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.

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.

Primary Laryngeal Tuberculosis: A Series of 15 Cases.

Tuberculosis usually involves the lungs, but can also involve various other organs. Extra pulmonary tuberculosis is very rarely confined to the larynx in the absence of an associated pulmonary lesion. In this retrospective study, clinicopathological characteristics of patients with final diagnosis of laryngeal tuberculosis (LTB) were reviewed. The diagnosis of LTB was based on: (1) the existence of chronic granulomatous inflammation with caseous necrosis in the histopathology of laryngeal lesions or (2) the presence of laryngeal lesions with atypical histopathology (chronic granulomatous inflammation) which had a complete response to anti-tuberculosis therapy. Fifteen cases with a diagnosis of LTB were collected. The patients' age ranged between 24 and 75 years with a mean of 49 years. On laryngoscopy, 66.6% of cases (10/15) had an ulceroproliferative lesion while the remaining 33.3% of cases (5/15) had an exophytic growth. The pathology of laryngeal lesions revealed chronic granulomatous inflammation with caseous necrosis in nine cases and chronic granulomatous inflammation without necrosis in six cases. Nine out of 15 cases (60%) showed presence of acid-fast bacilli on Ziehl-Neelsen stain. Any evidence of pulmonary tuberculosis was ruled out by chest X-ray findings. The response to anti-tuberculosis therapy was desirable in all patients. Since the introduction of anti-tuberculous therapy, the incidence of LTB has declined. However, with the incidence of TB increasing, the overall incidence of laryngeal involvement may be on the rise. This study highlights the importance to consider the rare possibility of LTB in the presence of non-specific clinical and laryngoscopic signs and to confirm this by histological examination.

[Laryngeal Tuberculosis Diagnosed in a Pathological Laboratory in Senegal (2011-2015)]. / La tuberculose laryngée diagnostiquée dans un laboratoire d'anatomie pathologique du Sénégal (2011­2015).

Laryngeal tuberculosis (LT) is a rare disease. The therapy for LT is easy but the diagnosis remains a challenge for the pathologist and the laryngologist because of the absence of specific signs. The objective was to analyze the epidemiological and pathological profiles of LT cases in Dakar (Senegal) with a view to better understand this pathology. This study was a retrospective and descriptive of LT cases diagnosed in pathology laboratories in Senegal during five years (2011-2015). The LT was found in 9 cases. The mean age at diagnosis was 41.9 years (18/58) without sex predominance (sex-ratio = 0.8). Tobacco intoxication (3/9), tuberculosis contagion (1/9), HIV immunodepression (2/9), and diabetes (1/9) were the various risk factors found. Dysphonia was a constant symptom (9/9) associated with dysphagia (2/9) and cervical adenopathy (1/9). The macroscopic presentation was tumoral-like (7/9) and erythematosus and fibrinoid (2/9). The LT was of glottic seat in all the cases (9/9) with participation on top-glottic in two of the cases. The biopsy was performed in all patients. It reported tuberculous granuloma in four cases (4/9), tuberculoid granuloma in one case (1/9), and chronic lymphocytic laryngitis in four cases (4/9). CT-scan of the lungs was pathological in five patients (5/9). Evolution was favorable in all cases under "conventional tuberculosis treatment" over a period of six months. The diagnosis of LT requires a high collaboration between the laryngologist and the pathologist.

La tuberculose laryngée (TL) est une affection rare de diagnostic difficile à cause de l'absence de signes spécifiques. L'objectif de cette étude rétrospective était d'analyser les profils épidémiocliniques et anatomopathologiques des cas de TL diagnostiqués dans un laboratoire d'anatomie pathologique du Sénégal. Il s'agissait d'une étude rétrospective et descriptive des cas de TL sur cinq ans (2011­2015). La TL a été retrouvée dans neuf cas. L'âge moyen au diagnostic était de 41,9 ans (18/58) sans prédominance de sexe (sex-ratio = 0,8). Le tabagisme (3/9), le contage tuberculeux (1/9), l'immunodépression au VIH (2/9) et le diabète (1/9) étaient les différents facteurs de risque retrouvés. La dysphonie était un symptôme constant (9/9), accompagnée d'une dysphagie (2/9) et d'adénopathies cervicales (1/9). L'aspect macroscopique était pseudotumoral (7/9) et érythématoblanchâtre (2/9). La TL était de siège glottique dans tous les cas (9/9), avec participation sus-glottique dans deux cas. La biopsie systématique notait un granulome tuberculeux dans quatre cas (4/9), un granulome tuberculoïde dans un cas (1/9) et une laryngite chronique lymphocytaire dans quatre cas. L'évolution était favorable dans tous les cas sous traitement médical. Le diagnostic de la TL nécessite une collaboration parfaite et étroite entre l'otorhinolaryngologue et le pathologiste.

