Tuberculosis in the Head and Neck: Changing Trends and Age-Related Patterns.

OBJECTIVE: To evaluate changing trends in patient collectives, age-related patterns of manifestation, and diagnostic pathways of patients with extrapulmonary head and neck tuberculosis (TB), and to provide strategies to fasten diagnosis in these patients. STUDY DESIGN: Case control study. METHODS: A 10-year retrospective analysis of 35 patients diagnosed with extrapulmonary TB in the head and neck at a tertiary university institution from 2009 to 2019, with special focus on the influence of the patient's age on consideration of TB and clinical patterns. RESULTS: The vast majority of patients younger than 40 years had their origin in countries with high TB burden (P = .0003), and TB was considered very early as a differential diagnosis (P = .0068), while most patients older than 40 years were domestic citizens initially suspected for a malignancy, who more often had an underlying immunosuppressive condition (0.0472). Most frequent manifestations in both groups were the lymph nodes, larynx, and oropharynx. Surprisingly, no differences in the rates of open TB or history of TB infection in the family anamnesis were found. CONCLUSION: The two groups of patients found most often are younger patients migrating from regions with high TB burden and elderly domestic patients suffering from immunosuppressive conditions, with the latter often being misdiagnosed as malignancies. TB remains an important but difficult differential diagnosis, due to the initially unspecific symptoms and the great variety in the presentation of manifestations in the head and neck. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:2701-2705, 2021.

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.

Head and neck tuberculosis: Literature review and meta-analysis.

BACKGROUND: Head and neck tuberculosis (HNTB), including cervical lymphadenopathy, is the most common extrapulmonary manifestation of TB. The proposed study investigated the epidemiologic and clinical characteristics of HNTB. MATERIALS AND METHODS: A literature search was conducted via PubMed, Embase, Cochrane Library and Wanfang for keywords (tuberculosis, head and neck, laryngeal, pharyngeal, tongue, oropharyngeal, nasopharyngeal, and oral cavity). Scientific articles published from January 1990 through July 2017 were selected and reviewed to assess the epidemiology, presentation, diagnosis and treatment of HNTB disease. RESULTS: Results from the included 57 studies revealed that the majority of HNTB cases were age<40 years and female. The most common HNTB sites were cervical lymph nodes (87.9%), followed by larynx (8.7%). Involvement of other HN-regions was rare (3.4%). Multidrug resistant TB was not common among the majority of studies. Given the paucibacillary nature of HNTB, sputum tests did not have a good performance on HNTB diagnosis. Most of HNTB cases were diagnosed by fine-needle aspiration, cytology and excision biopsies in combination with clinical presentations. CONCLUSION: HNTB disease is an important manifestation in the diagnostic process in an otolaryngologist practice. The developments of rapid, ultrasensitive, simple and cost-effective high-throughput methods for early diagnosis of HNTB are urgently needed.

Primary Laryngeal Tuberculosis: Our Experiences at a Tertiary Care Teaching Hospital in Eastern India.

INTRODUCTION: Primary laryngeal tuberculosis is a chronic bacterial infection of the larynx by Mycobacterium tuberculosis without affecting the lungs. It is a rare type of extrapulmonary tuberculosis seen in clinical practice. OBJECTIVES: This study aimed to evaluate the clinical presentation, diagnosis, and treatment of primary laryngeal tuberculosis at a tertiary care teaching hospital in eastern India. MATERIALS AND METHODS: This is a retrospective study of 11 cases of primary laryngeal tuberculosis managed between December 2013 and January 2018. The detailed clinical presentations, investigations, and treatment of primary laryngeal tuberculosis of the patients were studied. RESULTS: Primary laryngeal tuberculosis is common in men with mean age of 38.63 years. Hoarseness of the voice is the most common symptom, and the most common site for primary laryngeal tuberculosis is the vocal fold with ulcerative lesion. Endoscopic examinations of the larynx in laryngeal tuberculosis are nonspecific and are to be confused with laryngeal cancer. Histopathological and bacteriological examinations are confirmatory tests for the diagnosis. After confirmation of the diagnosis, all patients had taken antitubercular therapy for 6 months, which gave excellent outcome. CONCLUSIONS: Delayed diagnosis or untreatable laryngeal tuberculosis will lead to high morbidity and mortality of the patient. Although primary laryngeal tuberculosis has nonspecific clinical presentations, it is very important to have a high index of suspiciousness to rule out tubercular lesion in the larynx as this disease is curable.

