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Case Presentation

Tuberculous Laryngitis

Adrine Fragita 2009730121


Laura Darliani 2009730090
Identity
Name : Mr.Y
Age : 70 years old
Sex : Male
Occupation : Retirement
Race : Javanese
Address : Babakan Bandung, Sukabumi
Weight : 50 kg
Height : 170 cm
Anamnesis
Chief complaint:
sudden hoarseness and difficulty swallowing
Additional complaint:
Persistent cough, weight loss, blood when coughing
History of present illness:
Patient came with sudden hoarseness and difficulty swallowing.
He had a persisten cough for a year and had received medication
for about 6 months but never had any improvement. Bad cough
came with productive phlegm that was green in color. Sometimes
there was a stain of redness in the phlegm. The phlegm got often
swallowed by the patient. The cough was progressively worsening.
Patient also had a weight loss for around 10 kilos in the last 1 year.
He smoked 3 pack a week for 30 years.
Physical Examination
1. General status
General appearance : Calm
Consciousness : Compos mentis
Blood pressure : 120/70 mmHg
Pulse rate : 88 x/min
Respiratory rate : 24 x/min
Temperature : 37,4 C
2. Pulmonal
Inspection : Chest simetris in static and dynamic
condition
Palpation : Stem fremitus dextra increased
Percussion : Dull in apex region pulmonal
dextra
Auscultation : Ronchi +/+, wheezing -/-
3. ENT Status
Right ear :
Mucuos membrane : hyperemic (-), edema (-), mass (-), Secretion
(-), laceration (-), cerumen (-)
Tymphanic membrane : intact, bulging (-), light reflex (+)

Left ear :
Mucuos membrane : hyperemic (-), edema (-), mass (-), secretion
(-), laceration (-), cerumen (-)
Tymphanic membrane : intact, bulging (-), light reflex (+)
Right nose :
Mucous membrane: hyperemic (-), edema (-), secretion (-), mass (-),
laceration (-), crust (-)
Concha: eutrophy
Septum: no deviation
Air passage : normal

Left nose :
Mucous membrane: hyperemic (-), edema (-), secretion (-), mass (-),
laceration (-), crust (-)
Concha: eutrophy
Septum: no deviation
Air passage: normal
Throat:
Uvula in the middle
Pharynx: normal pharyngeal arch, hyperemic (-)
Tonsils :T1 / T1, detritus (-), enlarged crypt (-)

Neck: lymphadenopathy (+)


Planning
Laboratory finding ( Complete blood count )
Chest radiograph PA position
Mantoux test
Sputum test
Direct laryngoscopy
Workup
1. Laboratory
Haemoglobin : 13.4 g/dL
WBC : 7300/uL
ESR : 25/51 mm/hour
Haematocryte : 39.3%
Platelet : 289000/uL
Working Diagnosis
Hoarseness et causa infiltration stage of suspected
tuberculous laryngitis.
Therapy
To prevent dehydration :
Holliday-segard IV line 750 ml/hour
Emergency proceedings to hypovolemic shock e.c dehydration:
Airway : head tilt-chin lift maneuver
Breathing : look, listen, feel
Circulation : chest compression if necessary
To treat tuberculosis :
Rifampisin 450 mg 1x1
INH 300 mg 1x1
Pirazinamid 500 mg 2x1
Ethambutol 500 mg 1x1
LARYNGITIS TUBERCULOSA
DEFINITION
Laryngitis refers to inflammation of the larynx
This can lead to oedema of the true vocal folds, resulting in
hoarseness
Accompanying signs of infectious laryngitis include
odynophagia, cough, fever, and respiratory distress
EPIDEMIOLOGY
This accounts for approximately 7.3 million annual visits for
children and 6.7 million for adults
The Royal College of General Practitioners in the UK
reported a peak average incidence of patients with laryngitis
of 23 per 100,000 per week, at all ages, over the period of
1999 to 2005.
ETIOLOGY
Virus infection: Bacterial infection: Fungal infections:

Generally the most common Pathogens consist of Moraxella Generally caused by Candida
cause of infectious laryngitis catarrhalis, Haemophilus albicans, Blastomyces
Rhinovirus is the most influenzae, Streptococcus dermatitis, Histoplasma
common virus that is pneumoniae, Staphylococcus capsulatum, and Cryptococcus
etiologically associated with aureus, and Klebsiella pneumoniae neoformans.
URIs Epiglottitis is most frequently Noninfectious causes of
Other causative viruses include caused by Haemophilus laryngitis include the
parainfluenza virus, respiratory influenzae type B following:
syncytial virus, influenza, and Diphtheria is caused Irritant laryngitis (e.g., due to
adenoviruses by Corynebacterium diphtheriae. toxic fumes)
Parainfluenza viruses type 1 Occasional cases may be Allergic
and type 2, as well as influenza caused by Corynebacterium Traumatic, especially due to
viruses, are the most common ulcerans vocal abuse
pathogens responsible for Although atypical forms of
croup. acid-fast bacilli can play a role,
most TB infections are caused
byMycobacterium tuberculosis
Syphilis is a less common cause
PATHOPHYSIOLOGY
In acute infectious laryngitis there is generally a viral or bacterial
insult, leading to inflammation of the endolaryngeal structures
This results in tissue oedema and erythema
Tissue oedema decreases the pliability of the true vocal fold
mucosa over the lamina propria and increases the bulk of the vocal
folds
This leads to lowered vocal pitch and hoarseness
Meanwhile, there is increased mucus, as well as purulence
TB infection may lead to chronic laryngitis.
CLASSIFICATION
CLASSIFICATION ETIOLOGY
Infectious and non-infectious types
DESCRIPTION

Viral most common causative agent is the


rhinovirus. Others include influenza A, B,
C, adenoviruses, croup due to the
parainfluenza viruses, measles, varicella-
zoster

Infection Bacterial examples include epiglottitis due


to Haemophilus influenzae type B, beta-
haemolytic Streptococcus

Fungal examples include candidiasis,


blastomycosis, histoplasmosis, and
cryptococcosis.

Irritative laryngitis (e.g., due to toxic


fumes)