[The clinical and pathological features of laryngeal tuberculosis].

OBJECTIVE: To investigate the clinical and pathological features of laryngeal tuberculosis. METHODS: The clinical data of 75 patients with laryngeal tuberculosis from Jan 2010 to Jan 2013 in our hospital were studied retrospectively. There were 50 male and 25 female patients, aged from 18 to 91 years, with a median age of 44 years. The course of disease was 1 to 19 months. RESULTS: The prominent presenting symptoms were hoarseness (n=59, 79%), and sore throat (n=48, 64%). Systemic symptoms included fatigue with weight loss (n=26, 35%) and fever (n=17, 23%). Primary laryngeal tuberculosis was found in 23 patients (31%) while secondary laryngeal tuberculosis together with pulmonary tuberculosis in 52 patients (69%). There were 2 or less lesions in the larynx in 44 patients, while multiple lesions were found in 31 patients. Vocal cords were the most common sites affected(n=51, 68%), followed by epiglottis(n=41, 55%). Proliferation was the main type of lesions (n=34, 45%). After pathologic diagnosis, all patients received systemic anti-tuberculosis therapy, and the prognosis was good. CONCLUSIONS: Severe local symptoms of the larynx with slightly general symptoms are the clinical characteristics of laryngeal tuberculosis for the time being. Primary laryngeal tuberculosis often present with fewer (2 or less) lesions. Different morphology of laryngeal lesions can exist at the same time. The diagnosis of laryngeal tuberculosis depends on pathological biopsy. The treatment should be systemic anti-tuberculosis therapy.

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.

Laryngeal tuberculosis in the United States of America: a forgotten disease.

Laryngeal tuberculosis (TB) was a common manifestation of TB in the early twentieth century, but now represents only 1% of all cases. Most modern case series of laryngeal TB originate outside the USA. We report a case of laryngeal TB from our institution and review other US cases published between 1970 and 2012. One hundred twenty-seven cases were identified. The mean patient age was 49 y and 28% were female. The mean duration of symptoms was 19 weeks. Dysphonia and weight loss were the most common manifestations, seen in 96% and 47% of cases, respectively. These symptoms were usually attributed to malignancy initially. Most cases involved the vocal cords. Eighty-six percent of cases had underlying pulmonary involvement. Mortality was 3%. In the USA, laryngeal TB is rarely suspected and often confused with malignancy. This infection should be considered in patients with unexplained dysphonia and weight loss.

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]. / Gruzlica narzadów glowy i szyi - wciaz aktualny problem w praktyce laryngologicznej.

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.

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

OBJECTIVES: To evaluate dysphonia in patients treated for laryngeal tuberculosis, and to assess the effect of speech therapy on patients' vocal quality. MATERIALS AND METHODS: Seven of 23 patients with a confirmed diagnosis of laryngeal tuberculosis, treated at the Evandro Chagas Institute of Clinical Research, Oswaldo Cruz Foundation, underwent speech therapy for six months. These seven patients were evaluated by videolaryngoscopy and vocal acoustic analysis, before, during and after a course of speech therapy. RESULTS: The 23 patients with laryngeal tuberculosis comprised five women and 18 men, with ages ranging from 25 to 83 years (mean 41.3 years). Dysphonia was present in 91.3 per cent of these laryngeal tuberculosis patients, being present as the first symptom in 82.6 per cent. In laryngeal tuberculosis patients with dysphonia, laryngeal tuberculosis treatment resulted in dysphonia resolution in only 15.8 per cent. After speech therapy, dysphonia patients had better vocal quality, as demonstrated by statistical analysis of jitter, shimmer, fundamental frequency variability, maximum phonation time, and the ratio between maximum phonation time for voiceless and voiced fricative sounds. CONCLUSIONS: Following treatment of laryngeal tuberculosis, the incidence of dysphonia was very high. Speech therapy improved patients' vocal quality.

