The aim of this study was to determine the incidence of laryngeal tuberculosis (LT) among patients with active pulmonary tuberculosis. A total of 319 patients under treatment for pulmonary tuberculosis were subjected to laryngoscopy. Five patients (1.5%) with LT were identified. Odynophagia was the most common complaint, followed by alteration in voice. The larynx returned to its normal appearance in 3-8months (average 18weeks) by antituberculous medication. Physicians dealing with pulmonary tuberculosis should keep in mind that symptoms of laryngeal involvement may be minor, and laryngoscopy should always be performed when laryngeal involvement is suspected in order to isolate highly infectious patients. Response to antituberculous medication is usually late in LT and diagnosis by "wait and watch” policy will cause a significant delay in the diagnosis of a possible larynx carcinom

Kulekci, Mehmet

Oysu, Cagatay

Sahin-Yilmaz, Asli

Topak, Murat

Yelken, Kursat

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Eur Arch Otorhinolaryngol (2008) 265:327–330  DOI 10.1007/s00405-007-0459-xLARYNGOLOGYLaryngeal involvement in patients with active pulmonary tuberculosisMurat Topak · Cagatay Oysu · Kursat Yelken · Asli Sahin-Yilmaz · Mehmet Kulekci Received: 14 March 2006 / Accepted: 30 August 2007 / Published online: 6 October 2007©  Springer-Verlag 2007Abstract The aim of this study was to determine theincidence of laryngeal tuberculosis (LT) among patientswith active pulmonary tuberculosis. A total of 319 patientsunder treatment for pulmonary tuberculosis were sub-jected to laryngoscopy. Five patients (1.5%) with LT wereidentiWed. Odynophagia was the most common complaint,followed by alteration in voice. The larynx returned to itsnormal appearance in 3–8 months (average 18 weeks) byantituberculous medication. Physicians dealing with pul-monary tuberculosis should keep in mind that symptomsof laryngeal involvement may be minor, and laryngoscopyshould always be performed when laryngeal involvementis suspected in order to isolate highly infectious patients.Response to antituberculous medication is usually latein LT and diagnosis by “wait and watch” policy will causea signiWcant delay in the diagnosis of a possible larynxcarcinoma.Keywords Laryngeal tuberculosis · Pulmonary tuberculosisIntroductionPulmonary tuberculosis remains a signiWcant health prob-lem in developing countries. Since 1990, tuberculosis hasshown a rise in incidence worldwide and was declared aglobal emergency by the World Health Organization(WHO) in 1993 [1]. WHO reported 373,497 new tuberculo-sis cases in Europe in 2002, compared to 231,608 newcases in 1991[1]. Pulmonary tuberculosis is an endemicdisease in Turkey. The incidence of pulmonary tuberculosiswas 28/100,000 in 1999 [2].Laryngeal tuberculosis (LT) is one of the most commonextra-pulmonary manifestations of this disease [3, 4]. Theincidence of LT has signiWcantly declined to the rate of 1.8,1.5, and <1% in the last Wfty years [3, 5–7]. The aim of thisstudy is to determine the current incidence of laryngealinvolvement in a relatively large group of patients withactive pulmonary tuberculosis.Materials and methodsThis study was conducted from January through Septemberof the year 2003. 319 unselected patients with active pul-monary tuberculosis admitted in two major institutions ofchest diseases in Istanbul were enrolled in the study. Activepulmonary tuberculosis was deWned as positive sputumsmear microscopy and/or culture [8]. In smears, detectionof acid fast bacilli with the carbolfuchsin method (Ziehl–Neelsen stain) was considered positive. In cultures, myco-bacterial growth in specimens inoculated onto egg-basedculture media (Lowenstein–Jensen) was considered posi-tive. The sputum specimens were subject to drug sensitivitytesting on Lowenstein-Jensen medium if: (a) the patient hada previous history of tuberculosis infection, (b) if there wasM. Topak · K. Yelken · A. Sahin-Yilmaz · M. KulekciDepartment of Otolaryngology, Taksim Education and Research Hospital, Istanbul, TurkeyC. OysuDepartment of Otolaryngology, Haydarpasa Numune Education and Research Hospital, Istanbul, TurkeyC. Oysu (&)Haci Hakki Bey sk. Basel Ap. no.: 4/7, Erenkoy, 34728 Istanbul, Turkeye-mail: coysu@doruk.net.tr123328 Eur Arch Otorhinolaryngol (2008) 265:327–330a clinical suspicion of multidrug resistant tuberculosis. Ifthe smear or sputum culture was negative, the diagnosiswas conWrmed by positive tuberculin test results and/orradiological evidence of tuberculosis [8]. All the subjectshad been receiving antituberculous medication includingisoniazid, rifampicin and pyrazinamide with a durationvarying from 2 weeks to 3 months at the time of inclusion.All patients were subject to bedside indirect laryngos-copy by mirror or by endoscopic examination. The diagno-sis of LT was established