Pseudomonas laryngeal perichondritis: unexpected diagnosis.

A 57-year-old male chronic smoker with underlying diabetes mellitus presented with dysphonia associated with cough, dysphagia and reduced effort tolerance of 3 months' duration. Videoendoscope finding revealed bilateral polypoidal and erythematous true and false vocal fold with small glottic airway. The patient was initially treated as having tuberculous laryngitis and started on antituberculous drug. However, no improvement was observed. CT of the neck showed erosion of thyroid cartilage, which points to laryngeal carcinoma as a differential diagnosis. However, the erosion was more diffuse and appeared systemic in origin. The diagnosis of laryngeal perichondritis was made when the histopathological examination revealed features of inflammation, and the tracheal aspirate isolated Pseudomonas aeruginosa The patient made a good recovery following treatment with oral ciprofloxacin.

Candidiasis Causing Vocal Fold Leukoplakia: Review of Clinical and Pathological Results of 289 Cases With Vocal Fold Leukoplakia.

OBJECTIVE: In laryngology practice, vocal fold leukoplakia is frequently evaluated by suspension laryngoscopy and biopsy examination upon the patient's complaints of hoarseness and dysphonia. The purpose of the present study is to investigate and analyze risk factors, diagnosis, treatment, and follow-up results of cases with Candida leukoplakia. STUDY DESIGN: Retrospective case control study. SETTING: Tertiary medical center. SUBJECTS AND METHODS: Patients with a diagnosis of vocal fold leukoplakia who underwent direct laryngoscopy and biopsy between 2007 and 2017 and diagnosed as candida or noncandida in their histopathology were assigned into 2 groups. Then they were compared in terms of their demographic characteristics, predisposing factors, diagnosis, treatment, and follow-up results. RESULTS: Of the 289 vocal fold leukoplakia cases, 36 were candida, and 253 were noncandida. The mean age of the patients with Candida leukoplakia was 60.86 years. As for the age groups, the largest group (26.1%) was in the seventh decade (P < .001). The use of inhaled corticosteroids was a significant risk factor (P < .001). For their medical therapy, the patients were administered fluconazole 200 mg per day for 3 weeks, and the treatment yielded successful results in 91.66% of them. In 5 of the patients, candida leukoplakia and superficial epithelial dysplasia were observed, and no malignant transformation was observed during a mean follow-up of 28 ± 13 months. CONCLUSION: Candidiasis causing vocal fold leukoplakia is rare, and we report the findings of the largest published case series to date. Eliminating predisposing factors and administrating oral fluconazole 200 mg for 3 weeks are sufficient for medical treatment.

Primary Laryngeal Tuberculosis: Our Experiences at a Tertiary Care Teaching Hospital in Eastern India.

INTRODUCTION: Primary laryngeal tuberculosis is a chronic bacterial infection of the larynx by Mycobacterium tuberculosis without affecting the lungs. It is a rare type of extrapulmonary tuberculosis seen in clinical practice. OBJECTIVES: This study aimed to evaluate the clinical presentation, diagnosis, and treatment of primary laryngeal tuberculosis at a tertiary care teaching hospital in eastern India. MATERIALS AND METHODS: This is a retrospective study of 11 cases of primary laryngeal tuberculosis managed between December 2013 and January 2018. The detailed clinical presentations, investigations, and treatment of primary laryngeal tuberculosis of the patients were studied. RESULTS: Primary laryngeal tuberculosis is common in men with mean age of 38.63 years. Hoarseness of the voice is the most common symptom, and the most common site for primary laryngeal tuberculosis is the vocal fold with ulcerative lesion. Endoscopic examinations of the larynx in laryngeal tuberculosis are nonspecific and are to be confused with laryngeal cancer. Histopathological and bacteriological examinations are confirmatory tests for the diagnosis. After confirmation of the diagnosis, all patients had taken antitubercular therapy for 6 months, which gave excellent outcome. CONCLUSIONS: Delayed diagnosis or untreatable laryngeal tuberculosis will lead to high morbidity and mortality of the patient. Although primary laryngeal tuberculosis has nonspecific clinical presentations, it is very important to have a high index of suspiciousness to rule out tubercular lesion in the larynx as this disease is curable.

A comparison of sampling methods for examining the laryngeal microbiome.

