculosis should be considered in the differential diagnosis of soft tissue masses of the head and neck, particularly when the imaging findings and clinical presentation are atypical. The diagnosis of tuberculosis is mainly based on histopathological and/or bacteriological examination.

Changing trends in the clinical features of laryngeal tuberculosis: a report of 19 cases

OBJECTIVE

This study was undertaken to evaluate the changing trends in the clinical features of laryngeal tuberculosis, with the goal of reducing misdiagnosis and incorrect treatment.

METHODS

A retrospective clinical analysis compared the clinical patterns in five cases with pathologically confirmed laryngeal tuberculosis seen before 1990 with those of 14 cases of laryngeal tuberculosis seen after 1998.

RESULTS

The five patients seen before 1990 ranged in age from 19 to 41 years of age, with a mean of 32 years. The most frequent chief complaint was odynophagia accompanying system symptoms and pulmonary tuberculosis. The posterior part of the larynx was commonly involved and the lesions tended to be ulcerative and multiple. The 14 patients seen after 1998 were aged from 17 to 71 years with a mean age of 49.9 years. The most frequent chief complaint was hoarseness (71.4%). The most common lesion site was in the true vocal cords (57.2%). Most of patients with normal lung status had single, nonspecific, polypoid lesions. Stroboscopy revealed four different appearances.

CONCLUSIONS

Laryngeal tuberculosis may occur even without pulmonary tuberculosis, and the characteristics of the lesions appear to be more nonspecific. It is important to consider tuberculosis in the differential diagnosis of laryngeal disease.

[Mycoses of the head and neck]

OBJECTIVES

The ever growing number of immunocompromized patients and increasing travel to areas where fungal diseases are endemic explain why in recent years mycoses have emerged as important infections in clinical practice. It is essential that pathologists and clinicians be knowledgeable about them.

RESULTS

Head and neck infections are common in disseminated mycoses. The most frequent causative yeasts or yeast-like organisms include Candida albicans, Cryptococcus neoformans, Histoplasma capsulatum var capsulatum, Blastomyces dermatitidis, Paracoccidioides brasiliensis and Coccidioides immitis. Other causative fungal pathogens include Aspergillus fumigatus and less frequently, Rhizopus oryzae and Rhinosporidium seeberi. Since their pathophysiology is in most cases similar, those microorganisms share a common clinical pathological picture. Head and neck mycoses may simulate carcinoma or cause upper airway obstruction. Symptoms such as dysphonia or dysphagia associated with hyperplastic and ulcerative lesions on endoscopic examination should prompt biopsies. An inflammatory tissue reaction with pseudoepitheliomatous hyperplasia warrants caution since it may lead to a mistaken diagnosis of cancer.

CONCLUSION

The pathologist must look carefully for microorganisms with special stains. Clinicians and pathologists must be aware of these mycoses to identify the causative agent, isolated it by culture, and prescribe adequate treatment for the patients.

Les mycoses ORL

In recent years, mycoses have emerged as important infections in clinical practice. This phenomenon is explained by the ever growing number of immunocompromised patients and the increasing number of people travelling in areas where fungal diseases are endemic. Head and neck infections are common in disseminated mycoses and may simulate carcinoma or cause upper airway obstruction. The most frequent causative yeasts or yeast-like organisms include Candida albicans, Cryptococcus neoformans, Histoplasma capsulatum var capsulatum, Blastomyces dermatitidis, Paracoccidioides brasiliensis and Coccidioides immitis. Other causative fungal pathogens include Aspergillus fumigatus and less frequently, Rhizopus oryzae and Rhinosporidium seeberi. Since in most cases their pathophysiology is similar, those microorganisms share a common clinical pathological presentation. Symptoms such as dysphonia or dysphagia associated with hyperplastic and ulcerative lesions on endoscopic examination should prompt biopsies. A purulent or granulomatous inflammatory tissue reaction with pseudoepitheliomatous hyperplasia warrants caution since it may lead to a mistaken diagnosis of carcinoma. The pathologist must look carefully for microorganisms with Grocott and PAS stains. The causative agent can be identified if the pathologist is aware of the risk. Positive culture is needed to institute adequate treatment.