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.

Factors Associated with Clinical and Topographical Features of Laryngeal Tuberculosis.

INTRODUCTION: Laryngeal tuberculosis (LTB) is the most frequent granulomatous disease of the larynx and represents less than 2% of extrapulmonary TB cases. There are no pathognomonic clinical and endoscopic features of this disease and studies on LTB that can assist in its diagnostic characterization are lacking. OBJECTIVE: To identify factors associated with clinical and topographical features of LTB. METHOD: a retrospective cross-sectional study was conducted from the medical records of 36 patients with confirmed LTB diagnosis. RESULTS: Dysphonia and cough were the main symptoms presented by patients and the true vocal folds the most frequently affected site. The average of the duration of the disease evolution was significantly higher in patients with dysphonia than in patients without this symptom. We observed association between dysphonia and true vocal fold lesions and between odynophagia and lesions in the epiglottis, arytenoids and aryepiglottic folds. Odynophagia was more frequent in individuals with lesions in four or more laryngeal sites. Weight loss equal or above 10% of the body weight was more frequent in patients with odynophagia as first symptom and in patients with ulcerated lesion. Dyspnea on exertion was more frequent in individuals with more extensive laryngeal lesions. The percentage of smokers with lesions in four or more laryngeal sites was greater than that found in non-smokers. Laryngeal tissue fragment bacilloscopy and culture examinations were less positive than sputum ones. CONCLUSIONS: Smoking appears to be associated with the development of more extensive LTB lesions, and LTB with dyspnea on exertion and odynophagia with consequent impairment of nutritional status. We emphasize the need for histopathologic confirmation, once positive sputum bacteriological examinations seem not to necessarily reflect laryngeal involvement.

Primary tuberculosis involving epiglottis: a rare case report.

The case of a 29-year-old patient with active laryngeal tuberculosis predominantly involving the epiglottis, without pulmonary disease, is presented. The predominant symptoms are dysphagia, odynophagia, and hoarseness. Laryngeal carcinoma, which shares almost the same symptoms and signs, should be ruled out immediately. Laryngeal tuberculosis is discussed with a brief literature review.

Laryngeal involvement in two severe cases of childhood tuberculosis.

Laryngeal tuberculosis in children is seldom reported in the literature. We present 2 children from Cape Town, South Africa who had disseminated tuberculosis involving the cervical lymph nodes and the larynx. The cases emphasize the pathophysiology, the clinical picture, the bronchoscopic appearance, and the response to therapy in laryngeal tuberculosis.

[Epilaryngeal tuberculosis: epidemiologic, clinical and healthcare considerations]. / Tuberculose épilaryngée: considérations épidémiologiques, cliniques et sanitaires.

OBJECTIVE: To report a case of laryngeal tuberculosis and to consider tuberculosis management in ENT practice. MATERIAL AND METHODS: A 44-year-old man, a smoker with pulmonary sarcoidosis experienced dysphonia with dysphagia. Laryngeal fibroscopy revealed an ulcerated epiglottic lesion. Direct laryngoscopy was performed to detect carcinoma, laryngeal sarcoidosis or tuberculosis. The histologic study revealed granulomatosis with giant cells and caseous necrosis. Tissue culture identified Mycobacterium tuberculosis. RESULTS: Antituberculosis therapy decreased dysphonia and dysphagia. Isolated ulceration disappeared at three months. Pulmonary infiltration decreased in radiography. The discovery of this case of laryngeal tuberculosis instigated hospital and community tuberculosis surveillance. CONCLUSION: The ENT specialist should be aware of laryngeal tuberculosis in suspicious lesions. Mandatory declaration of such cases can motivate setting up tuberculosis surveillance.

[Simultaneous pulmonar, laryngeal and lingual affectation by Mycobacterium tuberculosis]. / Afectación simultánea pulmonar, laríngea y lingual por Mycobacterium tuberculosis.

The incidence of tuberculosis has lately increased in developed countries. The most frequent affectation is the pulmonar one and in the ORL area the laryngeal. The lingual affectation is exceptional. We present a case of a man 39 years old, with bilateral pulmonar, left vocal cord and mobile tongue affectation, negative Mantoux, positive spit culture and presence of acido-alcohol resistent bacillus in lingual and laryngeal biopsies. After antituberculosis treatment during 6 months the laryngeal and lingual lesions disappeared. We have only found two cases published of simultaneous tuberculosis in these three localisations in the last 30 years.