Shifts in healthy human microbial communities have now been linked to disease in numerous body sites. Noninvasive swabbing remains the sampling technique of choice in most locations; however, it is not well known if this method samples the entire community, or only those members that are easily removed from the surface. We sought to compare the communities found via swabbing and biopsied tissue in true vocal folds, a location that is difficult to sample without causing potential damage and impairment to tissue function. A secondary aim of this study was to determine if swab sampling of the false vocal folds could be used as proxy for true vocal folds. True and false vocal fold mucosal samples (swabbed and biopsied) were collected from six pigs and used for 454 pyrosequencing of the V3-V5 region of the 16S rRNA gene. Most of the alpha and beta measures of diversity were found to be significantly similar between swabbed and biopsied tissue samples. Similarly, the communities found in true and false vocal folds did not differ considerably. These results suggest that samples taken via swabs are sufficient to assess the community, and that samples taken from the false vocal folds may be used as proxies for the true vocal folds. Assessment of these techniques opens an avenue to less traumatic means to explore the role microbes play in the development of diseases of the vocal folds, and perhaps the rest of the respiratory tract.

Evaluation of voice disorders in patients with active laryngeal tuberculosis.

INTRODUCTION: Laryngeal tuberculosis (LTB) is the most frequent larynx granulomatous disease. In general there is lung involvement, but in an important proportion of cases you can find LTB without pulmonary disease. The lesions observed in LTB, such as ulceration and fibrosis, can interfere in the process of voice production. The involvement of the mucous lining of the vocal folds can change their flexibility and, consequently, change voice quality, and the main symptom is dysphonia present in almost 90% of cases. OBJECTIVE: To describe the anatomical characteristics and voice quality in LTB patients. MATERIAL AND METHOD: A descriptive cross-sectional study was conducted with 24 patients. RESULT: The most frequently affected sites were vocal folds in 87.5% patients, vestibular folds in 66.7%, epiglottis in 41.7%, arytenoid in 50%, aryepiglottic folds in 33.3%, and interarytenoid region in 33.3% patients. We found 95.8% cases of dysphonia. The voice acoustic analysis showed 58.3% cases of Jitter alterations, 83.3% of Shimmer and 70.8% of GNE. CONCLUSION: Voice disorders found in active laryngeal tuberculosis are similar to those reported after clinical healing of the disease, suggesting that sequelae and vocal adjustments may install during the active phase of the disease, negatively impacting the process of vocal quality reestablishment.

Cryptococcal infection of the vocal folds.

Cryptococcosis of the larynx is rare. In this manuscript we present a case of laryngeal cryptococcosis with a clear history of pigeon exposure. Cryptococcal laryngitis may present as hoarseness without other typical symptoms, even in immunocompetent individuals.

Bacterial biofilm associated with chronic laryngitis.

OBJECTIVE: To determine the incidence of biofilm on the vocal fold epithelium of patients with chronic laryngitis. Bacteria can grow in biofilm protected by a glycoprotein mass. Recent studies have shown the importance of biofilm in chronic otolaryngologic infections. Because chronic laryngitis is often recurrent and occasionally purulent, we hypothesized that it is biofilm related. DESIGN: Prospective, controlled, blinded study. Epithelial biopsy specimens from true vocal folds from patients with chronic laryngitis undergoing diagnostic laryngomicroscopy were prepared for confocal scanning laser microscopy (CSLM) and polymerase chain reaction (PCR) microarray: CSLM images were evaluated for bacterial biofilm morphologic characteristics; PCR with microarray-based diagnostic assay was used to identify the bacterial species involved. Patients with vocal fold polyp served as control cases. SETTING: Tertiary care university hospital. PATIENTS: Eighteen consecutive patients were enrolled in the study. Thirteen of them had chronic laryngitis, and 5 had vocal fold polyps. RESULTS: In 9 cases, the CSLM revealed bacterial growth in biofilm form, and most of these specimens (8 out of 9) were from patients with chronic laryngitis. The PCR results were positive in 13 cases, including all 9 biofilm-positive cases. CONCLUSIONS: Direct detection of biofilm in laryngeal biopsy specimens from patients with chronic laryngitis supports the hypothesis that chronic laryngitis may be biofilm related. Biofilm was found in 62% of the cases of chronic laryngitis. To our knowledge, this is the first report of bacterial biofilm associated with chronic laryngitis; however, further investigation is warranted before a clear conclusion can be drawn.

Methicillin-resistant Staphylococcus aureus laryngitis: a report of two cases with different clinical presentations.

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) infection has been described in multiple areas of the head and neck. Recently, otolaryngologists have recognized MRSA infection in the glottis. We describe 2 cases of MRSA laryngitis with divergent clinical presentations: acute airway obstruction and recalcitrant hoarseness. METHODS: Report of 2 cases and review of the literature. RESULTS: In the first case, a 44-year-old woman presented with near aphonia despite maximal medical therapy. Examination showed diffuse erythema and edema of the endolarynx with yellowish plaques lining the glottis and supraglottis. Complete resolution was achieved with long-term trimethoprim-sulfamethoxazole. In the second case, a 54-year-old woman presented with recent-onset hoarseness with rapid progression to respiratory distress and biphasic stridor. Endoscopy revealed exuberant granulation tissue in the glottis with a narrowed airway. Treatment required prolonged courses of antibiotics and steroids. Diagnosis in both cases was confirmed with biopsies taken during direct laryngoscopy. CONCLUSIONS: MRSA treatment is a growing part of otolaryngologic practice and should be included in the differential diagnosis of hoarseness and stridor.

