Teaching Case

A 10-year-old male patient presented to the paediatric emergency department with haemoptysis and a 2-month history of dysphonia, dysphagia, and odynophagia. Initial laboratory tests only showed raised C-reactive protein 5.11 mg/dL (0.03 - 0.50). The patient was treated with oral antibiotics and corticosteroids without resolution of his initial symptoms.

Posteroanterior chest radiograph demonstrated patchy consolidations in upper-lung lobes (Fig. 1).
Thoracic contrast-enhanced CT performed the same day showed patchy ground-glass opacities involving the apical and posterior segments of the upper-lung lobes and superior segments of the lower-lung lobes, as well as ill-defined consolidations localised in apical segments of the upper lobes, mainly in the right lung. These findings were associated with multiple centrilobular nodules and tree-in-bud branching pattern (Fig. 2). Some fibro-cicatricial changes with apical bronchiectasis and bronchial wall-thickening were also seen (Fig. 3). There was no evidence of cavitation or pleural effusion.
Axial and coronal CT images of the neck showed diffuse thickening of supraglottic and glottic larynx with compromised airway and increased density of parapharyngeal tissues (Fig. 4).
Homogeneous-enhanced cervical and mediastinal lymphadenopathies were observed.
The diagnosis of laryngeal and pulmonary tuberculosis was suggested and confirmed with positive sputum cultures.
After 3 months of antituberculosis therapy, patient was asymptomatic and supraglottic and glottic-narrowing had been resolved (Fig. 5).

Background:
Tuberculosis affects 1 million children worldwide, especially in developing countries [1].
21-44% of paediatric cases have extrapulmonary spread. Laryngeal tuberculosis is very rare (<1%), especially in children [1-4].
Bronchogenic spread into posterior part of the larynx from severe pulmonary foci of cavitation and consolidation is more frequent in young adults, whereas lymphogenic or haematogenous spread into anterior part of the larynx is more frequent in children, due to paucibacillary nature of sputum and higher incidence of cervical lymphadenitis [1-4].
In our case, long-term steroid treatment increased risk of pulmonary tuberculosis reactivation and bronchogenic spread into larynx.
Clinical Perspective:
Patients present with systemic symptoms (fever, asthenia and weight loss) and cervical pain, hoarseness, swallowing difficulty or foreign body sensation. Children can also present airway compression, especially those with epiglottis involvement [1-4].
Direct laryngoscopy shows mucosal swelling, ulcers, papillomas or granulomas and dirty exudate [5].
Virtually all patients associate active pulmonary tuberculosis and it is highly contagious [1-5].
Imaging Perspective:
In acute-subacute phases of laryngeal tuberculosis, there is a diffuse thickening of supraglottic larynx, especially aryepiglottic folds. But also free margin of epiglottis and false and true vocal chords, without impairment of their mobility. [1-2] Low-attenuation areas of caseation necrosis may be present.
It is associated with fat infiltration at pre-epiglottic and paraglottic spaces without sclerosis or destruction of cartilages. It rarely extends to hypopharynx or subglottis [1-4].
It is associated with cervical and mediastinal-enlarged lymph nodes, with low-density core and peripheral rim-enhancement, although homogeneous enhancement may be present in initial phases when necrosis is not already established [5-6].
In chronic phase, there is a nodular thickening secondary to formation of caseating granulomas [5-6].
Pulmonary tuberculosis reactivation or reinfection is demonstrated by changes on imaging in upper-lobes with ground glass, patchy ill consolidations and centrilobular nodules and tree-in-bud branching pattern associated with fibrocicatricial changes (atelectasis, reticular pattern, subpleural lines or traction bronchiectasis). [1]
Outcome:
Microbiological analysis of the sputum by PCR and Ziehl-Nielsen staining is positive in almost all patients, especially in adults (90-95%). Biopsy is necessary if it is necessary rule out laryngeal carcinoma [7-8].
Standard therapy for pulmonary tuberculosis (6 months, 4 drugs) is used for laryngeal tuberculosis, with excellent response. Symptoms disappear in 1-2 months [7-8].
Treatment delay or multidrug resistant Micobacterium increases the risk of irreversible laryngeal stenosis or cricoarytenoid fixation that may require surgery [7-8].
Take Home Message
Laryngeal tuberculosis should be considered in children with diffuse thickening of supraglottic larynx, especially in those at risk (immunocompromised or active close contacts).
It is almost always associated with lymphadenitis or pulmonary tuberculosis.
Written informed patient consent for publication has been obtained.