The Journal of Chest Disease and Tuberculosis. Photon 108 (2015) 141-144 https://sites.google.com/site/photonfoundationorganization/home/the-journal-of-chest-disease-and-tuberculosis Case Report. ISJN: 5743-8477: Impact Index: 6.13

The Journal of Chest Disease and Tuberculosis

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Laryngeal and Oropharyngeal Tuberculosis– A Case Report Appiah Thompson Petera*, Anthony Richardb, Edzie Kobina Mesic a

Ear, Nose and Throat Unit, Cape Coast Teaching Hospital & School of Medical Sciences, University of Cape Coast, Ghana, West Africa b Department of Medicine, Effia Nkwanta Regional Hospital, Sekondi & School of Medical Sciences, University of Cape Coast, Ghana, West Africa c Department of Radiology, Cape Coast Teaching Hospital & School of Medical Sciences, University of Cape Coast, Ghana, West Africa Appiah Thompson Peter, Anthony Richard and Edzie Kobina Mesi receive Antonie van Leeuwenhoek Research Award-2015 in Tuberculosis Article history: Received: 18 August, 2014 Accepted: 21 August, 2014 Available online: 12 March, 2015 Keywords: Tuberculosis, laryngeal, oropharyngeal, odynophagia, caseating, granulomatous

dysphagia,

Corresponding Author: Peter A.T. Doctor Email: [email protected]

Abstract Laryngeal tuberculosis is rare even though tuberculosis in general especially the pulmonary type is common in the tropics. The laryngeal disease tends to present with vague and nonspecific symptoms like hoarseness of voice or dysphagia which can pass for a laryngeal malignancy. Laryngoscopic features also simulate a malignancy. Thus confirmation of diagnosis of laryngeal tuberculosis can only be by biopsy of the

primary tumour itself. The histopathology would report caseating granulomatous inflammation. Antitubercular treatment gives excellent results when the diagnosis is made. The object of this article is thus to highlight the need for taking biopsies in suspected cases of laryngeal tuberculosis for the appropriate antituberculous medications to be started early. We report on an 18 year old woman who presented to our facility with hoarseness of voice, dysphagia and cough with blood-stained sputum. At direct laryngoscopy she was found to have soft, friable, tiny lesions on both true vocal cords with tonsillar hypertrophy. She was diagnosed of having laryngeal tuberculosis on histopathology. She had a good response to antituberculosis therapy and is now asymptomatic after three years and continuing her education in a tertiary institution. Citation: Peter A.T., Richard A., Mesi E.K., 2015. Laryngeal and Oropharyngeal Tuberculosis– A Case Report. The Journal of Chest Disease and Tuberculosis. Photon 108, 141-144. All Rights Reserved with Photon. Photon Ignitor: ISJN57438477D741612032015

1. Introduction Tuberculosis is a common disease in the tropics, due to widespread communities which are overcrowded with insanitary conditions. Tuberculosis remains a deadly disease worldwide. Laryngeal and oropharyngeal tuberculosis however is rare. Tuberculosis of the larynx and oropharynx results from either the inhalation of a bacillus or from secondary infection from tuberculosis elsewhere like the lungs. The diagnosis of this condition can be tricky as the disease might be isolated presenting only in the oropharynx or larynx without any lung involvement or may be misdiagnosed as a laryngeal malignancy. The object of this report is to highlight the need for

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histopathology of these lesions to be done for diagnosis to be established. 2. Case Report An 18 year old lady presented to the Ear, Nose and Throat Unit of our referral health facility with hoarseness of voice of 1 year duration with associated dysphagia, odynophagia, cough associated with blood-stained sputum, weight loss, night sweats and fever. The patient had thus been in and out of hospitals since the symptoms started without any improvement. She had had no previous contact with a patient with chronic cough.

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She was a secondary school student who did not smoke nor drink alcohol. On examination, she was a wasted young lady, afebrile, anicteric, and not pale. She had generalized lymphadenopathy (involving the submandibular, posterior triangle, axillary and inguinal regions). Chest was clinically clear. Ears and nose were normal. In the oropharynx, there were grossly enlarged palatine tonsils (left bigger than right) with whitish patches over both tonsils and posterior pharyngeal wall. Indirect laryngoscopy could not be done since patient was gagging and coughing a lot. The impressions made were Generalized Lymphadenopathy? Cause (with differentials of Tuberculosis and Lymphoma) and Chronic Tonsillitis. She was thus worked up for examination of the pharynx and larynx under anaesthesia and tonsillectomy for histology. The results of laboratory tests were as follows: Hb 10.4g/dL, WBC 5.5K/uL,GRAN 2.6, LYM 2.1, PLT 254,ESR 103mm fall/hr. HIV was negative, Sputum for AFB’s was negative and Chest X-ray looked normal. Examination of the pharynx and larynx under anaesthesia was then done. The intraoperative findings were as follows: (1) Soft friable nodules were on the entire lengths of both vocal cords which were thickened as well as on the posterior pharyngeal wall. (2) Both palatine tonsils were hypertrophied and friable. The left tonsil was much bigger than the right tonsil.