by biopsy and histologicalexamination or rapid regression of the laryngeal lesions byantituberculous medication. Following the diagnosis of LT,patients were subject to query in detail in order to discoverany neglected symptoms of LT. Taksim Education andResearch Hospital ethical committee approved the studyand we obtained informed consent from all subjects.ResultsA total of 319 patients with pulmonary tuberculosis wereexamined. All of the patients were from lower socio-economic classes. A total of 212 were living in rural areas.Totally, 273 were men, and 46 were women (male:female =6:1). The age range was 14–80 years, with an average of31.8 in men and 33.2 in women. Three hundred patients(94%) had a history of tobacco use and Wve (1.5%) werealcoholic. Totally, 249 of the patients were recently diag-nosed with tuberculosis, and 70 (22%) patients were admit-ted due to reactivation of the disease.Laryngeal involvement was identiWed in 5 out of 319(1.5%). All the patients with laryngeal involvement weremale and age-range was 25–46 years (mean 37.2). Allpatients were heavy smokers (mean: 22 packs/year). Onlyone patient had a history of heavy alcohol consumption. Allpatients had been under medical treatment for tuberculosisfor 2 weeks to 3 months (mean: 7 weeks) prior to inclusion.Commonly observed constitutional symptoms includedweight loss in all Wve patients and fatigue in four of thepatients with laryngeal involvement. None of the patientsreported fever. In four of the cases, a biopsy was performedand histological examination revealed chronic granuloma-tous infection. In the remaining one case with diVuse laryn-geal inXammation and edema, diagnosis was made by rapidrecovery of laryngeal lesions with medical therapy.Laryngoscopic examination revealed lesions in thesupraglottic area in all patients and involvement of the truevocal cords in case 2 (Table 1). Cases 1, 3 and 4 had aninvolvement of the epiglottis with an ulcerovegetativeappearance (Fig. 1). The appearance of the lesion in case 2was irregularity and edema. Case 5 had a granular lesion. Inall cases except case 3, the larynx returned to its near nor-mal appearance in 3–8 months (average 18 weeks); in caseTable 1 The summary of clinical Wndings of Wve cases with laryngealtuberculosisVC vocal cord, FVC false vocal cord, TVC true vocal corda The time interval between the date of initial pulmonary tuberculosisdiagnosis and the date of laryngeal involvement diagnosisCase Age/sex Durationa Site of lesion1 45/male 2 weeks Ulcerovegetative lesion of epiglottis2 28/male 8 weeks Irregularity of right TVC and edema of the right FVC3 25/male 3 weeks Destructive ulcerovegetative lesion4 42/male 7 years Ulcerovegetative lesion of the epiglottis5 46/male 15 years Granular lesion of the right FVCFig. 1 This patient is a 48-year-old male with complaints of weightloss, fatigue, odynophagia, hemoptysis and foreign body sensation inthe throat for the last 15 days. Diagnosis of laryngeal tuberculosis wasconWrmed by laryngeal biopsy. Endoscopic view at 2nd week of anti-tuberculous medical therapy was as shown (a). Endoscopic view at6 months of antituberculous medical therapy was as shown (b)123Eur Arch Otorhinolaryngol (2008) 265:327–330 3293, the tuberculous laryngitis healed in 8 months withsequel, but resulted in partial loss and scarring of theepiglottis.The query of symptoms revealed that odynophagia wasreported by all the patients. Mild to moderate changes invoice existed in three of the cases. Hemoptysis and foreignbody sensation in the throat was reported by one patienteach.DiscussionAccording to recent reports from the WHO, the situation oftuberculosis in the countries of central and eastern Europeis alarming [1]. As the incidence of tuberculosis increases,LT is encountered by an ever-increasing number of otolar-yngologists and chest physicians [4]. The number of LTcases reported from industrialized countries remained lowin the late twentieth century. Several studies reported anincidence of laryngeal involvement varying from <1% to1.8% [5–7]. In developing countries such as Pakistan andTanzania, the incidence of laryngeal involvement wasreported to be higher and equal to 37% and 27%, respec-tively [4, 9]. In autopsies of patients who died of pulmonarytuberculosis, Fetterolf [10] showed laryngeal lesions in upto 83% in 1914. This Wnding suggests that it is diYcult toestimate the exact current prevalence of LT among patientswith pulmonary tuberculosis. It is likely that LT is morecommon than is clinically recognized. Our study revealedan incidence of asymptomatic LT among hospitalizedpatients with pulmonary tuberculosis of 1.5%. However,the patients included in this study had already received anti-tuberculous medication, and it is possible that the incidenceof LT would have been much higher if the patients wereexamined prior to therapy.Our