[Helicobacter pylori infection: a potential pathogenic factor for laryngeal squamous cell carcinoma].

OBJECTIVE: To investigate the difference in Helicobacter pylori (Hp) infection rate between the patients with laryngeal squamous cell carcinoma and the patients with benign laryngeal lesions and to explore the role of Hp infection in the pathogenesis of laryngeal squamous carcinoma. METHODS: Nested polymerase chain reaction (nPCR) and Hp culture were used to identify the Hp in laryngeal mucosa in 30 patients with laryngeal carcinoma and 15 patients with benign laryngeal lesions including polyps of vocal cords or epiglottic cysts. RESULTS: nPCR showed that Hp-positive rate (73.3%) of patients with laryngeal carcinoma was significantly higher than that (20.0%) of control patients with benign laryngeal lesions (χ(2) = 11.520, P = 0.010). Regarding the 22 positive neoplastic cases that have 44 tissues, out of the 22 tumor tissues, 10 were positive with Hp (45.4%), and among 22 tissues beside the tumor, 19 were positive (86.4%). This event also indicated a statistical significance (χ(2) = 4.697, P = 0.030). Hp culture showed that Hp was negative in all specimens. CONCLUSIONS: Hp exist in the laryngeal mucosa, but with the higher rate of Hp infection in the patients with laryngeal squamous cell carcinoma than that in the patients with benign laryngeal lesions, which suggests Hp may be one of pathogenic factors of laryngeal squamous cell carcinoma.

Human vocal cord infection with the Microsporidium Anncaliia algerae.

We describe a biopsy proven case of microsporidial infection of the false vocal cords in a 69-yr-old male with a history of chronic lymphocytic leukemia. The patient had hoarseness for several weeks before his admission to the hospital for shortness of breath. He had received chemotherapy with fludarabine 6 wk before this hospital admission. A biopsy of vocal cord nodules demonstrated an organism that was identified as Anncaliia algerae by electron microscopy. Molecular analysis of the small subunit RNA gene amplified by polymerase chain reaction further confirmed the identification of this organism as A. algerae. This case illustrates the ability of this insect pathogen to cause disease in immune-compromised mammalian hosts.

Helicobacter pylori and its role in vocal folds' minimal lesions.

BACKGROUND: Chronic laryngitis and/or vocal fold minimal lesions (VFMLs) are common associations with gastro esophageal reflux disease. Helicobacter pylori (HP) is a Gram-negative spiral organism accused of being a common cause of gastritis, gastroesophageal reflux disease and peptic ulcer. HP has been recently isolated from tonsils, adenoids, sinus and middle ear mucosa in patients with chronic sinusitis or chronic middle ear effusion. OBJECTIVE: The objective of this study is to assess the presence of HP in VFMLs. METHODS: The study included 14 patients with VFMLs [six cases with vocal fold polyps and four cases with vocal fold nodules, and four cases with posterior granulomas; one of them associated with right vocal fold (VF) nodule]; all underwent carbon-13 urea breath test, esophago-gastro-duodenoscopy with gastric biopsy and direct laryngoscopy with microlaryngosurgery to extract the VF lesions. Biopsies were subjected for two tests: detection of the 23S ribosomal RNA gene of HP by real-time polymerase chain reaction (RT-PCR) and immunohistochemical reactions (IHC). RESULTS: HP was detected by RT-PCR in 10 of 14 patients with VFML; HP was also detected by IHC in the same number of VFML and gastric mucosa specimens. CONCLUSION: HP is a common finding in cases of VFML; its eradication should be considered when dealing with a patient with VFML.

Clinical and histopathologic examination of ulcerating vocal fold lesions in an immunosuppressed patient.

We present the unique opportunity to correlate videostroboscopic findings with histologic examination. An immunocompromised patient with hoarseness because of ulcerative lesions of both vocal folds of uncertain cause died within a few weeks of initial presentation, and the larynx was donated for postmortem examination. Relevant history, as well as endoscopic and histopathologic findings, is presented.

Atypical mycobacteriosis of the larynx: an unusual clinical presentation secondary to steroids inhalation.

