Otolaryngology Case Reports 2 (2017) 26e28

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Otolaryngology Case Reports

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Secondary laryngeal tuberculosis in Tibet China: A report of six cases

Huaidong Du a, *, 1, Guoyu Cai b, 1, Sang Ge b, Wang Ci b, Liang Zhou a, **
a
Department of Otolaryngology e Head and Neck Surgery, Fudan University Affiliated Eye, Ear, Nose and Throat Hospital, Shanghai, China
b
Department of Otolaryngology e Head and Neck Surgery, Shigatse People's Hospital, Tibet, China

a r t i c l e i n f o a b s t r a c t

Article history: Objective: This study was undertaken to illustrate the clinical features of laryngeal tuberculosis (TB) and
Received 2 December 2016 to help improve early diagnosis rate of laryngeal TB in Tibet China.
Accepted 14 February 2017 Methods: A retrospective analysis of six TB patients who presented hoarseness in ENT Outpatient
Available online 21 February 2017
Department of Shigatse People's Hospital in Tibet China from Jan 2015 to Jan 2016.
Results: Five males and one female were involved in this study, age range from 23 to 58 years old, with
Keywords:
an average of 40.17 ± 11.86 years (mean ± SE). The main symptom was hoarseness in all patients.
Tuberculosis
Endoscopic analysis indicated that true vocal folds were the anatomical structures most involved. Chest
Larynx
Tibet
X-ray showed positive lesions in the upper lobes of the lungs of all six patients. Sputum samples were
positive for acid-fast bacilli (AFB). All patients were admitted, placed in isolation. A four to eight months
antituberculous treatment was applied. During six months follow up, the patients showed complete
regression of endo-laryngeal lesions.
Conclusions: Laryngeal TB is not as rare as considered in ENT department in Tibet. It is important to
consider TB in the differential diagnosis of laryngeal disease.
© 2017 Elsevier Inc. This is an open access article under the CC BY license (http://creativecommons.org/
licenses/by/4.0/).

1. Introduction pulmonary TB cases and is the most popular granulomatous disease

Tuberculosis (TB) is a contagious infectious disease that spreads
through the air, caused by Mycobacterium tuberculosis. Patients of
TB present with fever, chills, night sweats, weight loss, and cough.
TB ranks the fourth among the major causes of death worldwide
and is the leading cause of death from a single infectious agent.
One-third of the world populations are believed to be infected with
bacteria, and 2, 000, 000 deaths are attributed to TB in a year [1].
Despite the progress in relation to the goals of disease control, TB is
still a global public health problem [2]. Nine million new cases of
this disease were registered in the world in 2013 by the World
Health Organization (WHO). TB mainly affects lungs, but can occur
in any organ. Laryngeal TB (LTB) represents less than 2% of extra
of this organ. Literature data indicates that LTB incidence rate
among patients diagnosed with pulmonary TB varies from 0.08 to
5.1% [3e5].
China is one of the 22 countries with the heaviest TB burdens
and has the second largest TB population in the world. There are
about 0.55 billion people infected currently, which is a much higher
infection rate than the global rates. The Tibet Autonomous Region
has the highest TB prevalence rate [7]. It is important to improve
the diagnosis of LTB. Because the clinical symptoms of LTB are
changing, diagnosis might be more difficult [8]. The aim of this
study is to illustrate the clinical features of LTB in Tibet and to
improve early diagnosis rate of LTB.
2. Materials and methods

A retrospective analysis of six patients' history and clinical ex-

* Corresponding author. Department of Otolaryngology e Head and Neck Sur-
gery, Fudan University Affiliated Eye, Ear, Nose and Throat Hospital, Shanghai,
200031, China.
** Corresponding author. Department of Otolaryngology e Head and Neck Sur-
gery, Fudan University Affiliated Eye, Ear, Nose and Throat Hospital, Shanghai,
200031, China.
E-mail addresses: huaidongd@hotmail.com (H. Du), zhoulent@126.com
(L. Zhou).
1
These authors contributed equally to this work.
amination was conducted in ENT Outpatient Department of Shi-
gatse People's Hospital in Tibet China. All of the six patients
presented hoarseness and came to our clinical for treatment during
January 2015 to January 2016.
Both Epidemiological and clinical parameters were collected.
Epidemiological parameters included age, gender, as well as iden-
tification of the risk factors presumed to induce or facilitate the

http://dx.doi.org/10.1016/j.xocr.2017.02.004
2468-5488/© 2017 Elsevier Inc. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
 H. Du et al. / Otolaryngology Case Reports 2 (2017) 26e28 27

Table 1
Patient profile.

