Glottic Tuberculosis Masquerading as Early Multifocal Carcinoma

The incidence of tuberculosis has progressively decreased in developed countries after the advent of antituberculous chemotherapy, but has recently been increasing again mainly due to migratory flows. Although common in the past and considered to be a prelethal event, laryngeal involvement has become a rarity. We report the case of a 52-year-old female smoker who complained of persistent aphonia. Videostroboscopy showed bilateral vocal fold erythroleukoplakias. A chest X-ray and CT scan aroused the suspicion of lung tuberculosis, which was confirmed by Ziehl-Neelsen staining for acid-alcohol-fast bacilli on bronchoalveolar lavage. Antituberculous chemotherapy rapidly improved the quality of her voice and led to complete disappearance of the vocal fold lesions. In conclusion, laryngeal tuberculosis may mimic an early glottic multifocal carcinoma and should therefore, despite its rarity, always be considered in the differential diagnosis of erythroleukoplakia-like lesions in order to avoid improper surgical treatment and voice damage.

Palatopharyngoplasty for treatment of nasopharyngeal stenosis secondary to extra-laryngeal tuberculosis

Nasopharyngeal stenosis is a rare sequela of extra-laryngeal tuberculosis that can adversely impact the quality of life of afflicted patients. Relying solely on the oropharyngeal airway, patients often complain of inspiratory dryness and decreased sensation of airflow as the nasal mucosa and turbinate complex is entirely excluded from the breathing mechanism. Often times, the oropharyngeal inlet can be narrowed as well, limiting the air flow through the oropharyngeal airway. In those circumstances, patients often require tracheostomy for establishment of a reliable airway. We present the unique case of a previously tracheotomized patient with nasopharyngeal stenosis secondary to tuberculosis successfully treated with a modified palatopharyngoplasty to reestablish a patent naso-oropharyngeal airway. During the follow-up period, the patient was decannulated and highly satisfied with his respiratory status. Although rare and more commonly used in the treatment of sleep apnea, palatopharyngoplasty can be a viable option for the treatment of naso-oropharyngeal stenosis and should be kept in the armamentarium of reconstructive craniofacial surgeons.

Interferon-γ release assay in the diagnosis of laryngeal tuberculosis

CONCLUSION

The T-SPOT test for Mycobacterium tuberculosis infection (T-SPOT.TB) can be used for early diagnosis of laryngeal tuberculosis (TB).

OBJECTIVE

The incidence of TB is increasing on a global scale. Laryngeal TB is the most common extrapulmonary form of TB and its early diagnosis is still difficult. This study investigated the performance of the interferon-γ release assay in the diagnosis of laryngeal TB.

METHODS

A total of 83 patients with laryngeal neoplasms were confirmed to have laryngeal TB by pathology, acid-fast staining, and/or fluorescence quantitative PCR. In addition, 52 patients with vocal cord polyps were enrolled as the control group. Two groups underwent both T-SPOT.TB and tuberculin skin test (TST).

RESULTS

T-SPOT.TB was positive in 75 cases in the laryngeal TB group and 4 cases in the control group, showing a sensitivity of 90.3% (75/83) and a specificity of 92.3% (48/52). The TST was positive in 42 cases and 20 cases, respectively, in these two groups. Obviously, TST and T-SPOT.TB were significantly different in terms of sensitivity when applied for detection of laryngeal TB (p < 0.05).

Clinical features of laryngeal tuberculosis in Iran

Tuberculosis is a major health problem in Iran and its laryngeal involvement is not uncommon. Laryngeal tuberculosis is so infectious and delay in diagnosis and treatment could result spread of disease and causes divesting complications. We reviewed clinical and para-clinical characteristics of patients with laryngeal tuberculosis in Iran. In a cross sectional study, patients with laryngeal tuberculosis were studied and followed. All patients admitted from May 2000 to Dec 2011 in Amir-Alam hospital, a referral center for laryngeal diseases in Tehran. We studied 19 cases of laryngeal tuberculosis with typical histopathology (chronic granulomatous inflammation with caseous necrosis and langhans-type giant cells) and 6 cases of laryngeal tuberculosis with atypical histopathology (chronic granulomatous inflammation or chronic inflammation without necrosis). They had laryngeal symptoms and signs from 2 to 12 months before definitive diagnosis. Macroscopic appearances of laryngeal lesions were exophytic in 11 cases and ulcerative in 14 cases. True vocal cords were involved in 22 cases. The primary clinical diagnosis was malignancy in 17 cases, tuberculosis in 5 cases, and nonspecific inflammation in 3 cases. The chest x-ray findings were compatible with tuberculosis in 14 patients. The response to anti-tuberculosis therapy was desirable in all patients. In endemic area, tuberculosis should be considered as an important diagnosis in patients with laryngeal lesions even when histopathology of laryngeal lesions is not typical. Association with pulmonary tuberculosis helps for diagnosis.

