International Journal of Advances in Medicine

Agarwal A et al. Int J Adv Med. 2017 Dec;4(6):1699-1701

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DOI: http://dx.doi.org/10.18203/2349-3933.ijam20175195
Case Report

Laryngeal Tuberculosis: an uncommon but important

cause of odynophagia
Abhishek Agarwal1*, Asna Khan1, Saurav Pandey1, A. K. Vaish2

1
Department of Pulmonary Medicine, Era’s Lucknow Medical College and Hospital, Lucknow, Uttar Pradesh, India
2
Department of Medicine, Hind Institute of Medical Sciences, Safedabad, Barabanki, Uttar Pradesh, India

Received: 14 September 2017

Accepted: 06 October 2017

*Correspondence:
Dr. Abhishek Agarwal,
E-mail: [email protected]

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Tuberculosis can occur as pulmonary tuberculosis or as extrapulmonary tuberculosis. The commonest forms of
extrapulmonary tuberculosis include the pleural tuberculosis and the lymph node tuberculosis. Here we are describing
an interesting case of laryngeal tuberculosis which presented to us with odynophagia. The diagnosis was suspected on
basis of chest x-ray and CT thorax, but it could only be confirmed after direct visualization of the larynx on fibreoptic
bronchoscopy and by taking biopsy from the epiglottis under direct visualization.

Keywords: Epiglottis, Fibreoptic bronchoscopy, Laryngeal tuberculosis, Odynophagia

INTRODUCTION history of antitubercular treatment or diabetes mellitus in

the patient. Patient had no other co-morbid illness. The
Tuberculosis affecting the lung parenchyma and general examination of the patient revealed presence of
tracheobronchial tree is known as pulmonary tuberculosis pallor. The respiratory system examination revealed
and when it affects other organ systems outside the lung presence of bilateral vesicular breath sounds with
parenchyma it is known as extrapulmonary tuberculosis. bilateral fine crepts in suprascapular and infrascapular
The commonest forms of extrapulmonary tuberculosis areas. The systemic examination was normal in the
include the pleural tuberculosis in the form of pleural patient.
effusion and lymph node tuberculosis.1,2 Extrapulmonary
tuberculosis is more common in HIV seropositive Investigation
patients in comparison to HIV seronegative patients.3
Here, we are describing an interesting case of laryngeal The blood examination revealed Hb%-8.6gm/dl, TLC-
tuberculosis which presented to us with odynophagia
rather than any dysphonia. 10,600/mm3, Platelet- 1.8 lakh/ mm3. Liver function test
and kidney function test were normal in the patient. Blood
CASE REPORT sugar was also normal in the patient. Patient’s viral
markers for HIV, HCV and HbsAg were all negative.
A 63-year-old male patient presented to us with chief Mantoux test was positive in the patient with an
complaints of fever and cough with scanty expectoration induration of 18mm after 72 hours. Chest x-ray revealed
for 2 months and pain on swallowing(odynophagia) along bilateral patchy opacities in bilateral upper and middle
with loss of appetite for 1 month. There was no previous

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 Agarwal A et al. Int J Adv Med. 2017 Dec;4(6):1699-1701

zones. High resolution computed tomography(HRCT) of Biopsy was taken from few of these nodules and
chest revealed bilateral patchy consolidation in right bronchoalveolar lavage (BAL) was taken from right and
upper lobe, middle lobe and lower lobe and left upper left upper lobes. BAL was positive for acid fast bacilli
lobe and lower lobe with bilateral centrilobular nodules (AFB) stain and biopsy from the nodules on the epiglottis
(Figure 1 and 2). Sputum examination for acid fast bacilli revealed multiple granulomas with Langhans giant cells
was negative in the patient. Hence, fibreoptic and necrosis (Figure 5).
bronchoscopy was done in the patient which revealed
swollen epiglottis (Figure 3) with multiple irregular
nodules on the laryngeal surface of the epiglottis (Figure
4).

Figure 4: Fibreoptic bronchoscopy showing irregular

areas on the laryngeal surface of epiglottis.
Figure 1: CT scan Thorax showing bilateral upper
lobe involvement.

Figure 5: Microscopy showing nectrotising granuloma

with langhans giant cells.
Figure 2: CT scan Thorax showing bilateral lower
lobe involvement. Treatment and follow up

Hence, the patient was initiated on four drug

antitubercular treatment comprising of Rifampicin
(600mg), Isoniazid (300mg), Ethambutol (1000mg) and
Pyrazinamide (1500mg) according to weight with gradual
subsidence of fever and relief in odynophagia in the next
three weeks.

Differential diagnosis

• Laryngeal carcinoma
• Chronic laryngitis
• Laryngeal tuberculosis
• Laryngeal papillomatosis
• Benign laryngeal tumors
Figure 3: Fibreoptic bronchoscopy showing swollen • Kimura disease of epiglottis
epiglottis.

