CASE DISCUSSION

TUBERCULOSIS LARYNGITIS

Supervisor
dr. Oscar Djauhari, Sp. THT-KL
Presentant
Rizgah M Jawas 2012.730.091
Army Oktavianto 2012.730.011
Yuka Puspita A. 2012.730.110

Clinical Rotation
Otolaryngology, Head and Neck Department
Medical Faculty of Muhammadiyah Jakarta University Syamsudin, S.H.
Regional General Hospital, Sukabumi
Period of 13th June 17th July 2016

PATIENTS IDENTITY
Name
: Mr. N
Age
: 58 years old
Gender
: Male
Weight
: 74 kg
Occupation : Labor
Address
: KP. Cihereus, Cibadak
ANAMNESIS
Chief complaint : unconsciosness

Additional complaint : Continuous cough

difficulty swallowing

hoarsely
History of present illness :
The patient came to the hospital with complaints continuous cough with
blood spots since two months ago. The patient also complaints about
difficulty swallowing, especially the solid food since one months ago and
his voice became hoarse since three weeks ago. The patient also tells about
night sweats and weight loss 10 kg in a month.
History of past illness

The patient has a history of pulmonary tuberculosis.

History of trauma (-)

History of tumor (-)
History of allergy (-)
History of diabetes mellitus (-)
History of hypertension (+)
History of tobacco (+)

History of family disease

The family has a history of hypertension

PHYSICAL EXAMINATION
1. General status
General appearance : moderately ill
Consciousness
: Compos mentis
Heart rate
: 120 times per minute (tachycardia)
Respiration rate
: 28 times per minute (inspiratory stridor)
Blood pressure
: 150/100 mmHg
Temperature
: 37 oC
2. ENT Status

Ear
Right ear
:
Auricle

: hyperemic (-), oedema

(-)
Canalis Acousticus Externa

: hyperemic (-), mass (-),

Discharge (+) minimal, yellowish
and purulent, cholesteatoma (-),

Odorous smell, laceration(-)

: marginal perforation, light
reflex (+)
: Normal.

Tymphanic membrane

Whisper test
Left ear
:
Auricle

(-)
Canalis Acousticus Externa

Tymphanic membrane

Whisper test
Nose
Right Nose :
Mucous membrane
Concha
Cavum
Septum
Left nose
:
Mucous membrane
Concha
Cavum

NPOP

Neck

: hyperemic (-), oedema

Septum
Mucous membrane
Arcus anterior
Pharynx
Tonsil

: hyperemic (-), mass (-),

discharge (-), cholesteatoma (-),
laceration (-)
: intact, bulging (-), light reflex
(+)
: Normal.

: edema(-), livid(-)
: eutrophy
: discharge(-),mass (-),crust (-),bleeding
(-), secretion (-)
: normal
: edema (-), livid (-)
: eutrophy
: discharge(-),mass (-),crust (-),bleeding
(-), secretion (-)
: normal
: hyperemic -/-, oedem -/: uvula in the middle, mass -/: normal pharyngeal arch, hyperemic (-)
: T1-T1, hyperemic (-)
: lymphadenopathy (-/-)

RESUME
Man, 58 years old came to the hospital with complaints cronic cough with blood spots
since two months ago, dysphagia especially the solid food since one months ago and

dysphonia since three weeks ago. The patient also tells about night sweats and weight
loss 10 kg in a month.
The patient has a history of pulmonary tuberculosis
History of Past Illness : History of hypertension (+)
: History of tobacco (+)
Physical examination:
Heart rate
: 120x/min (tachycardia)
Respiratory rate
: 28x/min (inspiratory stridor)
WORKING DIAGNOSIS
Suspect tuberculosis laryngitis stadium fibrotuberculosis e.c suspect pulmonary
tuberculosis
DIFFERENTIAL DIAGNOSIS
1. Suspect leutica laryngitis
2. Suspect laryngeal carcinoma
WORKUP
Laboratorium (bacteriological examination and a culture of germs)
Rontgen X-ray
Laryngoscopy direct or indirect
Anatomic pathology examination
THERAPY
Primary and secondary anti-tuberculosis drugs
Vocal rest
Tabel. Antituberculosis Drugs