[Head and neck tuberculosis - still current problem in ENT practice]

INTRODUCTION

It is estimated that between XVI and XIX century one fourth of European population died of tuberculosis. Nowadays tuberculosis is still one of the most important infectious diseases. In 2009 estimately 9 million new cases were registered worldwide, mortality due tuberculosis reached 1.5 million. In Poland extrapulmonary tuberculosis is rare (7% of overall morbidity) and most commonly affects pleura, lymph nodes, bones, joints and genitourinary system. Head and neck tuberculosis is rare and causes many diagnostics problems.

METHODS

Retrospective analysis of case histories of patients admitted to ENT Department of Silesian Medical University in Katowice.

RESULTS

Between 1993 and 2010 four cases of head and neck tuberculosis were diagnosed in our Clinic. Two of patients were admitted to the hospital with symptoms of laryngeal tumor such as difficulty in swallowing. During direct laryngoscopy tissue specimens were taken. Examination of the third patient showed tumor located below left angle of mandibule. During superficial parotidectomy tumor was removed. In the fourth registered case tuberculosis manifested as tumor of nasopharynx. In every case which is mentioned above pathology reports revealed epithelioid cell granulomas with caseous necrosis typical for tuberculosis. Patients underwent tuberculostatic treatment.

CONCLUSION

Rare occurrence and lack of characteristic symptoms of head and neck tuberculosis often lead to misdiagnosis. Histopathological examination is the most important diagnostic procedure. Microbiological examination is difficult in extrapulmonary tuberculosis, because of low concentration of pathogens in specimens. Tuberculostatic therapy is the leading method of treatment in every case of tuberculosis.

[Laryngeal tuberculosis in the patients of otholaryngology department--case reports]

Tubercular infection is still one of the most serious health and social problems. It's been estimated that one-third of the population is infected with Koch's bacillus. More than 90% of overall morbidity of tuberculosis in Poland pose pulmonary tuberculosis, in the worldwide level the percentage reaches 80. The most popular causes that spread the disease are famine, malnutrition, homelessness, limited availability to medical care, alcohol abuse, drug addiction, ageing of the society and more intensive migration. Among the cases of extrapulmonary tuberculosis the most common were certified as tuberculous empyema. Head and neck tuberculosis is diagnosed rarely nowadays. Its symptoms aren't pathognomonic and natural history of the disease is different from those described in medical books. It is essential to enclose laryngeal carcinosis in differential diagnosis. In 2002 two cases of laryngeal tuberculosis were diagnosed in the Department of Otolaryngology Head and Neck Surgery of Medical University of Wroclaw. Both patients had sustained hoarseness. Biopsy confirmed the diagnose of tuberculosis. Both patients underwent the tuberculostatic treatment. Videolaryngoscopic examination showed complete withdrawal of the infiltration in the larynx.

[Laryngeal tuberculosis]

INTRODUCTION

The aim of this study was to highlight the diagnostic problems posed by laryngeal tuberculosis and to incite practitioners to seek it more frequently, especially with the current resurgence in tuberculosis.

PATIENTS AND METHODS

Eleven cases of laryngeal tuberculosis were diagnosed over a period of 4 years and included in a retrospective study.

RESULTS

We identified seven men and four women (average age 43 years). Dysphonia was the primary symptom. Direct laryngoscopy revealed more often a budding ulcerative aspect and allowed us to perform laryngeal biopsy; the pathologic study confirmed the diagnosis in all patients. Medical treatment for tuberculosis for a short period of 6 months was introduced. In all cases, the long-term evolution was favourable, with an average of 15 months.

DISCUSSION AND CONCLUSION

The topography of tuberculosis is diverse, with many sites of localization. The otorhinolaryngologist must be able to discuss the diagnosis of laryngeal tuberculosis, especially when suggested by the clinical context.

