Vocal quality of patients treated for laryngeal tuberculosis, before and after speech therapy

Laryngeal tuberculosis in the early 21st century. Literature review of clinical, diagnostic and therapeutic data, according to SWiM guidelines

OBJECTIVES

Review of the scientific medical literature dedicated to clinical data, diagnosis and treatment for laryngeal tuberculosis published since the turn of the 21st century.

MATERIAL AND METHODS

Search of the Medline, Cochrane and Embase databases for the period 2000-2022. Selection of cohorts and case reports documenting clinical data, diagnosis and treatment for laryngeal tuberculosis.

RESULTS

In total, 119 articles were analyzed. Immunodepression, HIV infection, history of lung tuberculosis, general symptoms suggesting tuberculosis, smoking and associated laryngeal cancer were noted in 18%, 3%, 20% and 41% of cases, respectively. No pathognomonic symptoms or signs emerged. Voice impairment, of various types and severity, isolated and/or associated with other signs, was the most frequent laryngeal symptom, in 86% of cases. All laryngeal sites were involved, with numerous and various associations. Impaired laryngeal motion and tracheotomy were noted in 6% and 1% of cases, respectively. Time to diagnosis varied from less than 1month to 36months, for a median 3months, in case reports. Laryngeal tuberculosis was diagnosed bacteriologically with certainty in 28% of cases while diagnosis was based on indirect criteria and/or involvement of another site in the other 72%, with lung involvement in 54%. Treatment duration ranged from 6 to 24months (median, 6months), using 3 to 5 (median: 4) antitubercular antibiotics, with 4 used in 80% of cohorts and 77% of case reports. Overall rates of cure, death, treatment resistance, adverse events, and laryngeal sequelae were 99%, 0.5%, 0.5%, 6% and 5%, respectively.

CONCLUSION

The clinical presentation and diagnostic difficulty in laryngeal tuberculosis did not change since the end of the 20th century. Quadritherapy is highly effective, with a low resistance rate and few adverse effects or laryngeal sequelae.

Appearance and morphologic features of laryngeal tuberculosis using laryngoscopy: A retrospective cross-sectional study

Laryngeal tuberculosis (LTB) is highly contagious and can cause permanent laryngeal damage. Therefore, correctly identifying laryngoscopic LTB lesion locations, sizes, and morphologic features are essential for LTB diagnoses. This study aimed to explore the appearance and morphologic features of LTB and correlated these features with clinical symptoms.We retrospectively analysed 39 LTB patients in our hospital between January 2013 and December 2019. Medical records, including clinical presentation, lesion appearance (locations, sizes, and morphology), complementary examination results, and histopathologic features were summarized and analysed.In this patient cohort, dysphonia and sore throat were the two most common clinical symptoms. In LTB patients with extensive lesions, ulcerative lesions were most common, and the proportion of cases with concurrent pulmonary tuberculosis (86.4%, P = .033) infection was higher, as were the positive rates of sputum smears (72.7%, P = .011) and cultures (86.4%, P = .002) than patients without concurrent pulmonary TB and with more localized and exophytic lesions. The histopathologic features of LTB-related ulcerative lesions included fewer granulomas and more areas with caseous necrosis. These lesions were more likely to have acid-fast bacilli detected with a Ziehl-Neelsen stain than exophytic lesions that rarely showed detectable bacilli.A complete knowledge regarding the visual and morphologic features of LTB on laryngoscopy is needed for the early detection and diagnosis of LTB. Our study revealed the lesion sites, sizes, and morphologic features of LTB. These parameters were also correlated with patient clinical symptoms. Future studies are needed to support and expand the results of this retrospective study.

Atypical Laryngeal Infections: Localized Lesions from Unusual Organisms May Simulate Malignancy

Objective:

The identification of rare sources of laryngeal infection in immunocompetent patients. Recovered organisms were Mycobacterium tuberculosis (laryngeal tuberculosis [LTB]), Mycobacterium fortuitum (laryngeal Mycobacterium fortuitum [LMF]), and Blastomyces dermatiditis (laryngeal blastomycosis [LB]).

Method:

Single institution retrospective case series of three patients over a 2.5-year period and review of the literature on laryngeal infections by three atypical organisms.

Results:

Three patients presented with hoarseness and cough; one additionally had throat pain (LTB). Indirect laryngoscopy demonstrated diffuse laryngeal ulceration (LTB, LMF) and an exophytic, contiguous glottic mass (LB). Direct microlaryngoscopic biopsies and cultures established the diagnoses, including a frozen section in one case (LB), which prevented a simultaneously planned surgical resection. Appropriate antimicrobial therapy yielded dramatic laryngeal and corresponding vocal improvement, for which we provide unique photo and audio documentation. In the last 10 years, fewer than 500 cases of LTB have been reported in the English language medical literature, principally outside the United States. To date, there have been reports of only 34 LB and no cases of LMF.

Conclusion:

Atypical infections of the larynx may be localized and mimic laryngeal cancer on endoscopy. Tissue examination as well as microbiologic samples are diagnostic and complementary.