TUBERCULOSIS LARYNGITIS

DEFINITION
Laryngitis is an inflammation of the larynx that can happen, both acute and
chronic. Acute laryngitis occurs suddenly and usually takes place in a period of
approximately three weeks. When the symptoms have been more than three weeks is
called chronic laryngitis.
Acute inflammation of the larynx is generally a continuation of rinofaringitis
acute (common cold). While chronic laryngitis is a chronic inflammation of the larynx
that can be caused by chronic sinusitis, severe septal deviation, nasal polyps or
chronic bronchitis. It may also be caused by a relatively misuse of the voice (vocal
abuse) such as yelling or usually speak keras.
Chronic laryngitis chronic laryngitis is divided into non-specific and specific.
Non-specific chronic laryngitis can be caused by exogenous factors (physical stimuli
by voice abuse, chemical stimulation, chronic upper respiratory infections or down,
cigarette smoke) or endogenous factors (body shape, metabolic abnormalities). While
specific chronic laryngitis caused by tuberculosis and sifilis.
One specific form of chronic laryngitis is laryngitis tuberculosis. Laryngitis
tuberculosis is an inflammatory process in the mucosa of the vocal cords and larynx
that occur in the long term caused by the bacteria Mycobacterium tuberculosa.

EPIDEMIOLOGY
As the incidence and prevalence of pulmonary tuberculosis has decreased, the
incidence of tuberculosis laryngitis also decreased, although there was an increased
incidence of tuberculosis in a few years laryngitis terakhir.
In the past, it was stated that the disease often occurs in younger age groups
are 20-40 years old. In the past 20 years, the incidence of this disease in people aged
over 60 years clearly increased. Currently all forms of tuberculosis in two times more
often in men than women. Tuberculosis of the larynx is also more common in elderly
males, especially patients with economic circumstances and poor health, many of
them drink alkohol.

ETIOLOGY
Almost always due to pulmonary tuberculosis. Once treated pulmonary
tuberculosis usually recover but tuberculosis laryngitis settled, because the structure
of the mucosa of the larynx are very attached to the cartilage and not as pulmonary
vascularization. Laryngeal infection by Mycobacterium tuberculosa almost always as

a complication of active pulmonary tuberculosis, and this is a granulomatous disease

of the larynx is most often.

PATHOGENESIS
Tuberculosis laryngitis is generally a secondary lesion active pulmonary
tuberculosis, is rarely the primary infection of tubercle bacilli inhaled directly. In
general, infectious germs into the larynx can occur through breathing air, sputum
containing bacteria, or the spread through the blood or lymph.
Based on the mechanism of laryngitis tuberculosis categorized into two
mechanisms, namely:
1. Primary Tuberculosis Laryngitis
Primary tuberculosis laryngitis is rarely reported in the medical literature.
Laryngitis primary tuberculosis occurs when an infection is found Mycobacterium
tuberculosa of the larynx, without the involvement of the lung. The spread of
infection laryngitis primary tuberculosis that is currently received is a direct invasion
of the tubercle bacillus through inhalation.
Based on research by Shin et al (2000), stated that as many as 40.6% of
patients with tuberculosis laryngitis had normal lung
2. Tuberculosis Secondary Laryngitis
Secondary tuberculosis Laryngitis occurs when the larynx is found infections
due to Mycobacterium tuberculosa accompanied their lung involvement. Secondary
tuberculosis laryngitis is a complication of active pulmonary tuberculosis lesions. The
mechanism of spread of infection to the larynx can be either direct spread along the
respiratory tract of primary pulmonary infection such as sputum containing bacteria
and the spread through the blood or lymphatic system.
Through the deployment of sputum (Bronkogen)
The spread of infection to the larynx through the tubercle bacillus bronkogenik
mechanism is a theory commonly understood. Their bronkogen in this case, sputum
containing M. tuberculosis underlie the pathogenesis of tuberculosis laryngitis.
Tuberculosis laryngitis can be caused by being lodged sputum containing tubercle
bacilli in the larynx, especially in the posterior laryngeal structures including
arytenoid, interaritenoid chamber, vocal cords and the posterior part of the surface of
the epiglottis overlooking the larynx
Antigen of TB bacilli was in larynx digested dendritic cells and then taken to
the regional lymph nodes and present antigen of M. tuberculosis into Th1 cells. Th1
then proliferate and can return to the initial point of infection. Restimulasi by local
renderers cells produce IFN production and activate macrophages. If the elimination
of these microorganisms fail to continue on chronic inflammation occurs where