Vocal cords stiffness can be associated with a variety of etiologic agents, but it is rarely seen with atypical mycobacteria, for example, Mycobacterium avium complex. We report a case of a 35-year-old white woman who is and was maintained on inhaled steroids. She presented with hoarseness and low-grade fever, but her medical history was otherwise unremarkable. Laryngoscopy revealed bilateral scarring of the vocal cords. Vocal cord biopsies were performed. Histologic examination revealed unremarkable laryngeal mucosa, except for abundant subepithelial non-necrotizing granulomata. The differential diagnosis included sarcoid, Klebsiella scleroma, and tuberculosis. Special stains reviewed abundant acid-fast bacilli, later confirmed by a DNA assay on induced deep sputum, consistent with M avium complex. Subsequently, steroids were withdrawn, and the patient was treated with a multiple-drug antituberculous regimen and had a full recovery. This unusual clinical presentation of the atypical mycobacteriosis may be encountered by otolaryngologists and pathologists, and it is critical to recognize it in patients immunocompromised because of steroids.

Primary vocal cord aspergillosis caused by Aspergillus fumigatus and molecular identification of the isolate.

This is a case of vocal cord aspergillosis in a 36-year-old woman whose chief complaint was progressive hoarseness and vocal fatigue of one month duration. These symptoms followed the use of systemic administration of penicillin, cefotaxime natrium and dexamethasone to treat her rhinitis and asthma. Fiberoptic laryngoscopy revealed whitish plaques involving both vocal cords. Microscopic examination of KOH preparations and histopathology studies of tissue revealed dichotomously branching, hyaline, septate hyphae. Morphological and molecular biological identification of the fungal growth in cultures inoculated with clinical specimens from the patient indicated that the etiologic agent was Aspergillus fumigatus. The patient was cured with oral itraconazole without any side effects.

Does subepithelial hemorrhage cause persistence of laryngeal granuloma?

OBJECTIVES: To determine the incidence of black spots after resolution of laryngeal granuloma (LG), to compare the disease duration from the beginning of treatment to resolution between patients with and without black spots, and to assess the histologic findings of LG in resected or biopsied specimens. STUDY DESIGN: Retrospective. METHODS: Forty-six patients with LG on the cartilaginous portion of the vocal fold were included. Their clinical records were reviewed. Histologic specimens were re-examined. RESULTS: Causes of LG were postintubation in 10 patients, unilateral vocal fold immobility in 1, Candida infection in 1, and were not specified in 34 (either hyperfunctional vocal abuse, laryngopharyngeal regurgitation, or both). Of the 10 patients with postintubation LG, 9 resolved; of the 33 patients with LG from other causes, 21 resolved. Of the 28 resolved patients, 12 developed a black spot at the previous lesion site. Of the 18 patients whose LG resolved without surgical intervention, 11 developed a black spot at the previous lesion site, and the remaining 7 patients did not develop any black spots. The treatment period until LG resolution was significantly longer among patients with a black spot than those without a spot (P = .0372). Histologic examination revealed the presence of hemosiderin accumulation accompanied by infiltration of lymphocytes and macrophages in 8 of the 16 patients who had their LGs resected or biopsied. CONCLUSIONS: Accumulation of hemosiderin in the subepithelial layer, together with little blood flow and dense connective tissue in the cartilaginous portion of the vocal fold, are important factors contributing to the persistence of LG.

Helicobacter pylori colonization in the larynges of patients with hoarseness.

OBJECTIVES: Vocal nodules and polyps are two common noninfectious causes of hoarseness. Patients with persistent hoarseness often require microscopic laryngeal surgery to excise mass lesions of the larynx despite extensive voice resting and modification of voice use behavior. Helicobacter pylori has recently been reported to present in the upper aerodigestive tract. This study applies the rapid urease test to determine the colonization of Helicobacter pylori in surgical specimens of patients with vocal nodules and polyps. METHODS: In this prospective study, 53 consecutive patients with vocal nodules (n = 20) or vocal polyps (n = 33) were investigated from November 2004 to July 2005. Microscopic laryngeal surgery was performed in all cases. Tissue specimens harvested from the larynx were analyzed using the rapid urease test. RESULTS: The study population consisted of 33 females and 20 males with a mean age of 43.1 +/- 9.9 years. Thirteen (24.5%) of the 53 patients revealed Helicobacter pylori colonization, and all were histopathologically diagnosed with vocal polyps. The difference in incidence of Helicobacter pylori colonization between vocal nodules and vocal polyps was statistically significant (0% [0/20] vs. 39.4% [13/33], P = .001). CONCLUSIONS: Helicobacter pylori often colonizes in the larynxes of patients with vocal polyps. These results indicate the involvement of Helicobacter pylori in vocal polyps. However, the presence of Helicobacter pylori as an etiologic factor in vocal polyps remains inconclusive.