[Tuberculosis of the tonsils]

Introduction:

La localisation tuberculeuse des amygdales palatines est très rare même dans un pays d’endémie tuberculeuse. Le diagnostic peut être suspecté cliniquement dans un contexte évocateur, mais il ne peut être certifié qu’au stade histologique.

Patients et méthodes:

Cinq cas de tuberculose des amygdales palatine ont été diagnostiqués sur une période de 5 ans et inclus dans une étude rétrospective. Nous avons recensé trois hommes et deux femmes (âge moyen de 28 ans). La dysphagie haute était le maître symptôme. L’examen a objectivé une hypertrophie amygdalienne chez tous les patients avec des ulcérations chez trois d’entre eux. Une biopsie a été effectuée chez trois patients et une amygdalectomie a été réalisée chez les deux autres. L’étude anatomopathologique a posé le diagnostic chez tous les patients. Un traitement médical antituberculeux selon un régime court allant de 6 à 9 mois a été instauré. Dans tous les cas, l’évolution à long terme a été favorable avec un recul moyen de 13 mois.

Conclusion:

La tuberculose amygdalienne est rare. Son diagnostic repose essentiellement sur le résultat anatomopathologique de la biopsie où de l’amygdalectomie. L’évolution sous traitement anti-bacillaire est souvent favorable, la récidive est exceptionnelle.

Clinicopathological review of tubercular laryngitis in 32 cases of pulmonary Kochs

PURPOSE

The aim is to study the current clinical features of tubercular laryngitis in adult patients with pulmonary involvement in the absence of other nontubercular comorbidities.

MATERIALS AND METHODS

Medical records of histopathology confirmed cases with pulmonary Kochs in a tertiary medical center of a developing country from 1993 to 2007.

RESULTS

Thirty-two biopsy-proven cases of laryngeal tuberculosis with pulmonary involvement were found. Patients' ages ranged from 16 to 65 years. The male-to-female ratio was 4.3:1. Hoarseness of voice was the commonest symptom. Most of them were associated with advanced fibrocavitary tuberculosis of the lungs. In the larynx, multiple, granulomatous, bilateral lesions were the commonest. Most of these lesions could be reversed with appropriate antituberculous treatment.

CONCLUSION

Laryngeal tuberculosis with classic presentation continues to exist in developing countries. It can be the very first indication that the patient has tuberculosis. Hence, the otolaryngologist needs to remain vigilant to consider it in the differential diagnosis of chronic laryngeal disease.

[Extrapulmonary tuberculosis in the patients of otholaryngology department--case reports]

Tubercle bacillus infection is widespread in all areas of the world and affects one-third of the human population. Tuberculosis can affect each organ in the body and although the most common presentation is pulmonary tuberculosis it can also develop in laryngological organs. THE AIM OF THE STUDY was the analyze symptomatology and also the diagnostic and therapeutic process of tuberculosis in the larynx, the lymph nodes of the neck, the ear and the palatine tonsils.

MATERIAL AND METHODS

The evaluation of medical documentation of 9 patients hospitalized in department of otholaryngology in the period of last 4 years was conducted. In all of them extrapulmonary tuberculosis developed in tissues and organs of the upper respiratory tract, neck and middle ear was detected.

RESULTS

In the analyzed group there were 5 women and 4 men. The age of patients varied from 40 to 75 years (average 56.3). In the examined group there were three cases of the larynx tuberculosis, three cases of tuberculosis of the lymph nodes, two cases of the ear tuberculosis and one case of tuberculosis of the palatine tonsils.

CONCLUSIONS

The source of the diagnosis in analyzed cases was first of all histopathological examination. Tuberculosis process found in the area of middle ear and palatine tonsils imitated chronic, non-specific inflammation and in the case concerning the ear was the only location of the illness. Tuberculosis of larynx in all the patients co-existed with specific changes in lungs and took the form of tumors suggesting neoplasmatic background of the disease. Tuberculosis of the lymph nodes can take the form of the neck abscess.

Effects of antituberculosis treatment on self assessment, perceptual analysis and acoustic analysis of voice quality in laryngeal tuberculosis patients

OBJECTIVES

To evaluate the effects of antituberculosis treatment on the voice quality of laryngeal tuberculosis patients, measured by patient self-assessment, perceptual analysis and acoustic analysis.

