Laryngeal Tuberculosis : A Rare Case Report. J Pharm Biomed Sci 2014; 04(06):

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1 JOURNAL OF PHARMACEUTICAL AND BIOMEDICAL SCIENCES Yadlapalli AK, Veeranjaneyulu P, Krishna SB,Haseena Md, Mahajan A. Laryngeal Tuberculosis : A Rare Case Report. J Pharm Biomed Sci 2014; 04(06): The online version of this article, along with updated information and services, is located on the World Wide Web at: Journal of Pharmaceutical and Biomedical Sciences (J Pharm Biomed Sci.), Member journal. Committee of Publication ethics (COPE) and Journal donation project (JDP).

2 Case Report Laryngeal Tuberculosis: A Rare Case Report Ajay K Yadlapalli 1,*, Veeranjaneyulu P 2, Krishna Santosh B 3,Haseena Md 4, Asif Mahajan 5 Affiliation:- 1 Ajay K Yadlapalli, Assistant Professor, Department of ENT, 2 Veeranjaneyulu P, Professor & Head, Department of ENT, 3 Krishna Santosh B, Senior Resident, Department of ENT, 4 Haseena Md, Junior Resident, Department of ENT, 5 Asif Mahajan, Junior Resident, Department of ENT, GSL Medical College, Rajanagaram, Rajahmundry, Andhra Pradesh ,India The name of the department(s) and institution(s) to which the work should be attributed: GSL Medical College, Rajanagaram, Rajahmundry, Andhra Pradesh , India Author s contributions All of the authors drafted, revised the article and approved the final version. *To whom it corresponds: Dr. Ajay Kumar Yadlapalli, Assistant Professor, Department of ENT, GSL Medical College, Rajanagaram, Rajahmundry Andhra Pradesh , India address : dryadlapalliajay@yahoo.co.in Contact no: Abstract: Laryngeal tuberculosis is a rare form of extrapulmonary tuberculosis (TB) caused by Mycobacterium tuberculosis. It has been estimated that laryngeal TB accounts for less than 1% of all TB cases and may present as a primary infection or secondary to pulmonary tuberculosis. Due to uncommon clinical presentations and lack of clinical suspicion, laryngeal TB is frequently confused with other laryngeal diseases such as chronic laryngitis and laryngeal carcinoma. Here we present a case of a 32yr old male, daily labourer with laryngeal tuberculosis secondary to pulmonary tuberculosis. The approach to diagnosis and the treatment was presented followed by discussion on clinico-pathological features of laryngeal tuberculosis and the importance of its early diagnosis. Keywords: Antituberculous agents; carcinoma; Dysphonia; laryngeal tuberculosis; mycobacterium tuberculosis; stridor; vocal cords. Article citation: Yadlapalli AK, Veeranjaneyulu P, Krishna SB,Haseena Md, Mahajan A, Laryngeal Tuberculosis: A Rare Case Report. J Pharm Biomed Sci 2014; 04(06): INTRODUCTION Mycobacterium tuberculosis, a Gram positive, Acid fast bacillus is the causative organism for most forms of tuberculosis. It was first described by Robert Koch in Since the World Health Organization declared tuberculosis as a global emergency in 1993, the incidence of laryngeal TB has been on the rise worldwide. This has been largely attributed to the AIDS epidemic 2, increased poverty and drug addiction, lack of tuberculosis chemotherapy, development of resistant strains, immigration from TB-affected areas, and decreased immunization coverage. Laryngeal TB has gained interest not only because of its rising incidence but also because of its changing clinical manifestations 3. In preantibiotic era, laryngeal involvement was seen in more than one third of cases dying due to pulmonary tuberculosis. Incidence of laryngeal tuberculosis is less than 1% of all tuberculosis cases 4. At present, more than half of laryngeal tuberculosis cases are due to hematogenous seeding 3. Laryngeal TB is highly contagious and misdiagnosis can pose a serious risk to the public health. Health care staff and other patients are at a particularly high risk of exposure