Patient Sex Age Ethnic Symptom Laryngoscopy CXR

groups

1 Male 58 Han Hoarseness True vocal folds ulcer Bilateral upper lobe micronodular lesions
2 Male 23 Tibetan Hoarseness Cough Interarytenoid, false vocal folds and True vocal folds Right upper lobe macronodular lesions
ulcer
3 Male 34 Tibetan Hoarseness Low fever True vocal folds fibrinous exudate left upper lobe micronodular lesions and
cavitations
4 Male 37 Tibetan Hoarseness True vocal folds and false folds ulcer Bilateral upper lobe micronodular lesions
5 Male 43 Tibetan Hoarseness Cough Wight arytenoid and True vocal folds ulcer Bilateral upper lobe macronodular lesions
loss
6 Female 46 Tibetan Hoarseness Wight loss True vocal folds ulcer right upper lobe micronodular lesions

onset of LTB. Clinical parameters included the patient's symptoms, 4. Discussion

signs, nasopharyngeal flexible endoscopy findings and systemic
signs of TB. All patients, whose clinical examination and chest X-ray
indicated active lung infection, were considered as having pulmo-
nary TB. In this case, antituberculosis chemotherapy was initiated
right after confirmation of diagnosis.
3. Results
Six adult LTB cases (five males and one female; one Han na-
tionality and five Tibetans) were identified (Table 1).
The patients's age ranged from 23 to 58 years old, with an
average of 40.17 ± 11.86 years (mean ± SE). There were 5 males and
1 female. All of the six patients presented certain degree of true
vocal folds lesion. Three of the patients presented lesions on mul-
tiple structures, one on the surface of false vocal folds, and two on
interarytenoid (Fig. 1).
Chest X-ray (CXR) indicated micronodular, macronodular
parenchymal infiltrates or cavitating lesions in the upper lobes in
all six patients (Fig. 2). The CXR findings were consistent with the
diagnosis of TB. The six patients were then admitted, and placed in
isolation. Sputum samples for acid-fast bacilli (AFB) were ordered.
The results of the sputum samples were positive for AFB. Therefore,
the patient started the following antituberculous medications:
isoniazid 300 mg/day, ethambutol 2 g/day, rifampin 600 mg/day,
and pyrazinamide 2 g/day for 4e8 months. The period of treating
depended upon clinical response and the results of fiberoptic lar-
yngoscopic evaluation. During follow up, the patients presented
complete regression of endo-laryngeal lesions. Regressing level of
lesions varied for each patient; however, within an average of 4
months, all of them showed complete resolution of lesion.
TB has been one of the most common health issues in China. In
2002, a TB epidemiology survey conducted in China reported the
average prevalence of TB was 0.0036%, with an estimated 4.5
million active pulmonary TB patients and 1.5 million new infections
a year [9]. The prevalence rate of TB in western China was higher
than other regions of the country. The incidence of LTB maybe is
higher in this region.
In our study, laryngeal TB predominated in males (5 males but
one female). Although our sample is small, we don't want to
overlook this fact. Therefore, we would like to especially alert about
TB infection when facing male patients with unusual laryngeal le-
sions in Tibet. The natural history of laryngeal TB has changed in
recent decades. The age group of patients is on a rise from young
adults earlier to elderly people. The incidence of LTB was reported
to be more in the age group of 20e30 years old, and some studies
showed a shift of the same to fourth and fifth decades [10]. In our
series, the patients were between 23 and 58 years of age, with a
mean age of 40.17 years. In the literature, some reports have
stressed that it is the posterior larynx more commonly involved in
majority of cases, other reports does mention equal involvement of
anterior part of larynx along with epiglottis [11]. In our study, the
lesions were disturbed in the true vocal folds of glottis. The true
vocal folds are the oscillatory component of voice production. Their
function is directly related to voice quality [12]. As the true vocal
folds are the main affected anatomical structures in LTB, hoarseness
is usually observed as the main symptom [13e15].
In the literature, there are two theories that attempt to explain
the etiology of LTB. The first one is called bronchogenic theory,
which states that the larynx is infected by direct spread of Myco-
bacterium tuberculosis from the endobronchial tree, secondary to

