445

Laryngeal

Woo

Kyung Mooni
Moon
Hee Han1

Kee Hyun

Chang1

Hyung-Jin
Kim2
Jung-Gi lm1

Kyung
Man

MoYeon1

Chung

Han1

OBJECTIVE.The
tuberculosis

purpose

CT Findings

of this study was to evaluate

the CT findings

of laryngeal

(TB).

SUBJECTS
radiographs

Tuberculosis:

AND

METHODS.

CT scans,

laryngoscopic

examinations,
and chest
= 8) or bacterlologi-

of 12 patients (21-63 years old) with histologically

(n
4) confirmed
laryngeal TB were retrospectively
reviewed.

cally (n =
RESULTS. Bilateral diffuse thickening of the vocal cords and diffuse thickening and
increased density of the aryepiglottic folds and paralaryngeal
tissues were present in
all patients. Diffuse thickening of the epiglottis was observed in seven patients. In
four patients,

a focal

mass

3) or tip of the epiglottis

Subglottic

extension

was noted
(n

of the

in the anterior

1). Destruction

lesion

was

portions

or sclerosis

suspected

in only

of the vocal

of cartilage
one

patient.

cords

(n

was not found.

Enlarged

caM-

cal lymph nodes were found in five patients.

On laryngoscopic
examinations,
swelling of the vocal cords (n = 12) or epiglottis (n = 6) was present in all patients and was
bilateral
in nine patients. Vocal cord mobility was impaired
in only one patient. Radio-

graphic findings consistent with active pulmonary TB were present in all patients.
CONCLUSION.
Although the CT appearances
of laryngeal TB are not specific, the
possibility
of laryngeal TB should be raised when bilateral and diffuse laryngeal
lesions are encountered
without destruction of the laryngeal architecture
in patients
with pulmonary TB.
AJR

Received July 17, 1995: accepted

September 22,
Presented

can

at the annual

Roentgen

meeting

Ray Society,

April-May 1995.
1 Department
of Radiology,

versity

after revision

1995.

College

of

of the Amen-

Washington,
Seoul

Medicine,

28

National

DC,
Uni-

Yongon-Dong

Chongno-Gu, Seoul 110-744. South Korea. Address correspondence

to M. H. Han.

2Department of Radiology, Gyeongsang National

University

College

of Medicine,

Chinju 660-280,

South Korea.
Presented

in part at the annual meeting of the

American

Roentgen

April-May

1995.

Ray Society,

Washington,

0361-803)096/1662-445

American

Roentgen

Ray Society

DC,

1996;166:445-449

Tuberculosis
(TB) of the larynx is now a rare form of extrapulmonary
TB. However, before the advent of modern anti-TB chemotherapy,
extrapulmonary
TB was
found in 25-30%
of patients with sputum that tested positive for tubercle
bacilli [1].
Today, the incidence
is estimated
to be less than 1 % of patients
with pulmonary
TB [2]. However,
it may occur more often in the future because
of the resurgence
of TB in Western
countries.
The natural history of laryngeal
TB has evolved during the past several decades
[3-5]. In the past, the typical patient was 20-40 years old and had advanced
cavitary lung disease.
Now it is more commonly
found in elderly
patients
with less
severe lung disease.
Prior to antibiotic
therapy, the posterior
larynx was predominantly involved,
but most current cases are reported
to involve the anterior
part of
the larynx and epiglottis
[4, 5], suggesting
hematogenous
or lymphatic
spread
rather than direct airborne
infection. These patients
frequently
pose a diagnostic
problem as well as a potential threat to the examining
physician
because
the lanyngeal lesion may simulate
a carcinoma
and is highly infectious.
Only a few reports of the radiologic
findings
of laryngeal
TB have appeared
[1,
2, 6, 7], most of which are descriptions
of conventional
radiography
and lanyngography. The findings
include swelling,
ulceration,
and masses
that most frequently
involve the vocal cords, epiglottis,
and anyepiglottic
folds [1 , 2]. Little has been
written about the CT appearance
of laryngeal
tuberculosis
[6-8]. Accordingly,
the
purpose
of the current study was to describe
the CT features
of laryngeal
TB.