3 Varied clinical presentation may occur in laryngeal tuberculosis ranging from dysphonia to pain and stridor 6. Antituberculosis chemotherapy is the mainstay of treatment for patients with tuberculosis of head and neck. CASE REPORT A 32 yr old male patient who is a daily labourer presented with a complaint of hoarseness of voice for 2 months which is gradual in onset and slowly progressive. There was history of difficulty swallowing for 1 month which is more for solids. History of productive cough and low grade fever were present. No history of breathlessness or stridor, aspiration, swelling in throat, Ulcer in mouth, Trismus, Burning sensation, Foul breath, foreign body sensation in throat, Swelling over face, Nasal regurgitation. No past history suggestive of usage of any antitubercular regime. Indirect laryngoscopic examination revealed the findings as described: Epiglottis Erect with pale mucosa and granulomatous ulcers. Thin atrophic pale and oedematous mucosa with intermittent hyperaemic areas over the larynx. Arytenoids and Aryepiglottic folds Oedematous arytenoids with granulomatous lesions over arytenoids and Aryepiglottic folds. Movements of arytenoids normal. Vocal cords are mobile. Both pyriform fossa and area behind the arytenoids-normal. The clinical findings were confirmed with videolaryngoscopic examination (fig. 1, 2 and 3). Figure 1. Videolaryngoscopic picture showing pale and erect epiglottis with granulations over it. Figure 2. Videolaryngoscopic picture showing pale granulations over the arytenoids and aryepiglottic folds. Figure 3. Videolaryngoscopic picture of pyriform fossae and area behind the arytenoid regions showing to be normal. Routine blood investigations were performed and were found to be normal. CHEST X-RAY (PA view) Diffuse Milliary Lesions as shown in fig. 4. Microbiological sputum examination showed tubercle bacilli. CT SCAN Bilateral miliary mottling, ground glass opacities, tree in bud appearances and cavitary lesions with an internal hypodense area in left lungs with associated segmental consolidation represents Tuberculosis both lungs fig. 5. Figure 4. X- ray chest P/A view showing diffuse miliary lesions. 498

4 A diagnosis of laryngeal tuberculosis secondary to pulmonary tuberculosis was made. The patient was categorized to category I of DOTS regime and was prescribed Isoniazid 600 mg, Rifampicin 450 mg, ethambutol 1200 mg, pyrizinamide 1500mg weekly thrice for 2 months and then Isoniazide and rifampicin for 4 months and the lesions subsided with chemotherapy. Patient has symptomatically and clinically improved with treatment. DISCUSSION Tuberculosis, caused by Mycobacterium tuberculosis, an acid fast bacillus, can almost produce disease everywhere in the body. Figure 5. CT scan chest showing bilateral miliary mottlings and ground glass appearance suggestive of tuberculosis. Tubercular laryngitis is the most common otorhinolaryngological manifestation of tuberculosis and is more commonly secondary to pulmonary tuberculosis, especially in relapse cases and in defaulters of antituberculous regime 7. Laryngeal tuberculosis is the most common granulomatous disease of the larynx. In the recent past, it has been on an increase due to higher incidence of human immunodeficiency virus infection. Low standards of living, poor sanitation and hygiene, consumption of unboiled milk contribute towards the high incidence of tuberculosis in our country 8. Both pulmonary and extrapulmonary forms of tuberculosis are more common in the middle age and in the elderly, with the highest incidence between ages of years and year groups. Pulmonary tuberculosis is more commonly seen in males while the extrapulmonary forms have an equal sex distribution 9. A clinico pathological study of 200 laryngeal biopsies of patients presenting with hoarseness of voice reported 65% inflammatory lesions and 32% neoplastic lesions. The most common inflammatory lesion was tuberculosis (40%) 10. The clinical features of laryngeal TB vary from hoarseness of voice, pain and dysphagia to stridor, in rare instances. Constitutional symptoms like fever, weight loss and loss of appetite also often form a part of symptom complex. Primary tuberculosis is extremely rare though cases of primary laryngeal tuberculosis were reported 11,12. Secondary tuberculosis is most often secondary to pulmonary tuberculosis and pathways of spread include: (a) From the surface of mucous membrane by sputum, or (b) From the sub mucous area where the tubercle bacilli arrive from the lungs by the blood and lymph streams. Posterior half of the larynx is the most frequently attacked where the sputum is apt to collect and linger and that the surface of the larynx is more apt to be irritated and perhaps abraded, by the over use of voice and coughing, when compared to trachea and bronchi. The ciliary activity also propels the bacteria towards the posterior commissure preventing the stagnation and penetration of bacteria into the mucosa of trachea and bronchi. The differential diagnosis of laryngeal tuberculosis includes various types of chronic non- specific laryngitis and scleroma, lupus vulgaris, syphilis or carcinoma. DIAGNOSIS The diagnosis of laryngeal tuberculosis is not only important on account of local condition, but also because laryngoscopy can sometimes settle the diagnosis of some uncertain pulmonary condition and is also valuable to assess the prognosis of tuberculosis. In a large proportion of cases the appearance of larynx is almost sufficient to enable a diagnosis to be made from inspection only and pale and is frequently associated with ulceration. 499