[Laryngeal tuberculosis in the patients of otholaryngology department--case reports]. / Gruzlica krtani u pacjentów leczonych w klinice otolaryngologii --opis dwóch przypadków.

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]. / La tuberculose laryngée.

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.

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

OBJECTIVE: This study was undertaken to evaluate the changing trends in the clinical features of laryngeal tuberculosis, with the goal of reducing misdiagnosis and incorrect treatment. METHODS: A retrospective clinical analysis compared the clinical patterns in five cases with pathologically confirmed laryngeal tuberculosis seen before 1990 with those of 14 cases of laryngeal tuberculosis seen after 1998. RESULTS: The five patients seen before 1990 ranged in age from 19 to 41 years of age, with a mean of 32 years. The most frequent chief complaint was odynophagia accompanying system symptoms and pulmonary tuberculosis. The posterior part of the larynx was commonly involved and the lesions tended to be ulcerative and multiple. The 14 patients seen after 1998 were aged from 17 to 71 years with a mean age of 49.9 years. The most frequent chief complaint was hoarseness (71.4%). The most common lesion site was in the true vocal cords (57.2%). Most of patients with normal lung status had single, nonspecific, polypoid lesions. Stroboscopy revealed four different appearances. CONCLUSIONS: Laryngeal tuberculosis may occur even without pulmonary tuberculosis, and the characteristics of the lesions appear to be more nonspecific. It is important to consider tuberculosis in the differential diagnosis of laryngeal disease.

Tuberculosis en faringe y laringe: presentación de un caso / Tuberculosis in pharyn and larynx: case presentation

La tuberculosis, infección bacteriana crónica causada por el Mycobacterium tuberculosis, declarada por la OMS (1993) como emergencia epidemiológica, afecta mayoritariamente los pulmones, pero puede afectar a otros órganos (Tb. Extrapulmonar), entre estos a la laringe, constituyendo la más frecuente enfermedad granulomatosa a este nivel y considerada una localización rara (menos de 1 por ciento); por ello nuestro interés de presentar un caso de Tuberculosis en faringe y laringe, con el objetivo de resaltar lo infrecuente de esta ubicación, los problemas diagnósticos y la importancia del estudio histopatológico. Paciente de 49 años, femenina, consulta por Odinofagia, se encuentra tumor en faringe, se realiza biopsia y el diagnóstico fue: Sarcoidosis faríngea, no regresó a consulta. Meses después asiste por disfonía, se visualiza tumor en laringe, se realiza biopsia y el informe fue carcinoma de laringe; se negó a tratarse. Cuatro meses más tarde, ingresa en el Hospital Neumológico, por disnea, tos y disfonía, el diagnóstico fue tuberculosis pulmonar (Cod 9). Interconsultan con Otorrinolaringología el tratamiento del cáncer laríngeo. Decidimos nueva revisión de las biopsias, y se arribó a las conclusiones siguientes: Tuberculosis miliar acorde con su cuadro clínico y hallazgos anatomo-patológicos: (faringitis y laringitis granulomatosa); no se corresponde ni con Sarcoidosis ni con carcinoma Epidermoide previamente reportado(AU)

Tuberculosis is a chronic bacterial disease caused by Mycobacterium tuberculosis, declared by WHO in 1993 as epidemilogical emergency warning, affecting mostly the lungs but it can also damage others organs (Extra lung Tb) such as the larynxbeing the most frequent granulomatous disease as this level and it considered as a rare location (less than 1 percent), that is why we are so interested in presenting this case report of larynx and pharynx disease, with the aspiration to highlight how few are the cases with this location, the diagnostic problems and the importance of a histopathologic analysis. 49 years, female patient came to the consultation because of odenaphagia. A pharyngeal tumour was diagnosed and a biopsy was undergone which revealed pharyngeal Sarcoidosis. The patient did not come back to the consultation until several months later due to diphonia. A tumour in the larynx is visualized and a biopsy is undergone again which shoved to the positive for laryngeal cancer; the patient refuses to be treated. Four months later the patient is admitted to the hospital in the Neumology hospital with a clinical picture of dyspnea, cough and dysphonic. The diagnosis was pulmonary tuberculosis. A consult is carried out which the otorrhynolaringologyst and a new consideration came out, concluding by pathological anatomy as tuberculosis. Taking into account the clinical picture and the anatomopathological firdings that do not corresponded inther with Sarcoidosis or Epidermoide carcinoma previously reported. The characteristics of this case led to this presentation(AU)

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.