Fig. 1. Laryngoscopic images of lesions on the true vocal folds, false vocal folds, and interarytenoid:A:True vocal folds fibrinous exudate; B:Interarytenoid, false vocal folds and True
vocal folds ulcer; C:True vocal folds ulcer.
28 H. Du et al. / Otolaryngology Case Reports 2 (2017) 26e28
Fig. 2. The CXR showed micronodular lesions in the upper lobes.
laryngeal TB. This accounts for the majority of cases. The other
theory is called hematogenous theory. It states that the larynx is
infected by hematogenous spread of Mycobacterium tuberculosis
from sites other than the lungs [16]. This theory applies on primary
laryngeal TB mainly. These patients do not show pulmonary
involvement as demonstrated by a normal CXR.
The clinical exam results of this study indicated that all patients
involved were secondary laryngeal TB. The possible reason for so
many secondary laryngeal TB cases being noted could be that our
department is a tertiary care ENT center. Therefore, patients with
laryngeal symptoms approach voice clinic for dysphonia first
without being ruled out other possibilities. A general diagnosis
procedure of TB must be performed in order to eliminate LTB. This
assessment consists of looking for TB history of a patient and his
(her) family, as well as any clinical signs of TB of the patient. CXR,
test for AFB in sputum and PPD skin test are needed to confirm LTB.
If TB is suspected, the patient should be placed in isolation. When
TB is confirmed, treatment is initiated with antituberculous medi-
cations. However, if symptoms and/or physical findings persist
during the course of treatment, further evaluation is required. The
surgical procedure of choice is direct microlaryngoscopy because it
allows direct visualization of the endolarynx and a means of
obtaining tissue for diagnosis. Biopsy confirms the histological
diagnosis and excludes a cancer based on the appearance of the
lesions [17].
LTB may occur even without pulmonary TB, and the character-
istics of the lesions now appear to be more nonspecific [18]. It is
important to consider TB in differential diagnosis facing the patient
with hoarseness.
Disclosure statement
The authors disclose no conflicts of interest.
References
[1] Drobniewski FA, Caws M, Gibson A, Young D. Modern laboratory diagnosis of
tuberculosis. Lancet Infect Dis 2003;3:141e7.
[2] WHO. Tuberculosis. World Health Organization. 2015.
[3] Topak M, Oysu C, Yelken K, Sahin-Yilmaz A, Kulekci M. Laryngeal involvement
in patients with active pulmonary tuberculosis. Eur Arch Otorhinolaryngol
2008;265(3):327e30.
[4] Ricciardiello F, Martufi S, Cardone M, Cavaliere M, D'Errico P, Iengo M.
Otorhinolaryngology-related tuberculosis. Acta Otorhinolaryngol Ital
2006;26(1):38e42.
[5] Shin JE, Nam SY, Yoo SJ, Kim SY. Changing trends in clinical manifestations of
laryngeal tuberculosis. Laryngoscope 2000;110(11):1950e3.
[7] Wang H, Bai Z, Wang K, Suo L, Liu X, Ma Y, et al. Secondary laryngeal tuber-
culosis at high altitudes of Tibet. Lin Chung Er Bi Yan Hou Tou Jing Wai Ke Za
Zhi 2011;25(21):977e81.
[8] Kandiloros DC, Nikolopoulos TP, Ferekidis EA, Tsangaroulakis A, Yiotakis JE,
Davilis D, et al. Laryngeal tuberculosis at the end of the 20th century.
J Laryngol Otol 1997;111(7):619e21.
[9] National Technic Steering Group Of The Epidemiological Sampling Survey For
T, Duanmu H Report on fourth national epidemiological sampling survey of
tuberculosis. Zhong hua Jie He He Hu Xi Za Zhi 2002;25:3e7.
[10] Galli J, Nardi C, Contucci AM, Cadoni G, Lauriola L, Fantoni M. Atypical iso-
lated epiglottic tuberculosis: a case report and a review of the literature. Am J
Otolaryngol 2002;23:237e40.
[11] Soda A, Rub o H, Salazar M, Ganem J, Beilanga D, Sanchez A. Tuberculosis of
the larynx: clinical aspects in 19 patients. Laryngosccpe 1989;99:1147e50.
[12] Sataloff RT, Heman-Ackah YD, Hawkshaw MJ. Clinical anatomy and physi-
ology of the voice. Otolaryngol Clin North Am 2007;40(5):909e29.
[13] Lucena MM, da Silva Fdos S, da Costa AD, Guimara ~es GR, Ruas AC, Braga FP,
et al. Evaluation of voice disorders in patients with active laryngeal tuber-
culosis. PLoS One 2015;10(5):e0126876.
[14] Wang CC, Lin CC, Wang CP, Liu SA, Jiang RS. Laryngeal tuberculosis: a review
of 26 cases. Otolaryngol Head Neck Surg 2007;137(4):582e8.
[15] Lim JY, Kim KM, Choi EC, Kim YH, Kim HS, Choi HS. Current clinical propensity
of laryngeal tuberculosis: review of 60 cases. Eur Arch Otorhinolaryngol
2006;263(9):838e42.
[16] Ramadan HH, Tarazi AE, Baroudy FM. Laryngeal tuberculosis: presentation of
16 cases and review of the literature. J Otolaryngo 1993;122:39e41.
[17] Rizzo PB, Da Mosto MC, Clari M, Scotton PG, Vaglia A, Marchiori C. Laryngeal
tuberculosis: an often forgotten diagnosis. Int J Infect Dis 2003;7(2):129e31.
[18] Ling L, Zhou SH, Wang SQ. Changing trends in the clinical features of laryngeal
tuberculosis: a report of 19 cases. Int J Infect Dis 2010;14(3):e230e5.