Allergic

Non infection
Traumatic, especially due to vocal abuse

Reflux laryngitis.
Onset and duration of symptoms
Acute: usually lasts <7 days
Chronic: persistence of symptoms for 3 weeks or longer
Subacute: when the clinical presentation lies between these 2
subtypes, it may be of clinical utility in certain cases to
classify them as subacute.
DIAGNOSIS
A. HISTORY
presence of risk factors (common)
Risk factors associated with laryngitis include a recent hx of URI, incomplete or absent
Haemophilus influenzae type B (Hib) or diphtheria vaccination, contact with a virally infected
individual, travel to an area where diphtheria or tuberculosis is endemic, immunocompromise,
residence in a nursing home, HIV infection.
Laryngeal candidiasis is more common in patients using inhaled corticosteroids or on prolonged
courses of antibiotics.
hoarseness (common)
The most characteristic symptom of laryngitis.
In acute laryngitis, history of hoarseness is generally <7 days.
There can be periods of aphonia.
Due to increased oedema, the bulk of the vocal folds increases, and normal pitch is lowered.
In TB, the patient will present with chronic hoarseness (>3 weeks).
dysphagia (common)
Common symptom associated with sore throat.
odynophagia (common)
Pain on swallowing is a common symptom of URIs.
cough (common)
Common symptom of URIs.
Post-nasal drainage and increased laryngeal mucus exacerbate the cough.
Chronic cough with weight loss are symptoms of laryngitis due to TB.
hyperaemia of the oropharynx (common)
Feature of acute infectious laryngitis.
hx of vocal abuse (common)
Patients with vocal strain will usually present with a history of prolonged or excessive vocal
use.
oropharyngeal white-grey exudates (uncommon)
Seen on oropharyngeal examination in patients with diphtheria.
May extend to the soft palate and vallecula.
These pseudomembranes in diphtheria may also be found covering the laryngeal structures,
leading to airway compromise.
Firmly adherent to the underlying mucosa, which bleed when the exudate is removed.
rhinitis (common)
Common symptom of URIs.
Post-nasal drainage and increased laryngeal mucus may exacerbate cough.
fatigue and malaise (common)
May accompany more localised laryngeal symptoms.
Malaise is profound in diphtheria infection.
fever (common)
Patients with acute infectious laryngitis can present with symptoms varying from
very subtle features to high-grade fever.
Fever presenting with exudative tonsillopharyngitis and anterior cervical
lymphadenitis is highly suggestive of bacterial origin.
enlarged tonsils (common)
May occur in acute infectious laryngitis.
enlarged, tender anterior cervical lymph nodes (common)
When accompanied by exudative tonsillopharyngitis and fever, it is highly suggestive
of bacterial origin.
post-nasal drip (common)
May be detected on oropharyngeal examination and may exacerbate cough.
dyspnoea (common)
May occur due to laryngeal oedema.
weight loss (uncommon)
Weight loss and chronic cough are symptoms of laryngitis due to TB.
tonsillopharyngeal exudate (uncommon)
When accompanied by anterior cervical lymphadenitis and fever, it is highly
suggestive of bacterial origin.
acute respiratory distress (uncommon)
Generally seen in cases of acute epiglottitis, croup, or diphtheria.
Uncommon with uncomplicated acute laryngitis in adults.
toxic appearance (uncommon)
Generally seen in cases of acute epiglottitis or diphtheria.
Uncommon with uncomplicated acute laryngitis.
drooling (uncommon)
Generally seen in cases of acute epiglottitis. Uncommon with
uncomplicated acute laryngitis.
stridor (uncommon)
Generally seen in cases of acute epiglottitis, croup, or diphtheria.
Uncommon with uncomplicated acute laryngitis.
DESCRIPTION RESULT
TEST

Mainstay of diagnosis. acute infectious laryngitis: oedema and


Can be performed by the use of a rigid or erythema of the true vocal folds; thick,
flexible laryngoscope. copious, white-yellow secretions in the glottis;
Performed if the patient presents initially to an chronic TB laryngitis: exophytic or nodular
otolaryngology specialist, but most primary laryngeal lesions commonly involving the
care physicians are not experienced in the posterior glottis; reflux laryngitis: no exudative
Laryngoscopy technique and diagnose most cases of viral changes in the larynx, may show hyperaemia
laryngitis clinically. of the arytenoids and the posterior true vocal
Some primary care physicians may use mirror folds
indirect laryngoscopy, depending on
experience

Biopsies should be obtained in cases where TB Chronic TB laryngitis: granulomatous necrosis,


is suspected. positive stain for acid-fast bacilli

biopsy during laryngoscopy Procedure is usually performed with a general


anaesthetic

Cultures should be obtained if bacterial Positive culture in bacterial infection


infection, diphtheria, or TB are suspected.

oropharyngeal cultures Loeffler or Tindale selective media are used


when diphtheria is suspected.
Cultures should be obtained if Positive culture in bacterial infection
diphtheria is suspected.
Loeffler or Tindale selective media are
used when diphtheria is suspected.
Nasal swab for culture

Definitive diagnosis of diphtheria can also Positive in diphteheria


be made by the demonstration of toxin
Serum immunoprecipitation, PCR, or production
immunochromatography for diphtheria