[Tuberculous epiglotittis, an atypical form of laryngeal tuberculosis. Presentation of a case and revision of litterature]. / Epiglotis tuberculosa, una forma atípica de tuberculosis laríngea. Presentación de un caso y revisión de la literatura.

An important arousal of tuberculosis has been observed in the last years, together with a change in it's clinical patterns, specially the extrapulmonar form, among wich is this laryngeal tuberculosis. This two facts and the marked polymorphism and mimetism proper of this condition may suggest that the Mycobacterium tuberculosis should be included in the differential diagnosis of any atypical lesion of the larynx, in order to obtain an earlier diagnosis excluding carcinoma and instaurate a chimotherapic protocol for minimizing or even avoiding any sequelae. Tuberculous epiglotittis is one of these atypical and unusual forms. The authors report a case of a 67 year-old male and provide a discussion on the diagnostic problems of this condition.

Side effects of anticytokine strategies.

Anticytokine strategies probably represent the most important breakthrough in the treatment of inflammatory diseases in the last decade. However, blocking the bioactivity of proinflammatory cytokines, crucial activators of host defence, has proved to be accompanied by an increased susceptibility to infections, especially with Mycobacteria, Salmonellae and fungal pathogens. Multiple mechanisms for these side effects have been proposed, such as inhibition of gamma-interferon production, decreased expression of pattern-recognition receptors, and leucocyte apoptosis. Caution is therefore warranted when these treatments are given to patients with an increased risk for infections. A range of side effects other than infection have been reported.

Tonsillar tuberculosis in a rheumatoid arthritis patient receiving anti-TNFalpha (adalimumab) treatment.

This case report describes a 61-year-old rheumatoid arthritis patient with an atypical clinical presentation of a sore throat. Because of rheumatoid arthritis refractory to conventional disease-modifying antirheumatic drug therapy, anti-TNFalpha was felt to be indicated, and a screening for tuberculosis was carried out. As the screening for tuberculosis (PPD) was positive, isoniazid was prescribed prophylactically for six months. After eight months of anti-TNFalpha (adalimumab) treatment, he developed tonsillar enlargement and nodular pulmonary lesions. Histopathological and microbial investigations established the diagnosis of tonsillar tuberculosis.

Laryngeal tuberculosis masquerading as carcinoma.

With the advance of effective anti-tuberculosis drugs and the natural decline of tuberculosis (TB) in the developed world, the incidence of laryngeal TB has decreased and remains stable. However, compared to the situation in the past, the otolaryngologist may encounter uncommon clinical presentation of laryngeal TB nowadays. We describe one such case presenting with a laryngeal lesion with clinical and radiological features of a neoplastic rather than an infectious process.

[Laryngeal tuberculosis: a diagnosis not to be forgotten]. / La tuberculose laryngée: diagnostic à ne pas oublier.

Tuberculosis of the larynx has become a rarity since the discovery of streptomycin in 1944. In this article a personal case history is described, together with a review of the literature and an analysis of the main clinical features of tuberculosis of the larynx. The pseudo-tumoural form of tuberculosis is often indicative of the presence of pulmonary tuberculosis, but may also occur in isolation. Histology is often the only definitive diagnostic test.

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.

Infectiousness of a university student with laryngeal and cavitary tuberculosis. Investigative team.

A search for the source of infection for four children with tuberculosis (TB) identified a university student with cavitary and laryngeal TB. An investigation was conducted at the university, including tuberculin skin test (TST) screening and the use of questionnaires, chest radiographs, and DNA fingerprint analyses of Mycobacterium tuberculosis isolates. Six students with active TB were identified. All were linked to the source case. TSTs were positive for 22.4% of 419 students who had contact with the source case vs. 3.6% of 1,306 students without contact. The odds of a positive TST increased to 9.0 with 80 hours of classroom contact. Infectiousness increased significantly in the last of three semesters during which the source case was symptomatic (RR of a positive TST in classmates, 4.8; 95% CI, 1.8-11.8). TST conversions were documented in 23 students; eight had, at most, 5 hours of classroom contact. The source case was highly infectious; transmission following only a few hours of exposure was documented. Her infectiousness increased as her clinical course progressed. This report illustrates the potential infectiousness of TB cases and demonstrates important aspects of tuberculosis control.