A case report of Talaromyces marneffei Oro-pharyngo-laryngitis: a rare manifestation of Talaromycosis.

BACKGROUND: The incidence of Taralomyces marneffei infection in HIV-infected individuals has been decreasing, whereas its rate is rising among non-HIV immunodeficient persons, particularly patients with anti-interferon-gamma autoantibodies. T. marneffei usually causes invasive and disseminated infections, including fungemia. T. marneffei oro-pharyngo-laryngitis is an unusual manifestation of talaromycosis. CASE PRESENTATION: A 52-year-old Thai woman had been diagnosed anti-IFNÉ£ autoantibodies for 4 years. She had a sore throat, odynophagia, and hoarseness for 3 weeks. She also had febrile symptoms and lost 5 kg in weight. Physical examination revealed marked swelling and hyperemia of both sides of the tonsils, the uvula and palatal arches including a swelling of the epiglottis, and arytenoid. The right tonsillar biopsy exhibited a few intracellular oval and elongated yeast-like organisms with some central transverse septum seen, which subsequently grew a few colonies of T. marneffei on fungal cultures. The patient received amphotericin B deoxycholate 45 mg/dayfor 1 weeks, followed by oral itraconazole 400 mg/day for several months. Her symptoms completely resolved without complication. CONCLUSION: In patients with anti-IFN-É£ autoantibodies, T. marneffei can rarely cause a local infection involving oropharynx and larynx. Fungal culture and pathological examination are warranted for diagnosis T. marneffei oro-pharyngo-laryngitis. This condition requires a long term antifungal therapy.

Chronic laryngitis caused by Mycobacterium Kansasii in a traveler.

Chronic laryngitis commonly presents with dysphonia, and infectious causes include tuberculosis and endemic mycoses. We present a 58-year-old female with laryngitis for 5 years, fevers, chills, fatigue, malaise, myalgias, anterior neck pain, and night sweats after multicontinent exposure. Bronchoscopy cultures were negative. Bilateral microflap excision of vocal fold lesions demonstrated thickened epithelium and a deep vocal fold mass. Biopsy showed necrotizing granulomatous inflammation with acid-fast bacilli. Mycobacterium kansasii was identified. Treatment led to improvement in dysphonia, systemic symptoms, and vocal fold irritation. To our knowledge, this is the first case of isolated nontuberculous mycobacterial vocal fold infection. Laryngoscope, 129:2534-2536, 2019.

Laryngeal Cryptococcosis: An Evolving Rare Clinical Entity.

OBJECTIVES: Describe the demographics and clinical manifestations of laryngeal cryptococcosis. Develop a simple approach to the diagnostic workup and treatment of localized laryngeal cryptococcal infection. METHODS: A new case of laryngeal cryptococcosis encountered at our institution is presented and placed in context of the literature surrounding prior reported cases. PubMed, Google Scholar, SCOPUS, and Web of Science were queried from inception to August 2018 with the terms Larynx or Laryngeal and Cryptococcosis or Cryptococcus by two independent reviewers for English-language cases of cryptococcal infection of the larynx. RESULTS: Twenty-nine unique cases of laryngeal cryptococcosis were identified. Median age at presentation was 65 years old. All patients presented with persistent or progressive hoarseness. Lesions were predominantly on the true vocal cords (79%), 38% associated with an adherent white exudate or leukoplakia. A minority (28%) was immunocompromised, and of the remaining immunocompetent hosts, 67% were found to be using nebulized or inhaled corticosteroids (ICS) prior to infection. Diagnosis should be suspected in patients with chronic laryngitis or mass lesions with the aforementioned risk factors. Diagnosis was made by histopathology with cryptococcal yeasts identified on methenamine silver (55%) and/or mucicarmine stains (48%). Serum cryptococcal antigen testing was unreliable (sensitivity = 39%). The mainstay of effective treatment was prolonged oral Fluconazole therapy, with two cases of laser therapy ablation of residual lesions. Improvement in voice and vocal lesions varied from weeks to months. CONCLUSIONS: Laryngeal cryptococcosis is a rare cause of persistent hoarseness, which appears to be clinically evolving and more frequently affecting immunocompetent hosts chronically using nebulized or inhaled corticosteroids. Laryngeal cryptococcal infection is readily treatable with prolonged oral antifungals once biopsy and histopathological stains confirm the diagnosis.