MATERIALS AND METHODS

A total of 14 laryngeal tuberculosis patients were enrolled. Laryngeal tuberculosis was established either by biopsy and histopathological examination or by rapid regression of the laryngeal lesions after antituberculosis medication. Before and after treatment, all patients were evaluated perceptually (on a scale of zero to three), and 12 assessed their own voices using the voice handicap index-10 scale. Acoustic analysis was performed to allow objective evaluation.

RESULTS

Patients' ages ranged from 21 to 72 years (mean, 41). The male to female ratio was 12:2. Eight patients (57 per cent) had tuberculous involvement of the epiglottis, four (28 per cent) had involvement of the aryepiglottic fold and eight (57 per cent) had involvement of the false vocal folds. The glottis was the less commonly involved part of the larynx, including true vocal folds (28 per cent, n = 4) and posterior commissure (14 per cent, n = 2). Perceptual evaluation, on a scale of zero to three, gave the patients a median score of six; after commencement of treatment, the median score decreased to two. The mean voice handicap index-10 score decreased from 24 to 12 after treatment. An obvious improvement in acoustic analytical parameters was also found following treatment.

CONCLUSIONS

Antituberculosis treatment clearly improved the voice outcomes of laryngeal tuberculosis patients, according to self-assessment, perceptual analysis and acoustic analysis.

[Laryngeal tuberculosis: a case report]

The laryngeal tuberculous is the most frequent granulomatous disease of the larynx. It is generally associated with a pulmonary cave, and represents a prognosis element extremely serious and can be complicated extreme dysphagia and pains. Among all the extrapulmonary localisations. The isolated laryngée localisation is rare. It is secondary the dissemination coming hematogen, air or lymphatic way. All the structures of the larynx can be reached. The beginning is progressive and insidious and appears by the dysphony, cough, the odynophagy and dyspnea. We report the case of laryngeal tuberculosis in a 21 year old young man. The authors point out the characteristics of this localization and insist on the biopsy in front of any chronic laryngitis no aetiology. The treatment is medical.

Tuberculosis of the aryepiglottic fold and sinus pyriformis: a rare entity

Tuberculosis of the larynx and hypopharynx is an uncommon entity and rarely considered in the differential diagnosis of the laryngo-pharyngeal diseases. We describe a case of a 40-year-old man with tuberculous involvement of the aryepiglottic fold and medial wall of the sinus pyriformis mimicking a malignancy. Current literature concerning the clinical, histopathological, radiological and diagnostic features of this rare entity is discussed.

Current clinical propensity of laryngeal tuberculosis: review of 60 cases

Although laryngeal tuberculosis is not frequent, it still occurs with an increasing incidence of pulmonary tuberculosis. Clinical pattern and spread mechanism of this disease have also changed as well. This study was performed to examine the current propensity seen in laryngeal tuberculosis and the clinical characteristics of this disease in patients showing atypical clinical pattern. The medical and videostroboscopic records of 60 patients with laryngeal tuberculosis diagnosed from the year 1994 to 2004 at the department of otorhinolaryngology in Severance Hospital were analyzed. The age of the patients ranged from 25 to 78 years, with their average age being 49.7 years. The ratio between men and women was 1.9:1. The major symptom encountered was hoarseness (96.6%). Clinically, granulomatous (n=22) and ulcerative types (n=11) of laryngeal tuberculosis were still prevalent, however, the incidence of atypical types such as polypoid (n=16) and nonspecific (n=11) were on the rise. Among the 27 cases that showed polypoid or nonspecific types, unilateral lesion was seen in 20 cases (74%). The most frequently affected area by this disease was true vocal cord, followed by false vocal cord, epiglottis, arytenoids and posterior commissure. Active pulmonary tuberculosis was present in 28 (46.7%), inactive pulmonary tuberculosis in 20 (33.3%), normal lung status in 12 cases (20%). Primary laryngeal tuberculosis was present in 9 cases (15%). Single lesion, polypoid and nonspecific type were prevalent in patients with inactive tuberculosis or normal lungs status. Physicians should be aware of the changes in the clinical pattern of laryngeal tuberculosis, which poses serious complications and risk of spreading.

[Clinical manifestation and laryngoscopic characteristics of laryngeal tuberculosis]

OBJECTIVE

To evaluate the clinical manifestations of laryngeal tuberculosis and its laryngoscopic characteristics.

METHOD

Clinical analysis of 36 laryngeal tuberculosis cases confirmed pathologically was carried out retrospectively.