446

MOON

Subjects

and Methods

Nineteen
patients
with histologically
or bacteniologically
firmed laryngeal
TB were identified
by a retrospective
review
medical

tions.

records

Fifteen

over

the

hundred

past

7 years

patients

ing the same period. Among

(1988-1994)

with pulmonary

at two

TB were

those 19 patients,

conof the
institu-

treated

dun-

CT was performed

on 12 (63%), and these patients

formed the subject group of the
study. All patients had lanyngoscopic
records and chest radiographs.
There were six men and six women
21-63 years old (mean, 39
years old). The presenting
symptoms
were progressive
loss of voice
on hoarseness
in all patients,
cough and sputum
in six patients

(50%),

odynophagia

in four patients

(33%),

and dyspnea

in three

patients (25%). Eight patients (67%) had a history of anti-TB therapy

for pulmonary
TB, and five patients (42%) were under anti-TB treatment at the time of the study. Pulmonany
disease was known prior to
the development
of the lanyngeal lesion in seven patients. No patient

had a previous

history

of laryngeal

neoplasm

or trauma,

nor was

any patient immunocompromised.

The diagnosis
was established
by direct lanyngoscopic
biopsy in
eight patients
(67%) and by positive acid-fast-bacillus
(AFB) staining of aspirated
materials
from the larynx and improvements
in
laryngeal
lesions after anti-TB therapy
in four patients
(33%). Pulmonary disease was confirmed
by positive sputum for AFB in eight
patients
(67%), by bronchoscopic
biopsy in three patients
(25%),
and by improvement
of pulmonary
lesions after anti-TB therapy on
plain radiognaphs
in one patient (8%).

CT was performed
examinations.

5-12

Ten studies

days (mean,
were

9800 scanner (General Electric

and two studies were performed

performed

Medical

6 days) after the clinical

with

Systems,

a GE 8800

or a

Milwaukee,

WI),

with a Somatom
Plus-S scanner
(Siemens
Medical,
Iselin, NJ). Scanning
was performed
with contiguous 3- to 5-mm sections
from Ci to the thoracic
inlet after IV
administration
of 2.5 mI/kg
of 76%
ioxithalamate
meglumine

ET AL.

AJR:166,

February

(Telebnix-38;
Guenbet
Laboratories,
Aulnay-sous-Bois,
Quiet breathing
was allowed during scanning.

CT scans

were

retrospectively

analyzed

was bilateral

or unilateral,

whether

France).

independently

radiologists,
with particular
attention
given to the location
of the lesions; when their interpretations
differed,
they
mutual agreement.
The radiologists
determined
whether

the lesion

1996

by

two

and extent
came to a
the lesion

was symmetric

or

asymmetric,
and whether there was a more swollen lesion that gave
the impression
of a focal mass.
Correlation
of CT and lanyngoscopic
findings
was done for all
patients.
The extent
of involvement
on chest
radiographs
was

graded using the National Tuberculosis

Associations
classification
[9]. Pulmonary disease was graded as minimal when the lesions
were noncavitany and did not exceed in total extent the area of one
lung above
fourth

or

the second
body

chondrosternal

of the

fifth

junction

vertebra

and

as

and the spine

moderately

of the

advanced

when the lesions did not exceed the area of one lung and had a total
cavitation
diameter
of less than 4 cm; more extensive
disease was
graded as far advanced.
All patients received
medical treatment.
Follow-up
assessment
of
clinical status was available
in 10 patients
with repeated
laryngoscopic studies. Ten patients
also had follow-up
chest radiographs.
The range of follow-up
was 2-28 months (mean, 6 months).

Results
Bilateral
diffuse
thickening
of the vocal
cords
was
observed
in all patients
(Figs. 1 and 2). Bilateral
diffuse thickening of the epiglottis
was seen in seven patients
(58%). The
vocal cord lesion was symmetric
in two patients
and asymmetric
in 1 0 patients.
The true and false vocal
cords,
aryepiglottic

in all patients.

folds,

and

Among

paralaryngeal

the seven

patients

spaces

who

were

involved

had thickening

Fig. 1.-Laryngeal
tuberculosis
in 32-year-old
woman.
A, CT scan obtained
at the tip of epiglottis
shows asymmetric
thickening
of epiglottis
(arrow)
and median glossoepiglottic
fold.
B, CT scan obtained at hyoid bone shows thickening of epiglottis
(arrow) and bilateral asymmetnc thickening
of aryepiglottic
folds with focal
hypodense
region on left side (arrowhead).
C, CT scan obtained
at false vocal cords shows
bilateral,
diffuse
thickening
of false vocal cords
and increased
density
of paralaryngeal
tissues.
Focal hypodense
region is also seen on left side
(arrowhead).
Enlarged
lymph nodes with central

low density

are seen in left internal

jugular and

right spinal accessory

chains (arrows).
D, CT scan obtained at true vocal cords shows
bilateral
diffuse
thickening
of vocal cords. Note
nodularity
in right anterior true vocal cord (arrow).

