Laryngeal tuberculosis.

Clinical History

A 33 years old man with dysphagia, swallowing difficulty and hoarseness

Imaging Findings

A 33 years old man was admitted for dysphagia, swallowing difficulty and hoarseness appeared 2 months before. He had no specific previous history besides moderate smoking habits (1 box/a day). Indirect and direct laryngoscopic exam showed a swelling and pinkish lesion located at the supraglottic level. A biopsy was performed: the results were not available when the patient was referred to CT and MR for evaluation of lesion extent. A routine chest X-Ray was also required and showed bilateral and superior interstitial opacities.

Discussion

Laryngeal invasion represent a serious complication of pulmonary tuberculosis. Today the incidence has significantly declined because of antibiotic therapy. According to previous reports, 15 à 37% of cases with pulmonary tuberculosis were associated with laryngeal tuberculosis. The modes of infection are through bronchogenic spread by direct infestation from active pulmonary tuberculosis and hematogenous or lymphatic spread. Clinical symptoms are dysphagia, swallowing difficulty, hoarseness, sore throat and foreign body sensation. Duration of the symptoms is variable from 1 to 8 months. Direct and indirect laryngoscopy exam can show mucosal swelling, pinkish hypertrophic and polypoid , dirty exudate, and fungating tumor-like appearance resulting in provisional diagnosis of laryngeal carcinoma. On chest X-ray film, active pulmonary tuberculosis can be seen, but lung spread is not always associated to laryngeal disease> The radiographic appearance of laryngeal tuberculosis depends of the stage and extent of the disease. - In the acute phase, the lesion is diffuse and bilateral, but not necessarily symmetric. - In the chronic phase, the lesion is usually localized with a focal mass. The supraglottic larynx is the most prevalent site of involvement. The most common site is the aryepiglottic fold, the next common sites are the free margin of epiglottis, the false and true vocal cords. Laryngeal tuberculosis rarely extends to the hypopharynx. Calcifications are uncommon and destruction of the laryngeal cartilages is rarely seen. Preepiglottic and paralaryngeal fat spaces are preserved. The most important differential diagnosis is primary laryngeal carcinoma, where the lesion is usually unilateral associated with an infiltration of preepiglottic and paralaryngeal fat spaces and cartilages destruction. Other diagnosis can be evoked : sarcoidis, syphilis, fungal diseases, chronic nonspecific laryngitis, and lethal midline granuloma. The diagnosis is based on Ziehl-Neelsen staining and Polymerase Chain Reaction on Mycobacterium tuberculosis. Laryngeal tuberculosis usually responds well to standard chemotherapeutic agents. Surgery may be needed for management of lymphadenitis or extensive lesions that are unresponsive to medical therapy. Although the CT or MRI appearances of laryngeal tuberculosis are not specific, the possibility of laryngeal tuberculosis should be raised when bilateral and diffuse laryngeal lesions are encountered without destruction of the laryngeal architecture in patients with pulmonary tuberculosis. Knowledge of this diseases is important because early diagnosis and therapy may prevent a permanent loss of function or unnecessary surgery.

Differential Diagnosis List

Final Diagnosis

Laryngeal tuberculosis.

URL:	https://www.eurorad.org/case/604
DOI:	10.1594/EURORAD/CASE.604
ISSN:	1563-4086