Performed routinely in patients with may be positive for mycobacteria in cases


suspected TB. of TB
Sputum cultures

Should be obtained in cases where TB is may be positive in cases of TB


Purified protein derivative skin test suspected.
(PPD)
DIFFERENTIAL DIAGNOSIS
Tonsillitis
Infectious mononucleosis
Allergic rhinitis
Laryngeal carcinoma
GORD
TREATMENT
Treatment approach
Treatment of acute infectious laryngitis will vary depending on the severity of
the illness.
Particular care must be taken with patients with any degree of airway
compromise.
The challenge for the physician is to decide when antibiotics may be required
for possible bacterial infection.
Chronic tuberculous laryngitis is treated with an antituberculosis regimen and
care provided by an infectious disease specialist.
Chronic laryngitis may also be due to fungal infection. Patients with fungal
laryngitis are managed by otolaryngology specialists. The detailed treatment of
fungal laryngitis is beyond the scope of this topic.
Acute infectious laryngitis (non-diphtherial)

Most cases of acute infectious laryngitis are viral, and the treatment is supportive
with analgesics and cough suppressants as required.
Vocal hygiene is the most important component of the treatment regimen.
Caffeine should be avoided because it has diuretic effects and will cause further
volume depletion.
Decongestants are not recommended. There is no evidence supporting the use of
corticosteroids for these patients.
mucolytics have been used widely to decrease the viscosity of the secretions
Antibiotics are indicated only when a bacterial infection is suspected, and are started
empirically. Most acute laryngitis cases are viral.
Patients with potential airway compromise

If there is respiratory distress, the patient should be assessed in a controlled


environment with the facility to perform safe intubation.
Emergency tracheotomy may be required if, through swelling, a normal intubation is
not possible.
Children presenting with symptoms and signs of epiglottitis should be examined in a
controlled setting, such as the operating room, where intubation is performed if
there is any doubt about the airway.
If the patient is an adult, flexible laryngoscopy may be performed.
Acute respiratory distress is unlikely in the setting of uncomplicated acute laryngitis
unless there is an underlying risk factor, such as a condition that limits the airway.
Conditions such as subglottic stenosis or bilateral vocal fold paralysis greatly increase
the risk of respiratory failure in acute laryngitis.
Corticosteroids are administered to alleviate oedema in all patients with potential
airway compromise, and early antibiotic treatment should be considered. The airway
should be monitored closely to assess the need for tracheotomy.
Patients with diphtheria appear toxic, and there is an imminent threat of airway
compromise.
Laryngitis due to tuberculosis or fungal infection

Detailed discussions of tuberculous laryngitis or fungal laryngitis


are beyond the scope of this topic. Patients with suspected
tuberculosis require referral to an infectious disease or pulmonary
specialist for antituberculosis therapy and care. Vocal hygiene,
analgesics, mucolytics, and cough medications may be used as
supportive care.
Patients with fungal laryngitis are managed by otolaryngology
specialists. Where hoarseness has developed in patients on inhaled
corticosteroids, it would be appropriate for the primary care
physician to advise the patient to rinse their mouth with water
before and after inhalation. The dose of corticosteroid should be
reduced if at all possible to the lowest dose required. Referral to
an otolaryngology specialist may still be required.
Non-infectious laryngitis
The mainstay of treatment for laryngitis due to chronic trauma is
speech therapy by an experienced voice therapist. For these
patients with vocal strain, vocal hygiene is essential. This
includes, but is not limited to, voice rest, increased hydration,
humidification, and limited caffeine intake. Voice rest is
important because heavy voice use in an already injured larynx
can lead to the formation of further pathology, such as injury to
the vocal folds and muscle tension dysphonia. The duration of
voice rest suggested may differ depending on each physician's
usual practice, but is usually between 3 and 7 days. Singers
should not sing or do vocal exercises during this period.
PROGNOSIS
Acute infectious laryngitis
A self-limiting disease. With adequate voice rest and hydration the
voice will return to normal within days.
Diphtheria
Elderly and very young patients generally have a poorer prognosis,
whereas past history of immunisation usually leads to a better
prognosis.
Any delay in administration of diphtheria antitoxin is more likely to
result in associated toxic complications
Tuberculosis
Once appropriate treatment is started, laryngeal lesions should regress.
If left untreated, progressing lesions can cause fibrosis, scarring, and, as
a result, laryngeal stenosis. This may necessitate tracheotomy.

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