study supports Wndings that the male gender pre-dominates among tuberculosis patients, a Wnding that hasbeen reported both in pulmonary and extrapulmonarytuberculosis [11–13]. Lower socio-economic and culturalconditions and higher level of social activity have been pos-tulated as factors that cause male predominance in tubercu-losis [14]. Besides these factors, one cannot exclude thepossibility of higher exposure to cigarette smoke in themale population of Turkey [15].The most commonly reported symptom of LT is hoarse-ness, followed by sore throat and odynophagia, whereasmost of our patients complained of odynophagia followedby alteration in voice [16]. Because our study was designedto scan unselected, asymptomatic cases, instead of hoarse-ness, minor symptoms such as odynophagia and mild tomoderate changes in voice were predominant complaints.This situation may also be attributed to the fact that thesupraglottic larynx was the predominant site of involve-ment in our patients. Furthermore, the fact that all of ourcases were under antituberculous medication might haveaVected the symptoms. Since all cases were heavy smokers,these symptoms may have been ignored by the patients andattributed to chronic laryngitis by the physicians. BecauseLT is the most infectious form of the disease, even minorsymptoms in patients at risk should be taken into accountby the physicians [17, 18].Moreover, laryngeal carcinoma that may easily mimicLT or laryngeal carcinoma may concurrently exist withlaryngeal or pulmonary tuberculosis [19]. Biopsy or rapidresponse to antituberculous treatment are two methods inthe diagnosis of LT [20, 21]. Although biopsy is crucialfor deWnitive diagnosis, the hazard of close proximity tothe “highly infectious” patient during indirect laryngos-copy and biopsy may sometimes lead the physician to fol-low a “wait and watch” policy [21]. Contrary to ourexperience, there are reports that most lesions resolveover a 2-month period [6, 19, 20]. To our experience, arapid response to the medication is possible only in aminority of the cases. In our study, only one of Wve casesshowed a rapid response. It took our patients severalmonths to get back to a near normal laryngeal appearance.For this reason, a “wait and watch” strategy will not beappropriate in patients with LT as it may cause a delay indiagnosis of laryngeal carcinoma.Conclusion• The incidence of unrecognized LT among patients withactive pulmonary tuberculosis is 1.5%.• Physicians dealing with pulmonary tuberculosis shouldkeep in mind that symptoms of laryngeal involvementmay be minor, such as odynophagia and minor alterationin voice. In these cases, an otolaryngological examina-tion should be performed. Early diagnosis of LT mayprotect the health care professionals from exposure to“highly infectious” patients.• Laryngeal carcinoma may mimic LT. Response to antitu-berculous medication is usually late. Diagnosis by “waitand watch” policy will cause a signiWcant delay in thediagnosis of larynx carcinoma. Therefore, early biopsyshould always be considered.References1. World Health Organization (2001). Global tuberculosis control,WHO report 2001. Geneva, Switzerland, WHO/CDS/TB/2001.2872. Mert A (2003) Eriokinlerde yüzeysel tüberküloz lenfadenopati.Proceedings of tuberculosis and its diagnosis in 21st century sym-posium, Samsun, Turkey, pp 93–105123330 Eur Arch Otorhinolaryngol (2008) 265:327–3303. Munck K, Mandpe AH (2003) Mycobacterial infections of thehead and neck. Otolaryngol Clin North Am 36(4):569–764. Beg MH, Marfani S (1985) The larynx in pulmonary tuberculosis.J Laryngol Otol 99(2):201–2035. 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BorgdorV MW, Nagelkerke NJ, Dye C, Nunn P (2000) Gender andtuberculosis: a comparison of prevalence surveys with notiWcationdata to explore sex diVerences in case detection. Int J Tuberc LungDis 4(2):123–13212. Holmes CB, Hausler H, Nunn P (1998) A review of sex diVerences inthe epidemiology of tuberculosis. Int J Tuberc Lung Dis 2(2):96–10413. Tu HY, Li HY, Huang TS (1997) Laryngeal tuberculosis: a seriesof 46 patients. Changgeng Yi Xue Za Zhi 20(2):94–9914. Martinez AN, Rhee JT, Small PM, Behr MA (2000) Sex diVer-ences in the epidemiology of tuberculosis in San Francisco. Int JTuberc Lung Dis 4(1):26–3115. Watkins RE, Plant AJ (2006) Does smoking explain sex diVer-ences in the global tuberculosis epidemic? Epidemiol Infect134(2):333–33916. Shin JE, Nam SY, Yoo SJ, Kim SY (2000) Changing trends inclinical manifestations of laryngeal tuberculosis. Laryngoscope110:1950–195317. 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Laryngeal involvement in patients with active pulmonary tuberculosis

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Laryngeal involvement in patients with active pulmonary tuberculosis

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