Post-transplantation laryngeal actinomycosis.

A case of laryngeal actinomycosis occurred after bone marrow transplantation was reported. The patient was a 14-year-old girl who had a history of bone marrow transplantation for the treatment of acute lymphocytic leukemia 4month before the onset of the disease. She was referred to our hospital complaining persistent sore throat since 2weeks ago. Fiberscopic observation proved the presence of white tumor-like mass on her right arytenoid of the larynx. As CT image demonstrated that the mass was localized at the arytenoid region with central low-density area surrounded by granulation tissue, we underwent biopsy under local anesthesia. Excision of the mass proved it to be a soft granulation including sulfur granules. Oral administration of amoxicillin 750mg per day was initiated as a postoperative medication. On day 17, histological study confirmed that the tumor-like mass was Actinomyces granuloma, and therefore amoxicillin administration continued. The medication was effective to subside the disease and the arytenoid lesion healed on day 31. Amoxicillin was further administered until day 70 to prevent recurrence. At 6month after the biopsy, she was free from the disease.

MRSA chronic bacterial laryngitis: A growing problem.

OBJECTIVES: Chronic bacterial infection of the larynx is characterized by long-standing hoarseness and exudative laryngitis. Prolonged antibiotic therapy is required to clear the infection, and methicillin-resistant staphylococcus aureus (MRSA) may be the responsible pathogen. The objective of this study was to describe the presentation, comorbidities, treatment response, and underlying etiology- including the incidence of MRSA-in our patient population with chronic bacterial laryngitis. METHODS: A review of patients with a diagnosis of chronic bacterial laryngitis from 2012 to 2016 was performed. Diagnosis of chronic bacterial laryngitis was based on clinical history and findings on flexible laryngoscopy. In selected cases, the diagnosis of bacterial laryngitis was confirmed by operative biopsy. Information regarding clinical presentation and course was collected. RESULTS: Twenty-eight patients were included in the study. Twenty-three were treated empirically with Amoxicillin-clavulonic acid for a minimum of 21 days. Twelve of the 23 (52%) had recurrence or nonresolution of infection. Seven of the 12 nonresponders (58%) were found to have MRSA by laryngeal tissue culture. Five patients were treated initially with Sulfamethoxazole and trimethoprim, and all resolved the infection without the need for further treatment. There was a nonstatistically significant increase in smoking and reflux in the MRSA population compared to the non-MRSA group. CONCLUSION: MRSA infection was documented in 30% of patients overall with chronic bacterial laryngitis. Based on the results of the study, a treatment algorithm for management of this unusual patient population is suggested. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:921-925, 2018.

[The prevalence of the fungal flora in association with chronic inflammatory pathology of the larynx]. / Rasprostranennost' gribkovoi flory pri khronicheskoi vospalitel'noi patologii gortani.

The present article was designed to analyze the prevalence and clinical features of laryngomycosis associated with chronic inflammatory diseases of the larynx. We examined 430 patients suffering from chronic pharyngitis and found the fungal flora in 100 (23.2%) of them. Diagnostics of the fungal infection was performed by the microscopic study of the stained preparations (including the Gram method, Romanovskiy-Giemsa and fluorescent microscopy). The sowing on elective nutrient media was used. The study revealed the presence of yeast fungi (Candida) in 98 patients (98%) and mold fungi (Aspergillus) in the remaining two (2%). The hyperplastic form of fungal pharyngitis was diagnosed in 55% of the patients. We have identified the following predisposing factors for fungal laryngitis: the gastroesophageal reflux disease in 56% of the patients, smoking in 50%, the long-term use of the removable dentures with the inadequate care for them in 30%, and the consistent use of inhaled corticosteroids in 27%. Hyperglycemia was documented in 6% and the history of long-term treatment with antibiotics in in 10% of the patients. The scheme for the combined antifungal therapy has been developed. Its practical application allowed to achieve the eradication of the fungal flora and to improve the clinical course of chronic laryngitis in 75% of the patients.