RESULTS

The patients' ages ranged from 19 to 78 years old (median 39.5 years old). The male to female ratio was 1.8 to 1. The most frequent chief complaint was hoarseness (83.3%). The true vocal cord and the false vocal cord were usually found involved by fibrolaryngoscope observations. The lesions appearances were mainly the proliferation such as nodules or granules. The laryngostroboscopy demonstrated that the wave of the mucosa and vibration of the involved vocal cords were markedly reduced or disappeared. Among 24 patients with multiple lesions in the larynx, 19 (79.2%) had active pulmonary tuberculosis,while 9 (75.0%) had normal lung status among 12 patients with single lesions in the throat. All the patients received a full course of antituberculosis treatment. The results of the antituberculous medication was satisfactory in all 26 cases patients who can be followed up, while 10 cases were lost for the follow-up.

CONCLUSIONS

The local clinical manifestations of laryngeal tuberculosis is nonspecific, while the whole manifestation is not apparent. The lesions commonly involve the true vocal cord and the false vocal cord. It can even occur without pulmonary tuberculosis.

Laryngeal tuberculosis following laryngeal carcinoma

Laryngeal tuberculosis is a rare entity and the disease related to laryngeal cancer is extremely rare. We describe a case of laryngeal tuberculosis in a 74-year-old man with a history of radiotherapy for laryngeal carcinoma four months earlier. Laryngoscopy demonstrated a white mass on the right vocal fold at the site carcinoma had previously occupied. Recurrence of the cancer was suspected, but the biopsy result showed histological features of tuberculosis. We discuss the derangement of the host's mucosal barrier by the malignancy as a contributing factor in secondary tuberculous infection. Tubercular bacilli may be reactivated due to the immunosuppression associated with the therapy.

Laryngeal tuberculosis: an often forgotten diagnosis

OBJECTIVE

Clinical description of laryngeal tuberculosis.

METHODS

Clinical case review.

RESULTS

The authors report three cases of laryngeal tuberculosis with lung involvement in HIV-negative patients; symptoms were mostly laryngeal. Diagnosis was made in all cases through laryngeal biopsy and examination of the sputum. Patients fully recovered after being given standard antituberculosis therapy.

CONCLUSIONS

Laryngeal tuberculosis almost disappeared after the 1950s, but, concomitant with the increase in pulmonary forms, may still be found and, being uncommon, is often misdiagnosed.

[Tuberculosis of pharynx and larynx: a report of 32 cases]

OBJECTIVE

To evaluate the trends and the clinical changes in tuberculosis of pharynx and larynx.

METHODS

The clinical data of 32 patients with tuberculosis of pharynx and larynx from Jan. 1982 to Dec. 2000 in Daping hospital were studied retrospectively.

RESULTS

(1) The local manifestations were mainly single lesion that commonly involved the vocal cord (10 cases). (2) The lesions appearances were mainly the proliferation such as mass (11 cases) or granulation(8 cases). (3) anti-tuberculosis is the main treatment, the operation is the second. Twelve patients cured in clinic, six patients received operation and cured without any complications. Fourteen patients condition controlled.

CONCLUSION

The classical manifestations with tuberculosis of pharynx and larynx were not exited, the new clinical manifestations were associated with local lesion in nowadays.

Epiglottic Tuberculosis in a Patient Treated with Steroids for Addison's Disease

Isolated epiglottic tuberculosis (TBC) is uncommon and has rarely been described. We report the case of a 40-year-old man with tuberculous involvement of the epiglottis and primary adrenal insufficiency. Endoscopic examination showed a severely swollen epiglottis with granulomatous and partially necrotic mucosa. The patient has been treated with glucocorticoids for four years due to primary adrenocortical insufficiency. We therefore assume that tuferculous involvement of epiglottis is due to the reactivation of pulmonary TBC. We also discuss differential diagnosis and management of epiglottic TBC and Addison's disease.

Laryngeal tuberculosis

Laryngeal tuberculosis is the most frequent granulomatous disease of the larynx. The disease has changed its behaviour with regard to average age of onset site and type of lesion. Laryngeal tuberculosis is usually secondary to, or at least contemporary with, pulmonary tuberculosis. Other recents studies, however, conclude by accepting a frequency of up to 20% for primary laryngeal tuberculosis. The age of presentation is between 41-50 years. Among the risk factors identified are the consumption of tobacco, alcohol, malnutrition and immunodeficiency. The predominant symptom was dysphonia (90%) either in isolation or accompanied by odynophagia (45%). Today, the ulcero-infiltrative lesions which predominantly affected the posterior larynx are not observed. At the present time the macroscopic appearance corresponds to a diffuse oedema or to a pseudo-tumoral image located in any zone. Any non-specific chronic laryngitis of poor evolution should lead us to suspect a laryngeal tuberculosis.