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 Agarwal A et al. Int J Adv Med. 2017 Dec;4(6):1699-1701

• Autoimmune disease of larynx CONCLUSION

• Sarcoidosis of larynx
• Mycosis of larynx The most common symptom of laryngeal tuberculosis is
dysphonia or hoarseness of voice, but it can also present
DISCUSSION as odynophagia. Laryngeal tuberculosis may occur with
or without pulmonary involvement. Fibreoptic
Laryngeal tuberculosis is an uncommon form of bronchoscopy with biopsy from involved area may be
extrapulmonary tuberculosis but is the most common required for the confirmation of the diagnosis of
granulomatous disease affecting the larynx. The most laryngeal tuberculosis.
common symptom of laryngeal tuberculosis is hoarseness
or change of voice.4,5 Funding: No funding sources
Conflict of interest: None declared
However, in our case the patient presented to us with Ethical approval: Not required
odynophagia with no change in voice. Laryngeal
tuberculosis can be primary or secondary. In primary REFERENCES
laryngeal tuberculosis there is no evidence of tuberculosis
1. Ramirez-Lapausa M, Menendez-Saldana A,
in the lungs while in secondary laryngeal tuberculosis
Noguerado-Asensio A. Extrapulmonary
there is concomitant pulmonary tuberculosis. The patient
tuberculosis: An overview. Rev Esp Sanid Penit.
in our case had secondary laryngeal tuberculosis with the
2015;17:3-11.
computed tomography of chest showing patchy
2. Prakasha SR, Suresh G, Peter D’sa I, Shetty SS,
consolidation in bilateral lungs and the bronchoalveolar
Kumar SG. Mapping the Pattern and Trends of
lavage fluid being positive for acid fast bacilli stain.
Extrapulmonary Tuberculosis. J Glob Infect Dis.
2013;5(2):54-9.
The vocal cords are most commonly involved in
3. Arora VK, Chopra KK. Extra Pulmonary
laryngeal tuberculosis in more than 50% cases while
Tuberculosis. Indian J Tuberc. 2007;54:165-7.
epiglottis is involved in only about 20% of the cases.6,7
4. Benwill JL, Sarria JC. Laryngeal tuberculosis in the
United States of America: a forgotten disease. Scand
Epiglottis was the only part of the larynx involved in our J Infect Dis. 2014;46(4):241-249.
case with the true and false vocal cords, arytenoids and 5. Gandhi S, Kulkarni S, Mishra P, Thekedar P.
inter arytenoid region being normal on Fibreoptic Tuberculosis of Larynx Revisited: A Report on
bronchoscopy. clinical characteristics in 10 cases. Indian J
Otolaryngol Head Neck Surg. 2012;64(3):244-247.
As there was no involvement of vocal cords in our case, 6. Ling L, Zhou SH, Wang SQ. Changing trends in the
hence it probably led to the normal voice of the patient. clinical features of laryngeal tuberculosis: a report
Direct visualization of the lesions in laryngeal of 19 cases. Int J Infect Dis. 2010;14(3):e230-5.
tuberculosis can be whitish ulcerative, nonspecific 7. Umadevi KR, Alavandar E. Tuberculosis of larynx.
inflammatory, polypoidal or ulcerofungative. 8 In our case Trop J Med Res. 2015;18:38-41.
the laryngeal surface of the epiglottis showed multiple 8. Shin JE, Nam SY, Yoo SJ, Kim SY. Changing
polypoidal lesions with the upper part of the epiglottis trends in clinical manifestations of laryngeal
diffusely swollen and erythematous. tuberculosis. Laryngoscope. 2000;110:1950-3.
9. Smulders YE, De Bondt BJ, Lacko M, Hodge JA,
As laryngeal tuberculosis often mimics laryngeal Kross KW. Laryngeal tuberculosis presenting as a
carcinoma,9 hence a biopsy is required from the lesion to supraglottic carcinoma: a case report and review of
confirm the lesion. The biopsy from the polypoidal literature. J Med Case Rep. 2009;3:9288.
lesions on the epiglottis revealed granulomas with 10. Yin N, Delord M, Giovanni A, del Grande J,
presence of Langhans giant cells and necrosis. Drancourt M, Brouqui P, Lagier JC. Laryngeal
Bronchoalveolar lavage fluid positive for acid fast bacilli tuberculosis diagnosed by stool sample cultures: a
stain further aided in confirming the diagnosis. Diagnosis case report. J Med Case Rep. 2015;9:74.
of laryngeal tuberculosis has also been reported to be
made by stool culture.10 Cite this article as: Agarwal A, Khan A, Pandey S,
Vaish AK. Laryngeal Tuberculosis: an uncommon
but important cause of odynophagia. Int J Adv Med
2017;4:1699-701.

International Journal of Advances in Medicine | November-December 2017 | Vol 4 | Issue 6 Page 1701