Factors Associated With Infectious Laryngitis: A Retrospective Review of 15 Cases.

OBJECTIVES: To identify the culturable microbes associated with infectious laryngitis and outline effective treatment strategies. METHODS: This is a retrospective chart review of adult patients with persistent dysphonia plus evidence of laryngeal inflammation who underwent biopsy for culture at a tertiary care medical center. Demographic factors, symptoms as reported on validated patient assessment tools, past medical history, social history, culture results, and treatment duration and response were reviewed. RESULTS: Fifteen patients with infectious laryngitis were included in this study. Culture results demonstrated Methicillin-sensitive Staphylococcus aureus (MSSA), Methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas aeruginosa, Serratia marcescens, and "normal respiratory flora." In most patients, multiple courses of prolonged antibiotics were needed to treat MSSA or MRSA. Infections associated with other microbes resolved with a single course of antibiotics. CONCLUSIONS: In this population, infectious laryngitis is defined as colonization with bacteria not found in the previously characterized laryngeal microbiome of benign vocal fold lesions. In suspected cases of infectious laryngitis, culture is recommended, by biopsy if needed. For MSSA- and MRSA-associated laryngitis, an extended course of antibiotics may be necessary for symptom improvement and resolution of laryngeal inflammation. However, the optimal treatment regimen has yet to be defined and will require larger, prospective studies.

Pulsed dye laser treatment of primary cryptococcal laryngitis: A novel approach to an uncommon disease.

An 82-year-old supplemental oxygen dependent woman with severe COPD presented with an eight month history of worsening hoarseness and stridor. Office laryngoscopy revealed laryngeal edema and ulcerative masses throughout the larynx. In-office biopsies were positive for Cryptococcus neoformans. This report details a novel approach to the treatment of cryptococcal laryngitis, a combination of in-office pulsed-dye laser (PDL) ablation and medical therapy. Despite treatment with oral fluconazole, the recommended treatment for cryptococcal laryngitis the patient continued to be symptomatic with dysphonia and throat discomfort. Repeated laryngeal exam demonstrated persistent cryptococcal nodules. The patient was subsequently effectively treated with an in-office PDL laser. This case demonstrates the efficacy of in-office laser treatment for residual laryngeal Cryptococcus. For patients like this one, who have failed medical therapy and are unfit for general anesthetic, the in-office laser provides an excellent alternative treatment approach.

Laringitis fúngica en pacientes inmunocompetentes / Fungal laryngitis in immunocompetent patients

Introducción: La laringitis fúngica es una patología poco planteada en pacientes inmunocompetentes, sin embargo se debería tener en consideración en el diagnóstico diferencial de leucoplaquias en estos pacientes, más aún con factores predisponentes como reflujo faringolaríngeo, tabaquismo crónico y/o uso de corticoides. Objetivo: Presentar una serie de casos de pacientes inmunocompetentes con diagnóstico clínico de laringitis fúngica y tratamiento antimicótico empírico. Describir la asociación con factores predisponentes claves. Material y método: Estudio retrospectivo que incluyó a 11 pacientes con diagnóstico clínico de laringitis fúngica por correlación de la clínica, factores predisponentes y hallazgos en la videoestroboscopía laríngea (leucoplaquias múltiples en los pliegues vocales) sumado a la respuesta a tratamiento empírico con fluconazol oral. Se realizó además una revisión de la literatura disponible hasta el año 2015. Resultados: Todos los diagnósticos fueron clínicos correlacionando síntomas con hallazgo de leucoplaquias características en la laringe. El principal factor asociado fue el reflujo faringolaríngeo (91%) seguido por uso de corticoides (55%). Todos los pacientes fueron tratados con un esquema empírico de fluconazol oral por 14-21 días. El 100% de los pacientes respondió de forma exitosa al uso de este fármaco con remisión de los síntomas y de las lesiones laríngeas. Conclusión: El diagnóstico clínico y tratamiento con fluconazol oral como tratamiento de primera línea generarían buena tasa de respuesta, siempre que se correlacionen los síntomas y signos del paciente con los hallazgos encontrados en la laringe.