Laryngeal tuberculosis: a report of 15 cases

Laryngeal tuberculosis is usually a complication of pulmonary tuberculosis. Recent studies have described a change in the clinical features of laryngeal tuberculosis. We present 15 cases of laryngeal tuberculosis treated at the Osaka Prefectural Habikino Hospital between 1993 and 2000. The results showed a mean age of 51 years, a male predominance by 2.75 to 1, and a 20% incidence (n = 3) of negative chest radiographic findings. The prominent presenting symptom was hoarseness (73.3%), and systemic symptoms were relatively rare. Seven patients showed ulcerative lesions, 5 showed granulomatous lesions, and the remaining 3 showed nonspecific inflammatory lesions in the larynx. Laryngeal lesions did not show any predilection for specific laryngeal sites in our series. In contrast to earlier studies, our study shows variations in clinical features of laryngeal tuberculosis. Physicians should consider tuberculosis in the differential diagnosis of laryngeal disease.

A case of tuberculosis in Memphis

The resurgence of tuberculosis has been of increasing concern to public health. Laryngeal and cutaneous tuberculosis have long been regarded as two of the most infectious forms of the disease. In this article, we re-emphasize the public health consequences of a case of laryngeal TB, which must be considered in the differential diagnosis of a patient with persistent fever, cough, weight loss, and hoarseness.

Changing trends in clinical manifestations of laryngeal tuberculosis

OBJECTIVES/HYPOTHESIS

Despite the dramatic decrease in the incidence of laryngeal tuberculosis, the disease has gained new interest as a result of claims that it has changed its clinical patterns. The aim of this study is to evaluate the changing trends in clinical manifestations of laryngeal tuberculosis.

STUDY DESIGN

Retrospective clinical analysis.

METHODS

Clinical analysis of 22 patients with pathologically confirmed laryngeal tuberculosis was carried out retrospectively.

RESULTS

Patients' ages ranged from 22 to 75 years. The male-to-female ratio was 2.14 to 1. The most frequent chief complaint was hoarseness. The true vocal cord and the false vocal cord were commonly involved, and 11 patients showed single lesions. Among 22 patients, only 7 had active pulmonary tuberculosis, and 9 were proven to have normal lung status. The patients with active pulmonary tuberculosis showed more ulcerative and multiple lesions. The patients with normal lung status showed nonspecific, polypoid, and single lesions. All patients responded satisfactorily to antituberculous medication.

CONCLUSIONS

The clinical manifestations of laryngeal tuberculosis have changed and seem to be different from those of classic reports. It can even occur without pulmonary tuberculosis, and the characteristics of lesions seem to be more nonspecific. It might be important to consider tuberculosis in the differential diagnosis of nonspecific laryngeal disease.

The association of secondary tonsillar and laryngeal tuberculosis: a case report and literature review

Tonsillar and laryngeal tuberculosis are rare diseases. We report a case with a tonsillar and laryngeal lesion. Histopathological and bacteriological examinations established the diagnosis of tonsillar and laryngeal tuberculosis associated with asymptomatic pulmonary focus.

[Laryngeal tuberculosis: considerations on the most recent clinical and epidemiological data and presentation of a case report]

