GRANULOMATOUS CONDITIONS OF LARYNX

DEPT OF OTORHINOLARYNGOLOGY

J J M M CDAVANAGERE

TUBERCULOSIS OF LARYNX

• Almost always associated with open pulmonary Tuberculosis

• Due to contamination of sputum containing acid fast bacilli

• May rarely develop by blood borne infections which causes extensive ulceration of mucosa

• Common age group : 20-40 yrs• Incidence increasing due to

emergence of AIDS

TUBERCULOSIS OF LARYNX- PATHOLOGY

• Posterior part of larynx affected than anterior

• Formation of submucosal tubercles which later may caseate and ulcerate producing undermined ulcers

• There may be infiltration of epiglottis and arytenoids

• Self limiting to some extent –> heals with fibrosis-> stenosis of larynx

• With reparative process tumor like swellings are found called Tuberculomas

• there may be diffuse oedematous reaction consistent to allergic response to AFB

TUBERCULOSIS OF LARYNX- SYMPTOMS

• Throat pain • Referred otalgia• Hoarseness with weakness of voice

(earliest symptom)• Painful speech• dysphagia

TUBERCULOSIS OF LARYNX- SIGNS

• Mucosal hyperemia and oedema• Inter-arytenoid mamillations• Undermined ulcers- mouse nibbled

appearance • Turban epiglottis• Ragged ulcerations on arytenoids and

inter-arytenoid region• Granulation tissue in inter-arytenoid

region• Pale laryngeal mucosa

TUBERCULOSIS OF LARYNX- DIAGNOSIS

• Chest X-ray

• Sputum examination for AFB

• Laryngoscopic examination

• Biopsy of laryngeal lesion

TUBERCULOSIS OF LARYNX- TREATMENT

• Anti tubercular drug regimen

• Vocal rest

• Nutritional supplements

SCLEROMA OF LARYNX

• Klebsiella rhinoscleromatis is the causative organism

• Laryngeal involvement is seen with or without nasal lesion

• Subglottic region is commonly involved

SCLEROMA OF LARYNX- SYMPTOMS AND SIGNS

• Non specific symptoms as seen in other chronic laryngeal infections like hoarseness, wheeze

• Dyspnoea may be presenting symptom in addition to nasal lesion

• Presents as smooth red swelling in subglottic region

SCLEROMA OF LARYNX- DIAGNOSIS

• Biopsy of the lesion• Histopathology -> specimen shows

Mikulicz cells, Russell bodies, gram negative organism within the Mikulicz cell

• Culture of organism from biopsy material

SCLEROMA OF LARYNX- TREATMENT

• Medical combination of an aminoglycoside such as gentamycin with an anti-metabolite such as tetracyclin

• Steroids to reduce fibrosis• Surgical1. Endoscopic removal of granulomatous

tissue2. Mild stenosis dilatation3. Severe subglottic stenosis

tracheostomy

SYPHILIS OF LARYNX

• Now rarely seen• All stages can manifest in larynx• Primary lesion described rarely• Tertiary stage is most important

gamma are seen• Peri arterial infiltration and

obliterative endarteritis• Prediliction for anterior part of

larynx epiglottis and AE folds

SYPHILIS OF LARYNX

• Oedematous mucosa with infiltration of plasma cells, lymphocytes and giant cells

• Deep ulceration with central sloughing

• Abundant necrotic tissue reaches and penetrates laryngeal cartilages

• Considerable destruction after healing leaves deformity of larynx and often stenosis

SYPHILIS OF LARYNX- CLINICAL FEATURES AND

MANAGEMENT• Hoarseness, sometimes dysphagia, pain

is rare• Oedema of mucosa leading to stridor • Diagnosis only on biopsy and serological

tests• Treatment Prolonged treatment with

high doses of penicillin• Local treatment by inhalation• Endoscopic removal of necrotic tissue to

maintain airway• tracheostomy

LEPROSY OF LARYNX

• Caused by mycobacterium leprae (Hansen's bacillus)

• Both lepromatous and tuberculoid can arise in larynx

• Epiglottis and AE fold most commonly affected

• Granulomatous swelling and often ulceration and destruction in supraglottic region

• Epiglottis may be curled• Mucosa may be studded with nodules• Virchow cells ( foamy histiocytes) and

mucosal thickening seen on HPE

LEPROSY OF LARYNX- TREATMENT

• Medical Dapsone, Clofazimine, Rifampicin

• Surgical tracheostomy in cases of stenosis

WEGENER’S GRANULOMATOSIS

• Diffuse systemic disease of unknown cause• Includes triad of necrotizing granulomatous

lesion in upper and lower respiratory tract (sinusitis, rhinitis), vasculitis involving pulmonary arteries and veins and necrotizing glomerulonephritis

• Larynx is rarely source of primary manifestation

• Lesion usually lies in subglottis laryngeal obstruction

• Edematous mucosa with granular appearance which bleeds easily and sometimes ulcerates

• If untreated can be rapidly fatal• Immunosuppressive drugs especially

cyclophosphamide are very active• Steroids should be started early

SARCOIDOSIS OF LARYNX

• Chronic idiopathic granulomatous disease also called Besnier-Boeck disease

• Head and neck manifestations in 10% of whom only minor proportion have laryngeal disease

• Disease is usually self limiting• Pathology non specific granuloma

later fibrosis and hyalinization• Main site involved is supraglottis

SARCOIDOSIS OF LARYNX- CLINICAL FEATURES AND MANAGEMENT

• Hoarseness, dysphagia and dyspnoea • Epiglottis and false vocal cords are

swollen and pale• True cords and subglottis rarely affected• Lesion can progress rapidly leading to

life threatening airway obstruction• Diagnosis biopsy • Positive Kveim’s test, elevated serum

angiotensin converting enzyme is highly suggestive

• Treatment high dose corticosteroids, tracheostomy

LUPUS OF LARYNX

• Indolent tubercular infection associated with lupus of nose and pharynx

• Involves anterior part of larynx.• Epiglottis is involved first and may be

completely destroyed. disease spreads to AE fold and ventricular bands.

• Painless asymptomatic condition may be discovered incidentally

• Prognosis is good• Treatment is anti tubercular drugs

MYCOSIS OF LARYNX

• Following mycosis can occur in the larynx1. Candidiasis2. Coccidioidmycosis3. Paracoccidioidmycosis4. Histoplasmosis5. Blastomycosis6. Cryptococcosis7. aspergillosis