Introduction: The fungal laryngitis is an unusual disease in immunocompetent patients, however should take into consideration in the differential diagnosis of leukoplakias, especially in patients with predisposing factors such as pharyngolaryngeal reflux, use of inhaled, oral or intravenous corticosteroids. Aim: Describe a series of cases of fungal laryngitis in immunocompetent patients with clinical diagnosis and empirical antifungal treatment. In addition, finding the association with predisposing factors keys. Material and method: Retrospective study of 11 patients with diagnosis of fungal laryngitis according to clinical presentation, predisposing factors and findings in the laryngeal videostroboscopy (vocal folds leukoplakias) joined the response to empirical treatment with oral fluconazole. Also an extensive literature review was conducted until 2015. Results: The main predisposing factor was the pharyngolaryngeal reflux (91%) followed by use of corticosteroids (55%). All patients were treated empirically with fluconazole for 14-21 days. 100% of patients responded successfully, with remission of symptoms and laryngeal lesions. Conclusion: Clinical diagnosis and treatment with fluconazole as first-line treatment generate good response rate, provided that the patient's symptoms and signs with the findings in the larynx are correlated.

[Deep neck infection: clinical analyses of 95 cases].

OBJECTIVE: To review the recent diagnosis and treatment experience with deep neck infection and emphasize the importance of radiologic evaluation, microbiology and appropriate treatment selection in these patients. METHODS: A respective review was conducted in 95 cases who were diagnosed as having deep neck from Jan. 2006 to March 2015. RESULTS: The primary diseases in 95 patients with deep neck infection were acute tonsillitis or acute laryngitis (27 cases), infection of upper respiratory tract (23 cases), odontogenic infection or oral inflammation (16 cases), foreign bodies in esophagus (9 cases), acute cervical lymphadenitis (5 cases) and cause uncertain (15 cases). Computed tomography was performed in all of patients to identify the location, extent, and character (cellulitis in 47 cases or abscesses in 48 cases) of the infections. The locations of abscess were parapharyngeal abscess (25 cases), retropharyngeal abscess (9 cases), submaxillary space abscess (6 cases), pretracheal space abscess (5 cases) and esophageal abscess (3 cases). COMPLICATIONS: mediastinitis (2 cases), pericarditis (1 case), bilateral pneumothorax (2 cases), and upper digestive tract (1 case). Bacterial cultivation performed in 35 patients and positive results were detected in 21. All patients were given intravenous antibiotic therapy. Tracheotomy was performed in 4 cases. Preoperative contrast enhanced CT was performed in 42 patients and indicated the formation of abscess. Three cases with the symptoms of septic shock were transferred to ICU and one was cured. All the patients were cured except two who died of massive hemorrhage of upper digestive tract and septic shock. CONCLUSIONS: The airway patency in patients with deep neck infections must be ensured. Drainage may be mandatory in selected cases at presentation or in cases who fail to respond to parenteral antibiotics within the first 24-48 hours. Imaging evaluation plays a significant role in the diagnosis and rational therapeutic management in deep neck infection. Bacterial cultivation can help to make the effective treatment and provide reliable evidence for the etiopathogenisis.

The role of biofilm in chronic laryngitis and in head and neck cancer.

