Management of laryngeal stenosis secondary to multifocal tuberculosis: Case report
Laryngeal stenosis is a permanent narrowing, most often acquired, of the laryngeal pathway. It is generally of progressive constitution, linked to an organic damage to the walls of the respiratory tract by a new tissue, usually fibrous, which eliminates the strictures by compression, the strictures of tumour origin and the laryngeal paralysis. It is largely dominated by the sequelae of assisted ventilation.
Before the advent of it, most laryngeal strictures were secondary to infections such as diphtheria, measles, smallpox, typhus, syphilis, leprosy, tuberculosis. Clinically, it manifests itself by nonspecific signs, limited to the larynx or part of a multi-organ pathology. Its eminently bacilliferous character requires rapid diagnosis and medical treatment.
Evaluating the degree and extensions of the stenosis is an essential prerequisite for any therapeutic management, the goal of which must be the restoration of a satisfactory respiratory system while preserving acceptable phonation. If the etiology, pathogenesis, and clinical aspects of laryngeal stenosis are currently well known, therapeutic management remains controversial, as evidenced by the multiplicity of surgical techniques and the lack of uniformity in therapeutic management.
The objective of paper published by Samaké Djibril was to report a case of laryngeal stenosis secondary to multifocal tuberculosis in order to discuss the difficulties associated with its management in a developing country.
A 35-year-old 40 packs / year smoker had been weaned for two weeks. Admitted on 12/04/2017 to the ENT department of CHME "Luxembourg" for dysphonia. The onset of symptoms would go back to about 7 months marked by dysphonia, especially in the morning, regressing during the day. It evolved on a permanent background followed by intermittent dysphagia to solid foods often accompanied by false routes. There was no dyspnea. Uncounted weight loss, asthenia and a feeling of fever were reported.
On physical examination, the general condition was altered with a Karnoski index at 50%, a weight of 48 kg. The first laryngoscopy of 07/12/2017 showed a disseminated ulceration of the laryngeal rim and vocal folds covered with mucopurulent secretion not bleeding on contact. The endo-laryngeal biopsy performed showed necrotic granulomatous laryngitis. The tuberculin intradermal reaction (IDR) measured 10 mm. A frontal chest X-ray performed showed reticulo-micronodular infiltrates associated with thickening of the bronchial walls sparing the two pulmonary bases suggesting an infectious origin. No pleural effusion or mediastinal abnormality was seen.
A gastric tube performed was positive with two crosses. The blood count revealed microcytic hypochromic anaemia and polynuclear neutrophilic hyperleukocytosis; CRP was high; HIV serology was negative and fasting blood sugar was normal.
These clinical and paraclinical elements made it possible to evoke the diagnostic hypothesis of laryngeal tuberculosis secondary to a pulmonary focus. The patient was put on oral tuberculosis treatment for six months on the two-month regimen of Rifampicin, Isoniazid, Pyrazinamide, Ethambutol and four months of Rifampicin, Isoniazid. Two weeks after the start of this treatment, inspiratory dyspnea suddenly set in. A control laryngoscopy revealed partial synechia (posterior commissure and interarytenoid notch) of the larynx with fixation of the arytenoids, considerably reducing the laryngeal pathway.
Faced with the absence of laser reconstructive microsurgery in country, authors performed symptomatic treatment such as tracheotomy. These various treatments made it possible to obtain a favorable outcome with gradual improvement of the general condition, the disappearance of clinical signs with weight gain. However, it was noted after 12 months of evolution the persistence of certain complications such as scarring stenosis sequelae of the larynx despite attempts of permeabilization with the impossibility of decannulating the patient.
Acquired laryngotracheal stenosis can be secondary to several etiology. However, prolonged endotracheal intubation remains the most common cause with 90% of cases. In this case it was secondary to multifocal tuberculosis.
Epidemiologically, laryngeal tuberculosis affects the same populations as pulmonary tuberculosis (socially disadvantaged individuals, migrants from countries with a high tuberculosis endemic, immuno compromised individuals, health workers). Alcoholism and to a lesser extent smoking are two known risk factors which explain, in addition to nonspecific laryngeal clinical signs, the frequent diagnostic confusions with laryngeal squamous cell carcinoma. It is more common in men than in women.
Laryngeal tuberculosis may be the only site of infection or may occur in a multi-organ setting. In the latter case, dissemination takes place via the lymphatic or bloodstream routes and can involve all organs. However, the association of laryngeal and pulmonary involvement is the most common. This infection of the cartilaginous and periarticular mucosa can lead to chondritis and periarthritis; their evolution can take place in a fibrous healing mode which can thicken the mucosa or create cricoarytenoid ankylosis, constitutive of laryngeal stenosis. The infection can go as far as necrosis of the cartilage, which creates a loss of the framework, the main element of strictures; it can also produce arthritis, resulting in arytenoid immobility
Laryngeal tuberculosis is diagnosed on clinical, radiological and bacteriological arguments (direct microscopic examinations, cultures, identification of the bacillus and antibiogram) and on characteristic anatomopathological signs (epithelio-giganto-cellular granuloma with caseous necrosis).
The management of laryngeal stenosis in adults is complex in its indications and in its implementation. It involves several diagnostic and therapeutic steps, involving several general anesthesias and, in some cases, requiring a tracheotomy as was in this case. Trans-oral laser reconstructive microsurgery (R-TLM) can effectively treat this type of stenosis and decannulate the patient. The total duration of the treatment before reaching decannulation is very often several months.
Laryngeal stenosis secondary to multifocal tuberculosis remains a rare and dreadful pathology. Clinically, it manifests itself by nonspecific signs, limited to the larynx or part of amulti-organ pathology. Treatment is often difficult, with several treatment options. The early and adequate management of this pathology conditions the therapeutic success.
Source: Samaké Djibril et al.: Laryngeal Stenosis, a Complication of Multifocal Tuberculosis