were found to be normal. The trachea was central and positional asymmetry noted. The radiologist’s impression was Diffuse Miliary Opacities?? Miliary Tuberculosis. Miliary carcinomatosis could not be ruled out. The histology report had delayed due to the unavailability of histopathology facilities at our centreand also the financial difficulties of the relations of the patient. The report was thus traced from the national capital since the patient’s condition was critical. The histology report of both vocal cords and left tonsil were reported as follows: Sections of soft tissue biopsies show many granulomas, some with central caseation and surrounded by Langhan’s giant cells. A normal skeletal muscle and mucinous glands are seen. Elsewhere, partly ulcerated squamous epithelium is seen. Features are those of tuberculosis of the larynx and tonsils. A new diagnosis of Laryngeal Tuberculosis was then made and antituberculous chemotherapy started being given via nasogastric tube. The drugs given included Rifampicin, Pyrazinamide, Ethambutol and Isoniazid. The patient then regained consciousness and symptoms subsided. Patient now (three years after the antitubercular treatment) speaks with a clear voice i.e. after the antituberculous medications were completed. She is currently in a tertiary institution. Figure 1: Chest X-ray showing diffuse opacities in both lung fields (miliary tuberculosis)

Biopsies of the vocal cord lesions were taken via direct laryngoscopy and tonsillectomy for histopathology also done. The patient recovered quite well and was discharged on the 3rd postoperative day having been given antibiotics. There was still some hoarseness of the voice. A month later she was brought again to this hospital with a 3 day history of severe hoarseness of voice, general weakness, cough, breathlessness and vomiting. The cough was productive of bloodstained sputum. On examination she was semiconscious. Chest - air entry was reduced bilaterally with coarse crackles in all lung fields. The impression at this stage was Bilateral Pneumonia/ Bronchopneumonia. Antibiotics were then started. A new chest X-ray was then requested. The new chest x-ray (figure 1) showed diffuse multiple miliary opacities in both lung fields with normal hilar, pleurae and hemidiaphragms. Costophrenic angles, thoracic cage and soft tissues

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3. Discussion Tuberculosis though common in the tropics the pulmonary type is the commonest. The extra pulmonary sites involved include cervical lymph nodes, abdomen, spine (also called Pott’s Disease), nose, larynx, pharynx and middle ear. Laryngeal and oropharyngeal tuberculosis are however rare and thus a high index of suspicion is needed to identify such cases. The laryngeal and oropharyngeal tuberculosis presents with hoarseness of voice, dysphagia and odynophagia as was noted in this case. The diagnosis of

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tuberculosis in the pulmonary type is much straighter forward in that acid fast bacilli can be seen on the smear or mycobacterium cultured from the sputum and a chest x-ray may also demonstrate patchy widespread opacification in both lung fields. A patient may have disseminated tuberculosis without an abnormal chest x-ray as was noted at the initial assessment of this patient. This however is not the case in the laryngeal type where until a physician suspects tuberculosis, the patient might be mismanaged. It was reported in the past that otorhinolarygneal tuberculosis presented with pulmonary involvement in 25 – 30% of cases. However with time many more cases without pulmonary involvement have been reported. In this case the diagnosis was dodgy as though the patient had the clinical features, sputum for AFBs was negative and chest x-ray was normal at the initial presentation. The diagnosis was only confirmed by histology which reported presence of caseating granuloma. This has been explained by the fact that those without pulmonary involvement present with non-pathognomonic clinical features. Skin sensitivity testing i.e. the mantoux test could also have been done. Erythrocyte sedimentation rate (ESR) is an also used as a marker for tuberculosis. In this case the ESR was 103mm/fall in 1 hour. Where available polymerase chain reaction can be used to detect DNA or RNA from samples within 48 hours. In the past, laryngeal tuberculosis was thought to be incurable. Others also suggested that local medication of the larynx could treat the condition. With time however, it has been found that when the diagnosis is established by histology, patients are cured when started on antitubercular treatment.

Consent Written informed consent was obtained from this patient for publication of this case report and accompanying image. A copy of the written consent is available for review by the Editor-inChief of this journal. Limitations (i) Patient’s diagnosis was delayed as she was always misdiagnosed at all the hospitals she had visited over the past one year. (ii) The histology report delayed due to the unavailability of histopathology facilities at our centre. (iii) Histopathology is currently not covered by the National Health Insurance of Ghana thus relations of the patient had to pay for the test. This also contributed to the delay of diagnosis and treatment. Recommendations (i) Histopathology facilities should be made available at the Cape Coast Teaching Hospital. (ii) Histopathology should be covered by the National Health Insurance Scheme. (iii) Education of general practitioners should be done to increase their awareness of extrapulmonary tuberculosis so that their diagnosis and treatment can be early. Funding and Policy Aspects No extra-mural funds were used for this article. Author’s Contribution and Competing Interests

Conclusion Extra pulmonary tuberculosis often poses a diagnostic challenge to the clinician. Laryngeal tuberculosis may be commoner in the tropics than is currently reported in literature. Laryngeal tuberculosis responds very well to conventional anti-tuberculous therapy. Clinicians should not hesitate to refer patients with unexplained hoarseness of voice for ENT evaluation. Biopsies for histology wherever possible should be an essential part in the investigation of a hoarse voice.

The corresponding author managed the patient the first time of admission, and wrote the abstract, introduction and discussion. The second author managed the patient when she was admitted for the second time and wrote the conclusion. The third author reported on the chest X-ray and helped with the write-up of the discussion. The authors declare that we do not have any competing interests. Acknowledgement

Research Highlights (i) High index of suspicion is needed to diagnose extra-pulmonary tuberculosis. (ii) Diagnosis of extra-pulmonary tuberculosis is mainly done by histology. (iii) Early diagnosis and treatment of extrapulmonary tuberculosis is crucial.

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We wish to thank the nurses who helped with the care of this patient. We also wish to express our gratitude to the secretaries who typed this article. References Singh B., Balwally A.N., Nash M., Har-El G., Lucente F.E. Laryngeal tuberculosis in HIV infected patients: a difficult diagnosis. Laryngoscope 1996; 106, 1238-40.

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