PURPOSE OF REVIEW: The importance of bacterial biofilm in the human body, both when associated in chronic infections and as the default mode of microbial growth in the normal flora, has been understood during the last two decades. The word biofilm has recently entered into clinical vocabulary especially in dentistry, and oral hygienists have begun to talk of oral or dental biofilm instead of oral plaque. Biofilm presence has been demonstrated widely in otorhinolaryngology, related to chronic infections of middle ear, paranasal sinuses and lymphoid tissue of adenoids and tonsils and to implanted materials; however, less literature exists considering the implication of biofilm to laryngeal infections or head and neck cancer. The research until now has been mainly descriptive and the mechanisms that lead to biofilm formation are unclear and thus there are limited options for specific treatment of biofilm infection. The focus of this article is to review the recent literature considering the bacterial biofilm in larynx and in head and neck surgery. RECENT FINDINGS: Bacterial biofilm has now also been implicated in chronic laryngitis. Among head and neck cancer patients, biofilm is the main reason for the short life cycle of indwelling devices such as voice prostheses and tracheal tubes. Recently, bacterial biofilm has been related to dysplasia and malignancies both as an aetiological factor and as a source of complications. SUMMARY: It has been shown that microbial biofilm is implicated in the mechanisms leading to chronic recalcitrant infections, implant contamination and even to dysplasia. Biofilm has an important role in finding new preventive measures and treatment of these diseases.

Laryngeal histoplasmosis: an occupational hazard.

Isolated laryngeal histoplasmosis is a very rare entity. It has variable clinical presentations that might mimic both benign and malignant lesions, and is usually associated with pulmonary and other disseminated forms of histoplasmosis. Herein, we report a case of primary laryngeal histoplasmosis without the involvement of other systems in a 70-year-old Chinese man, who previously worked as a miner. He presented with a history of hoarseness for two months, with no other associated symptoms. Direct laryngoscopy revealed irregularity of the posterior one-third of both vocal folds. Histopathological examination revealed the presence of Histoplasma capsulatumon periodic acidSchiff and Grocott's methenamine silver staining. The lesion resolved after one month of oral itraconazole treatment. However, the patient had to complete six months of antifungal treatment to prevent recurrence.

Helicobacter pylori infection in laryngeal diseases.

Clinical studies have shown that Helicobacter pylori can be found not only in the mucosa of the stomach, but in the pharyngeal and laryngeal regions as well. The aim of this prospective case-control study was to identify H. pylori infection in the biopsy material from the larynx of the patients suffering from benign laryngeal diseases (vocal fold polyps, laryngitis) and laryngeal cancer and to investigate the possible relationships between the laryngeal H. pylori and patients' socio-demographic data and laryngopharyngeal reflux. The results of the biopsy material from 67 adult patients treated for benign laryngeal diseases and laryngeal cancer and 11 individuals of the control group revealed that H. pylori infection could be identified in more than one-third of the patients. In the majority of cases H. pylori was found in the patients with chronic laryngitis (45.5%) and laryngeal cancer (46.2%). The findings of these sub-groups significantly differed from those of the control group (9.1%) (p < 0.05). No significant relationships between H. pylori infection found in the laryngeal region and patients' demographic data, their unhealthy habits and reflux-related symptoms or signs were obtained. It could be concluded that H. pylori can colonize in the larynx of patients with benign laryngeal diseases and laryngeal cancer. To clarify the role of H. pylori as a risk factor for laryngeal diseases further research is needed.

[Cycloferon in complex therapy management of chronic laryngitis].

The clinical course of various forms of chronic laryngitis, including contact granulomas not only persistant and relapsing, but also inclined to oncologic pathology due to hyperplastic changes in the larynx resulting in malignization was described. Inhibition of the leukocyte interferon-synthesizing activity was observed in more than 88.1% of the subjects. Pathogenic viruses were isolated from 48.2% of the patients, EBV and mycoplasma prevailing. High direct correlation between chronic laryngitis and Herpes viruses was shown. The presence of three-component virus associations in the larynx mucosa was likely indicative of the bening process malignancy. The use of the interferon inductor cycloferon in the complex surgical and medicamentous management of chronic laryngitis was shown valid. The rate of the relapses lowered to 1.7 episodes a year.

Methicillin-resistant and methicillin-sensitive Staphylococcus aureus laryngitis.