According to the "Global Tuberculosis Control" performed in 1999--the third complete, international, global report on tuberculosis infection--173 countries reported their infection data to the WHO; of these countries 102 met the criteria for "DOTS programs" at the end of 1997. The DOTS programs are the only control strategy able to produce a cure rate of 85%. Both at the national and international (Centers of Disease Control) levels, guidelines have been drawn up to improve and coordinate the fight against tuberculosis. New indicators and methods of analysis should be developed to quantify the full impact on the control of infection transmission, incidence, prevalence, mortality and prevention of drug resistance. In addition, two significant world-wide events have affected the increase morbidity rate seen in the last decade in the more highly industrial countries: immigration from countries outside the European Community and HIV infection. The tuberculosis infection worsens the evolution of HIV, facilitating viral replication. In the present work the authors discuss the most recent epidemiological data regarding tuberculosis infection and review the Literature on the primary laryngeal location of the disease. Then they present a clinical case which recently came under observation. This case is a typical example of the clinical picture of the laryngeal tuberculosis seen today. It must not be forgotten that in recent years there has been an increase in morbidity in Italy, in both the pulmonary and extrapulmonary forms of the disease, although in our country the problem of delayed or incomplete reporting is quite widespread. The data show that the age ranges with the highest incidence of both pulmonary and extrapulmonary forms are the 25-35 and 60-70 year groups. Distribution by sex, on the hand, shows that the pulmonary forms are most often seen in males while the extrapulmonary forms have practical the same frequency in both sexes. In recent years the clinical and morphological aspects of tubercular laryngitis have changed significantly from what they were before chemotherapy and the most common clinical form is pseudotumoral tuberculosis. This form requires a differential diagnosis to distinguish it from neoplasms because they present a similar objective picture and have no signs of simultaneous or previous pulmonary involvement.

Laryngeal tuberculosis

Since the introduction of antituberculous medications, the incidence of laryngeal tuberculosis (TB) has decreased and remains stable. However, with the incidence of TB increasing, mainly caused by the acquired immunodeficiency syndrome epidemic, the incidence of laryngeal involvement may be on the rise. The main presenting symptom of laryngeal TB is dysphonia. The diagnosis is confirmed with the identification of granulomatous inflammation, caseating granulomas, and acid-fast bacilli on histopathologic examination of biopsied laryngeal tissue. However, making the diagnosis difficult can be the presence of pseudoepitheliomatous hyperplasia, which mimics squamous cell carcinoma. Treatment is primarily with antituberculous medications with surgery reserved for those cases of airway compromise. Laryngeal complications can occur; thus, long-term follow-up is recommended. We report a case of laryngeal TB in a human immunodeficiency virus-negative patient and review the literature.

[Laryngeal tuberculosis and laryngeal cancer]

Account of 2 synchronic cases of tuberculosis and laryngeal carcinoma. Apart from bacteriostatic drugs one of them underwent a cordectomy the other one a total laryngectomy and neck dissection. Despite the great majority of laryngeal cancer it is compulsory to take in account the differential diagnosis with the tuberculosis, because of its possible coexistence. Perusal of national and international literature, having found only 11 of similar instances reported.

Laryngeal tuberculosis masquerading as carcinoma

Two patients were cared for during a 3-month period. Both smoked at least 1 pack of cigarettes a day for many years. Both complained of hoarseness, which did not respond to antibiotics and did not resolve with time. In both cases, the initial diagnosis was squamous cell carcinoma of the larynx. Both patients had laryngeal tuberculosis, and when appropriate therapy was instituted, their symptoms and lesions cleared.

[A case of tuberculous epiglottitis: an unusual form of presentation]

A case laryngeal tuberculosis with atypical presentation simulating epiglottitis is presented. The topic is reviewed and discussed.

Laryngeal tuberculosis at the end of the 20th century

Despite the dramatic reduction in the incidence of laryngeal tuberculosis after the 1950s, the topic has now gained new interest due to claims that the disease has changed its clinical pattern. In the past, the typical patient was 20-40 years old with ulcerated laryngeal lesions, perichondritis, and advanced cavitary lung disease. We studied nine cases of laryngeal tuberculosis confirmed by histological examination. The microlaryngoscopy revealed tumour-like lesions and/or chronic non-specific laryngitis. There were no significant ulcerations or signs of perichondritis. The patients' ages ranged from 48.5 years to 69.3 years (mean, 59.4 years). In three of our patients (33 per cent) we did not find any pulmonary involvement, thus suggesting primary laryngeal tuberculosis or haematogenous spread. In conclusion, the numerous physicians who deal with the various laryngeal symptoms and diseases should be aware of the existence of laryngeal tuberculosis and the changing patterns of the disease (at least in the developed countries).

Laryngeal involvement in pulmonary tuberculosis

Fifty-one patients with established pulmonary tuberculosis underwent clinical evaluation and endoscopic examination of the larynx to determine the manifestations of laryngeal involvement. There were 46 males and 5 females (mean age 38 years). Fever, cough and haemoptysis were the prime pulmonary complaints while hoarseness, weak voice and episodic dyspnoea were the main laryngeal symptoms. Sites of laryngeal lesions included true vocal cords, arytenoids and false vocal cords. Oedema, pallor, ulcers, vocal cord immobility and thickening were the main laryngeal lesions observed. Twenty-four (47%) cases showed morphological changes in the larynx. The presentation pattern was consistent with the classical description and predilection for laryngeal involvement was not demonstrated.