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.

Voice disorders in residual paracoccidioidomycosis in upper airways and digestive tract

BACKGROUND

Paracoccidioidomycosis (PCM) is a systemic mycosis of acute and chronic evolution, caused by species belonging to the genus Paracoccidioides. It is considered the most prevalent systemic endemic mycosis in Latin America, with cases in the tropical and subtropical regions. Residual PCM refers to the fibrotic scar sequelae resulting from the disease treatment which, when associated with collagen accumulation, leads to functional and anatomic alterations in the organs.

AIMS

The aim of this study was to evaluate the vocal function of patients with residual PCM in upper airways and digestive tract.

METHODS

We performed a cross-sectional study in 2010 in a cohort of 21 patients with residual PCM in upper airways and digestive tract.

RESULTS

The average age was 49.48±9.1 years, and only two (9.5%) patients were female. The study was performed in the 1-113 month-period (median 27) after the end of drug treatment. Five (23.8%) patients had alterations in the larynx as a sequela of the disease. However, all patients had vocal changes in vocal auditory perceptual analysis by GRBASI scale. The computerized acoustic analysis using the software Vox Metria, showed that 11 patients (52.4%) presented alterations in jitter, 15 (71.4%) in shimmer, 8 (38.1%) in F0, 4 (19%) in glottal to noise excitation (GNE), 7 (33.3%) in the presence of noise and 12 (57.1%) in the presence of vibratory irregularity.

CONCLUSIONS

The great frequency of alterations in residual PCM suggests that the patients in such phase could benefit from a multidisciplinary treatment, offering them integral monitoring of the disease, including speech rehabilitation after the PCM is healed.

Evaluation of voice disorders in patients with active laryngeal tuberculosis

INTRODUCTION

Laryngeal tuberculosis (LTB) is the most frequent larynx granulomatous disease. In general there is lung involvement, but in an important proportion of cases you can find LTB without pulmonary disease. The lesions observed in LTB, such as ulceration and fibrosis, can interfere in the process of voice production. The involvement of the mucous lining of the vocal folds can change their flexibility and, consequently, change voice quality, and the main symptom is dysphonia present in almost 90% of cases.

OBJECTIVE

To describe the anatomical characteristics and voice quality in LTB patients.

MATERIAL AND METHOD

A descriptive cross-sectional study was conducted with 24 patients.

RESULT

The most frequently affected sites were vocal folds in 87.5% patients, vestibular folds in 66.7%, epiglottis in 41.7%, arytenoid in 50%, aryepiglottic folds in 33.3%, and interarytenoid region in 33.3% patients. We found 95.8% cases of dysphonia. The voice acoustic analysis showed 58.3% cases of Jitter alterations, 83.3% of Shimmer and 70.8% of GNE.

CONCLUSION

Voice disorders found in active laryngeal tuberculosis are similar to those reported after clinical healing of the disease, suggesting that sequelae and vocal adjustments may install during the active phase of the disease, negatively impacting the process of vocal quality reestablishment.

Voice disorders in mucosal leishmaniasis

Introduction

Leishmaniasis is considered as one of the six most important infectious diseases because of its high detection coefficient and ability to produce deformities. In most cases, mucosal leishmaniasis (ML) occurs as a consequence of cutaneous leishmaniasis. If left untreated, mucosal lesions can leave sequelae, interfering in the swallowing, breathing, voice and speech processes and requiring rehabilitation.

Objective

To describe the anatomical characteristics and voice quality of ML patients.

Materials and Methods

A descriptive transversal study was conducted in a cohort of ML patients treated at the Laboratory for Leishmaniasis Surveillance of the Evandro Chagas National Institute of Infectious Diseases - Fiocruz, between 2010 and 2013. The patients were submitted to otorhinolaryngologic clinical examination by endoscopy of the upper airways and digestive tract and to speech-language assessment through directed anamnesis, auditory perception, phonation times and vocal acoustic analysis. The variables of interest were epidemiologic (sex and age) and clinic (lesion location, associated symptoms and voice quality.

Results

26 patients under ML treatment and monitored by speech therapists were studied. 21 (81%) were male and five (19%) female, with ages ranging from 15 to 78 years (54.5+15.0 years). The lesions were distributed in the following structures 88.5% nasal, 38.5% oral, 34.6% pharyngeal and 19.2% laryngeal, with some patients presenting lesions in more than one anatomic site. The main complaint was nasal obstruction (73.1%), followed by dysphonia (38.5%), odynophagia (30.8%) and dysphagia (26.9%). 23 patients (84.6%) presented voice quality perturbations. Dysphonia was significantly associated to lesions in the larynx, pharynx and oral cavity.

Conclusion

We observed that vocal quality perturbations are frequent in patients with mucosal leishmaniasis, even without laryngeal lesions; they are probably associated to disorders of some resonance structures (larynx, pharynx and nasal and oral cavities) or even to compensation mechanisms caused by the presence of lesions in the upper airways and digestive tract.