OBJECTIVES/HYPOTHESIS: Despite the fact that a wide variety of head and neck methicillin-resistant Staphylococcus aureus (MRSA) infections have been described, only four cases of MRSA laryngitis are reported in the literature. Our clinical experience suggests that this diagnosis is more common and can be more subtle that previously reported. The objective of this study was to identify and describe the clinical presentation, diagnosis, treatment, and outcomes of MRSA and methicillin-sensitive S aureus (MSSA) laryngitis, highlighting the in-office workup of these patients. STUDY DESIGN: Retrospective case series. METHODS: All patients with a culture-proven diagnosis of S aureus laryngitis treated within the Emory Voice Center, Department of Otolaryngology-Head and Neck Surgery at Emory University between 2007 and 2011. Demographic, diagnostic, and treatment data were retrospectively collected from the patients' hospital records. RESULTS: Three patients with culture-proven MRSA laryngitis were identified. Three further cases of MSSA were also identified. Patients ranged in age from 34 to 74 years. All three patients with MRSA were diabetics. All six patients in the study were current or past users of cigarettes. The most common presenting symptoms were vocal roughness, vocal fatigue, and decreased vocal endurance. There were no symptoms of airway or swallowing compromise. The duration of symptoms at the time of initial assessment ranged from 3 months to 5 years, and most patients had undergone numerous previous treatments. Common signs on laryngeal examination included thickened vocal fold epithelium, whitish debris or the appearance of leukoplakia, edema, and crusting. Signs and symptoms were similar in MRSA and MSSA patients. The diagnosis was made in all patients via awake in-office culture of the larynx. All patients were treated with a prolonged course of trimethoprim-sulfamethoxazole (2-4 weeks). Although repeated courses of treatment were required, most patients had an excellent response to treatment. CONCLUSIONS: This is the largest, single, case series of patients with MRSA laryngitis. Our study findings suggest that the diagnosis may be more common than previously recognized, and that the presenting signs and symptoms may be subtle and similar to MSSA. Diagnosis can be made via in-office laryngeal culture. Clinicians must have a high index of suspicion for this diagnosis.

Bacterial biofilm associated with chronic laryngitis.

OBJECTIVE: To determine the incidence of biofilm on the vocal fold epithelium of patients with chronic laryngitis. Bacteria can grow in biofilm protected by a glycoprotein mass. Recent studies have shown the importance of biofilm in chronic otolaryngologic infections. Because chronic laryngitis is often recurrent and occasionally purulent, we hypothesized that it is biofilm related. DESIGN: Prospective, controlled, blinded study. Epithelial biopsy specimens from true vocal folds from patients with chronic laryngitis undergoing diagnostic laryngomicroscopy were prepared for confocal scanning laser microscopy (CSLM) and polymerase chain reaction (PCR) microarray: CSLM images were evaluated for bacterial biofilm morphologic characteristics; PCR with microarray-based diagnostic assay was used to identify the bacterial species involved. Patients with vocal fold polyp served as control cases. SETTING: Tertiary care university hospital. PATIENTS: Eighteen consecutive patients were enrolled in the study. Thirteen of them had chronic laryngitis, and 5 had vocal fold polyps. RESULTS: In 9 cases, the CSLM revealed bacterial growth in biofilm form, and most of these specimens (8 out of 9) were from patients with chronic laryngitis. The PCR results were positive in 13 cases, including all 9 biofilm-positive cases. CONCLUSIONS: Direct detection of biofilm in laryngeal biopsy specimens from patients with chronic laryngitis supports the hypothesis that chronic laryngitis may be biofilm related. Biofilm was found in 62% of the cases of chronic laryngitis. To our knowledge, this is the first report of bacterial biofilm associated with chronic laryngitis; however, further investigation is warranted before a clear conclusion can be drawn.

Methicillin-resistant Staphylococcus aureus laryngitis.

Infections due to methicillin-resistant Staphylococcus aureus (MRSA) have become more prevalent, in part because of the emergence and spread of community-acquired MRSA. This trend is particularly concerning because of the significant rates of morbidity and mortality associated with MRSA infections, and because MRSA strains are often resistant to many classes of antibiotics. Reports of infections of the head and neck, including wound infections, cellulitis, sinusitis, otitis media, and otitis externa, are well documented. However, to our knowledge, there have been no reports of bacterial laryngitis due to MRSA. We report the first published case of bacterial laryngitis caused by MRSA.