Cavitary tuberculosis produced in rabbits by aerosolized virulent tubercle bacilli

Liquefaction of solid caseous tuberculous lesions and the subsequent cavity formation are probably the most dangerous processes in the pathogenesis of human pulmonary tuberculosis. In liquefied caseum, the tubercle bacilli grow extracellularly for the first time since the onset of the disease and can reach such large numbers that mutants with antimicrobial resistance may develop. From a cavity, the bacilli enter the bronchial tree and spread to other parts of the lung and also to other people. Of the commonly used laboratory animals, the rabbit is the only one in which cavitary tuberculosis can be readily produced. This report is the first to describe and analyze the complete course of cavitary tuberculosis, produced by aerosolized virulent bovine-type tubercle bacilli in commercially available New Zealand white rabbits. After the inhalation of 220 to 880 bacillary units, all of the rabbits were overtly well until they were sacrificed at 33 weeks. After the inhalation of 3,900 to 5,800 bacillary units, half of the rabbits died of progressive tuberculosis between 5 and 9 weeks and the other half lived until they were sacrificed at 18 weeks. Pulmonary cavities developed in both low- and high-dose groups, some beginning as early as 6 weeks. Bacilli from primary cavities sometimes caused nearby secondary cavities, but more frequently, they ascended the bronchial escalator, were swallowed, and caused secondary tubercles in the lymphoid tissue of the appendix and ileocecal junction. Histologically, and by culture, the number of bacilli found in the liquefied caseum varied from many to comparatively few. Strong tuberculin reactions at 4 weeks after infection were associated with fewer primary lesions, while strong tuberculin reactions at 33 weeks were associated with more cavitary lesions. In the tuberculous granulation tissue surrounding caseous and liquefied pulmonary foci and cavities, we found many mature epithelioid macrophages that contained high levels of the proteinase cathepsin D. Therefore, cathepsin D probably plays a major role in the liquefaction of solid caseous material and in the subsequent cavity formation.

[Laryngeal tuberculosis today. A case report]

We report the clinical, CT and histopathological findings of an 84-year-old female with laryngeal tuberculosis. Despite extensive clinical investigations no other manifestation of tuberculosis was found. Antituberculous therapy healed the disease. The clinical relevance and the differential diagnosis of laryngeal tuberculosis are discussed.

Tuberculosis of the upper respiratory tract misdiagnosed as Wegener's granulomatosis--an important distinction

Four cases, two personal, of mis-diagnosis of tuberculosis of the upper respiratory tract as Wegener's granulomatosis have been presented. Greater awareness of this possibility of mis-diagnosis may diminish the possibility of mis-treatment. It is suggested that fresh specimens should be sent for bacteriological examination and culture in all relevant upper respiratory tract lesions.

Laryngeal tuberculosis in the eighties--an Indian experience

Laryngeal tuberculosis is one of the rarer forms of extrapulmonary tuberculosis. A retrospective analysis of 26 patients seen in the last nine years in our hospital was conducted to illustrate the various modes of clinical presentation. Of the 26 patients, twenty were male and six female. The average age of presentation was 47 years with an age range of 15 months to 71 years. Hoarseness (92.3 per cent) was the commonest symptom. The laryngoscopic appearances often simulated malignancy. Most patients (69.2 per cent) had lesions involving the anterior two-thirds of the true vocal cords. Hypertrophic lesions (69.2 per cent) out-numbered ulcerative ones (38.5 per cent). Laryngeal oedema was infrequent (7.7 per cent). Diagnosis was based on a laryngeal biopsy in 18 patients and on evidence of associated pulmonary tuberculosis and response to anti-tuberculous therapy in eight. Chest X-rays showed apical cavitation and infiltration as the commonest findings. Three patients had miliary tuberculosis and one had no pulmonary lesion. Diabetes mellitus was present in seven (26.9 per cent) patients. Four illustrative cases are described. The problems in diagnosis and management of laryngeal tuberculosis are discussed.

Paediatric laryngeal tuberculosis presenting with stridor

A rare case of laryngeal tuberculosis in a 15-month-old Indian child is described. The unusual mode of presentation with stridor, suspicious radiological signs and papillomatous nature of the laryngeal lesion are highlighted.