Acute epiglottitis (AE), or more precisely termed supra-glottitis [121, 331], is a potential risk of fatal airway obstruction in previously healthy persons. In the past, AE was mainly a childhood disease caused by Haemophilus influenzae type B. Due to the introduction of an immunisation programme in the late 1980s, the disease has been steadily decreasing in children, but still has a high incidence in the adult population, more frequently in a form related to infections with pyogenic cocci [75,

Laryngeal tuberculosis (LT) was considered one of the most common diseases in the pre-antibiotic period, affecting the larynx in 35 to 83% of patients with pulmonary tuberculosis [268, 390]. By the 1980s, the disease had become very rare in the developed world, owing to the advent of antibiotic therapy, immunisation and improved social and economic conditions. However, since 1980, tuberculosis has again been showing a rising in-

Fig. 7.3. Laryngeal tuberculosis. Granulomas are composed of epithelioid cells, Langerhans giant cells without necrosis, surrounded by mononuclear inflammatory cells

cidence worldwide, including developed countries, owing to the spread of the HIV infection, poor living standards with malnutrition, the emergence of drug-resistant mycobacteria and immigration from countries where tuberculosis is still endemic [61, 78, 125, 184, 268, 311, 315]. Consequently, the World Health Organisation has declared tuberculosis to be a global emergency [258].

LT currently affects mostly males; the average age of patients is about 50, with a history of heavy drinking and smoking. The most common presenting symptom is dysphonia, followed by dysphagia, odynophagia, stridor, a cough, and haemoptysis, generally associated with more or less obvious signs of pulmonary involvement [315, 390]. The true vocal cords are most commonly affected, although the supraglottic region is also involved [311]. The majority of cases present as hypertrophic, exophytic, hyperaemic lesions, sometimes nodular or ulcerated.

Histologically, the subepithelial stroma contains ca-seating granulomas with a central caseous necrosis, surrounded by epithelioid macrophages, Langerhans-type giant cells and lymphocytes (Fig. 7.3). The covering epithelium may be normal, ulcerated or show pseudoepi-theliomatous hyperplasia. Identification of Mycobacterium tuberculosis by special stainings or molecular genetic methods confirms the diagnosis of LB.

Differential diagnosis includes a large spectrum of granulomatous diseases, such as sarcoidosis, cat-scratch disease, fungal infections, Wegener's granulomatosis and tumourous lesions. Differentiation between sar-coidosis and tuberculosis is difficult. Generally, granulomas in sarcoidosis lack caseation and stainings for mycobacteria are negative. Cat-scratch disease can be ruled out by the presence of rounded or stellate gran-

ulomas containing central granular debris and neutro-phils. Fungal granulomas can be confirmed by identification of the microorganism. Granulomas in Wegener's granulomatosis are not closely packed, fibrinoid necrosis of collagen is prominent and vasculitis is occasionally present.

The treatment of LT primarily consists of antituber-culous treatment, while surgical procedure is reserved for cases of air compromise [390].

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