persistent pathogens in the body, then there is a transfer of immune response in the
form of delayed type hypersensitivity reactions forming granulomas.
After initial contact with the antigen, sensitized Th cells, proliferate and
differentiate into cells DTH (delayed type hypersensitivity) where deployment of
sustainable macrophage cells will form epitloid form Datia cells in granuloma.
Tubercles avascular region containing perkijuan in the middle surrounded by
epithelioid cells and in the periphery of the cells by mononukleus. Then-tubercles
tubercles are united to form nodules. Because of its location in Subepithelial,
melampisinya epithelium may be lost and often ulceration with secondary infection.
This process is the first time tend to be about the process of the vocalist and epiglottis.
The existence of tubercles might stimulate epithelial hyperplasia and subepithelial
fibrosis tissue. This may manifest in the form of thickening interaritenoid area that
resembles pakiderma. Processus vocalist possible is covered by nodules that
resembles morbili. This is a manifestation of the repair process because only found
little perkijuan lesions.
Edema more clearly on the circumstances and may occur as a result of
obstruction of lymphatic tissue by granuloma. Edema may arise in the fossa
interaritenoid, then to arytenoid, vocal cords, cords ventrikularis, epiglottis, and the
latter is subglotik. Epiglottis and connective tissue above the arytenoid was the most
visible edema.
Laryngeal tuberculosis healing is accompanied by the formation of fibrous
tissue capsule and tissue replaces tubercles.
Through the deployment of Limfohematogen
In addition bronkogenik mechanism, the spread of M. tuberculosis of the
larynx can also through limfohematogen system. Spreading through the system
limfohematogen usually the anterior larynx and epiglottis.

CLINICAL FEATURES
In the clinical manifestations of pharyngitis tuberculosis consists of four
stages, namely:
1. Stage infiltration
2. Stage ulceration
3. Stage perikondritis
4. Stadium tumor formation
Stadium Infiltration
Laryngeal mucosa posterior section swelling and hyperemia in the posterior, it
can sometimes be on the vocal cords. At this stage laryngeal mucosa pale.

Later in the submucosa formed tubercles, that mucosa uneven, appear bluish
spots. Tubercles grow in size and some adjacent tubercles unite, so that the top of the
mucous stretch. At one time, because it is stretched, it will burst and ulcers.
Stadium ulceration
Ulcers that arise in end-stage dilated infiltration. These ulcers shallow, covered
essentially perkijuan and felt very painful by the patient.
Stadium Perikondritis
Ulcer deepened so that the cartilage of the larynx, especially arytenoid
cartilage and epiglottis. Thus there is damage to the cartilage, thus forming smelling
pus, this process will continue and sequestering formed. At this stage the patient is
very bad and can die. If the patient can survive the disease process continues and
msuk in the last stage is fibrotuberkulosis.
Stadium Fibrotuberkulosis
At this stage fibrotuberkulosis formed on the posterior wall, the vocal cords
and subglotik.
Based Shin et al (2000), the findings in tuberculosis laryngitis can be
categorized into four groups, among others, (a) ulcerated lesions (40.9%), (b) nonspecific inflammatory lesions (27.3%), (c) polypoid lesions (22.7%), and (d)
ulcerofungative mass lesions (9.1%).

Figure 1. Findings laryngoscopy on the laryngitis Tuberculosis, A. Ulcerative lesions

(on the whole larynx), B. granuloma lesions (on the posterior glottis), C. polyploid
lesions (on the right false vocal cords), D. Nonspecific lesions (on the right of the
vocal cords )

CLINICAL SYMPTOMS
Depending on the stage, in addition there are the following symptoms:
- The taste is dry, heat, and pressure in the area of the larynx.
- Hoarse voice that lasts for weeks and miggu, while at an advanced stage may
arise Afoni.
- Hemoptysis.
- Painful swallowing times greater when compared with other pain due to
inflammation, a characteristic markings.
- General condition worse.
- In lung examination (clinical and radiological) there is an active process
(usually on the stage or on the formation kaverne exudative).

DIAGNOSIS
Diagnosis can be made by history, physical examination and investigation.
1. Anamnesa
In the anamnesis can be asked:
- When did you first arise and the factors that trigger and reduce symptoms
- Employment history, including contact with a substance that can lead to
laryngitis such as dust, smoke.
- The use of excessive sound
- The use of drugs such as diuretics, antihypertensives, antihistamines which
can cause dryness of the mucosa and mucosal lesions.
- History of smoking
- History meal
- Hoarse voice or dysphonia
- Chronic cough, especially at night
- Stridor for their laryngospasm when there secretions around the vocal cords
- Dysphagia and otalgia
2. Symptoms and Physical Examination
On physical examination, look unwell, fever, there is inspiratory stridor,
cyanosis, shortness of breath which is characterized by the nostril breath and / or
retraction of the chest wall, frequency of breathing can be increased, and the presence
of tachycardia are not in accordance with the increase in body temperature is a sign of
hypoxia.
3. Laboratory
-

Examination of bacteriological
Material inspection :
Bacteriological examination to find the germs of tuberculosis has a
great significance in establishing the diagnosis. Material for bacteriological

examination can be derived from sputum, pleural fluid, cerebrospinal liquor,

bronchial
washings,
gastric
washings,
bronchoalveolar
kurasan
(bronchoalveolar lavage / BAL), urine, faeces and tissue biopsy (including
fine needle biopsy / BJH).
How the collection and delivery of materials
How sputum collection three times (SPS):
When / spot (phlegm during the time of the visit)
Am (the following morning)
When / spot (at the time of delivering sputum in the morning) or every
morning 3 days in a row.
-

Culture germs
The role of culture and identification M.tuberkulosis TB control in
particular to determine whether the patient concerned is still sensitive to OAT
used.