5 Arytenoid eminences appear smooth, pear shaped which are usually pale and flabby (pseudoedema). Aryepiglottic folds may show asymmetrical infiltration with ulcerations most frequently inner laryngeal surface and at the arytenoid end of the fold. Vocal folds show mouse-eaten appearance with a series of erosions along the free margin giving a serrated appearance. Vegetations may spring from the ulcers and sometimes the glottic space is encroached upon. Ventricular band lesions may vary from superficial abrasion to in tumescence overhanging the folds to ulcerations. Epiglottis is the least frequently invaded and it may become velvety, congested and deep red sometimes. A localised and solitary tuberculoma is a rare form of infection in the larynx. Stenosis of the larynx can also occur which may be mechanical due to the lesions of the mucosa and submucosa or due to the affections of the cartilages and joints, Vocal cord palsy is a described entity. Sputum microbiological examination for tubercle bacilli invariably clinches the diagnosis. Mantoux test may be of great value sometimes. The importance of having a chest X-ray done in the diagnosis of pulmonary tuberculosis is universally recognized. A biopsy tends to interfere with local healing and is seldom called for. TREATMENT The treatment may be directed to complete arrest of pulmonary/laryngeal tuberculosis and to relieve the laryngeal symptoms. Antituberculous chemotherapy is the mainstay of treatment for tuberculosis. The drugs include isoniazid, rifampicin, pyrizinamide, ethambutol, streptomycin. Local treatment of the lesions in the larynx rarely includes local cleansing alkaline sprays, local antiseptic insufflations, curetting, galvano-cautery etc. The general care and hygiene of the patient is particularly of great importance. Complete rest to the larynx helps in early healing of the lesions. Tracheostomy may be is required in cases of increasing or established stenosis with granulations or in case of cicatricial contraction in healed cases. CONCLUSION Laryngeal involvement in a case of pulmonary tuberculosis is not uncommon and a otorhinolaryngologist needs to be vigilant to establish a diagnosis of laryngeal tuberculosis, invariably avoiding an unnecessary laryngeal biopsies. In a tubercular endemic area, every case of hoarseness of voice should be evaluated to rule out tuberculosis as its cause. Antituberculous therapy and local care usually helps in curing the disease and relieving the symptoms. REFERENCES 1.Ismael Kassim, Ray CG (editors) (2004). Sherris Medical Microbiology (4 th ed.). McGraw Hill. ISBN Scott-Brown s Otolaryngology; 6 th edition; volume 5; pg no 5/5/14-5/5/15. 3.Changing trends in clinical manifestations of laryngeal tuberculosis Jung-eun et al; The Laryngoscope; Volume 110; Issue 11; pg no ; November Case report: Acute tuberculous laryngitis presenting as acute epiglottitis El Beltagi Ah etal Indian journal Radial Imaging 2011, October 21 st ; Volume 4; pg no Tuberculosis, S.K.Sharma, A. Mohan 1 st edition : 2001 page no : Kulkarni Neeta et al., Epidemiological and clinical study of ENT tuberculosis reported that the commonest presenting feature in all the patients was hoarseness. J Laryngol Otol. 2001; 115(7): Rajat Bhatia et al., Tubercular laryngitis: case series, Indian J. Otolaryngol. Head Neck Surg.(October December 2008) 60: Khan KA, Khan NA, Maqbood M, Otorhinolaryngological Manifestation of Tuberculosis, JK science, July-september 2002;4(3): Galletti F et al., Laryngeal tuberculosis: considerations on the most recent clinical and epidemiological data and presentation of a case report, Acta Otorhinolaryngol Ital Jun;20(3): Varshney S, Hasan SA. Clinico Histopathological study of Laryngeal Biopsies. SDMH Journal.1995;19: Anil Mehndiratta et al., Primary tuberculosis of larynx, Ind J Tub 1997;44: Keyvan Kiakojuri, Mohammad Reza Hasanjani Roushan, Laryngeal tuberculosis without pulmonary involvement : Caspian J Intern Med. 2012;3(1): Source of support: None Competing interest / Conflict of interest 500

6 The author(s) have no competing interests for financial support, publication of this research, patents and royalties through this collaborative research. All authors were equally involved in discussed research work. There is no financial conflict with the subject matter discussed in the manuscript. Copyright 2014 Yadlapalli AK,Veeranjaneyulu P,Krishna SB,Mahajan A, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 501