4. Direk or indirect laryngoscopy

Examination with direk or indirect
help with the diagnosis. This examination of the vocal cords
red and looked edema, especially at the top and
bottom of the glottis.

laryngoscopy can
of

Figure 2. Laryngitis Tuberculosis

5. Chest X-ray
To see if there is swelling and a picture of
pulmonary tuberculosis. CT scanning and MRI
can also be used and provide better results. View
radiology suspected active TB lesions:
- Shadow cloudy / nodular in the apical and
posterior segments of the upper lobes and
lung lower lobe superior segment.
- Cavity, particularly more than one,
surrounded by cloudy or opaque shadow
nodular.
Figure 3. Thoracic Tuberculosis

6. Examination of anatomical pathology

In the picture macroscopically visible
surface of the mucous membranes dry and
craggy whereas there are microscopic
surface epithelium is thickened and opaque,
granuloma formation, large cells Langhans,
serbukan chronic inflammatory cells in the
submucosal layer.

Figure 4. Histopathology Pharyngitis Tb

MANAGEMENT
1. Non Medical Treatment
- Resting vocal cords in a way the patient does not talk much.
- Avoid irritants that trigger sore throat or cough for example, fried, spicy food.
- Consume a lot of fluids.
- Stop smoking and alcohol consumption.
2. Drug treatment: Drug antituberculosis (OAT)
Drugs used for tuberculosis classified into two groups:
Primary drug:
- INH (isoniazid)
- Rifampicin
- Etambutol
- Streptomycin
- Pyrazinamide
- Secondary drug:
- Exionamid
- Paraaminosalisilat
- Cycloserine
- amikacin
- capreomycin
- Kanamycin

Tabel 1. Anti-Tuberculosis Drug Dosage

Drug
Daily Dose

Dose 2x/week

Dose 3x/week

(mg/kgbb/hari)
5-15 (maks. 300 mg)

(mg/kgbb/hari)
15-40 (maks. 900

(mg/kgbb/hari)
15-40 (maks. 900 mg)

Rifampisin

10-20 (maks. 600

mg)
10-20 (maks. 600

15-20 (maks. 600 mg)

Pirazinamid
Etambutol
Streptomisin

mg)
15-40 (maks. 2 g)
15-25 (maks. 2,5 g)
15-40 (maks. 1 g)

mg)
50-70 (maks. 4 g)
50 (maks. 2,5 g)
25-40 (maks. 1,5 g)

15-30 (maks. 3 g)
15-25 (maks. 2,5 g)
25.40maks. 1,5 g)

INH

3. Operative
Operative measures conducted for the purpose of sequestering appointment.
Tracheostomy is indicated in case of laryngeal obstruction.
tracheostomy
Tracheostomy is the act of making luabang on the front wall / anterior tracheal
breathing. Tracheostomy performed on the indication, the following:
- Overcoming laryngeal obstruction
- Reduce the dead space (dead air space) in the upper airway as the area of the
oral cavity, around the tongue and pharynx.
- Easing the secret exploitation of the bronchi in patients who are not able to
issue a secret physiologically.
- To put on a respirator (breathing apparatus).
- To menambil foreign objects from subglotik, if it does not have facilities
bronchoscopy.
Tracheostomy in cases of tuberculosis laryngitis done on indications that in
case of laryngeal obstruction and reduces the dead space in the upper airway as the
area of the oral cavity, around the tongue and pharynx.

PROGNOSIS
Depending on the socio-economic condition of the patient, healthy living
habits and perseverance treatment. When the diagnosis can be established at an early
stage, the prognosis is good.

COMPLICATION
Laryngitis due to inflammation of other areas they can lead to progressive
inflammation and can cause breathing difficulties. This can be accompanied by
difficulty breathing stridor well in the period of inspiration, expiration, or both.

Laryngitis tuberculosis sequelae can occur, including the posterior glottis stenosis,
subglottic stenosis, paralysis of the vocal cords, and persistent dysphonia

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