AJR:166,

February

LARYNGEAL

1996

TUBERCULOSIS:

of the epiglottis,
the base was predominantly
involved in five
patients
and the tip in two patients.
Four patients
(33%) had
a focal mass; in three of these patients the mass was at the
anterior
portion
of the vocal cords (Fig. 2) and in the other
the mass was at the tip of the epiglottis.
Thickening
of the
anterior commissune
was found in three patients
(25%) (Fig.
2).

Involvement

of the

paralaryngeal

spaces

appeared

as

reticulation
of the fat or edema in eight patients
(67%) (Fig.
1) and as a soft-tissue
mass
in four patients
(33%).
Increased
density of the preepiglottic
tissue was found in six
patients
(50%),
and thickening
of the glossoepiglottic
fold
was seen in three patients
(25%) (Fig. 1). In one patient,
a
focal hypodense
region was present in the thickened
aryepiglotticfold and false vocal cord (Fig. 1).
Although

encroachment

or deviation

was noted in four patients (33%),

the laryngeal
cartilage was seen
who had a focal mass

of the

no destruction
in any patient.

in the true vocal

cord,

laryngeal

airway

on sclerosis of
In one patient

soft-tissue

thicken-

ing extended
to the subglottic
region (Fig. 2C). Tracheal stenosis or wall enhancement
suggestive
of TB involvement
was
found in three patients (25%). Enlarged
cervical lymph nodes
were seen in five patients
(42%), four of whom had bilateral
lesions and one of whom had a unilateral lesion. A central, lowdensity area with peripheral
rim enhancement
was noted in four
patients (Figs. 1 and 2). Calcified nodes were not found in any
patient. Abnormal
lymph nodes were mostly
1 .5-2.0 cm in
maximal
diameter
(range, 0.7-2.7
cm; mean, 1 .8 cm). The
internal jugular
and the spinal accessory
nodes were most
commonly
involved, seen in four patients each.

Fig. 2.-Laryngeal
old man.
A, CT

scan

tuberculosis

obtained

at true

in 63-yearvocal

cords

shows focal mass lesion involving left cord

(arrow).
Anterior
commissure
(arrowheads)
right cord also are thickened.
B, CT scan obtained
at false vocal

and

cords
diffuse thickening
of left false cord
(arrow)
and paralaryngeal
space. Small node
with central low density is seen in right spinal accessory chain (arrowhead).
C, CT scan obtained
at subglottic region
shows soft-tissue thickening (arrow) suggestive
shows

of subglottic
extension
of lesion.
D, Chest radiograph shows areas of consolidation and cavitation
in both lungs, suggestive
of advanced
pulmonary
tuberculosis.

CT FINDINGS

447

Laryngoscopic
examinations
revealed swelling of the vocal
cords
in all patients
and swelling
of the epiglottis
in six
patients (50%). Five lesions (42%) were covered with whitish
patches on granules. The lesion was bilateral
in nine patients
(75%), unilateral
in three patients
(25%), symmetric
in two
patients
(22%), and asymmetric
in seven patients
(78%). In
five patients
(42%), an exophytic
on a polypoid
mass was
seen on the vocal cords (n = 3) or epiglottis
(n = 2). The site
of involvement
was widely distributed
and, contrary
to previous reports [4, 5], a predilection
for the posterior
larynx was
not noted. In nine patients
(75%), CT scanning
was better
than laryngoscopy
in demonstrating
the diffuse nature of the
disease.
In three patients
(25%), an ulcerative
lesion was
seen by lanyngoscopy.
With CT scanning
an ulcerative
lesion
was demonstrated
in only one patient, and it appeared
as a
focal hypodensity
in the lesion (Fig. 1). Vocal cord mobility
was impaired
in only one patient who had a multilobulated
mass at the left true vocal cord. On CT scans, the anterior
commissure,
night vocal cord, pamalamyngeal
spaces,
and
subglottis
also were involved in this patient. Laryngeal
stenosis and fibrosis
involving
the vocal cords was noted in only
one patient. In nine patients
(75%), carcinoma
of the larynx
was the initial diagnosis
following
laryngoscopy,
but in five
patients
(42%) younger
than 30 years, the clinical diagnosis
of TB on fungal infection also was suspected.
Chest radiogmaphs
revealed a pulmonary
abnormality
in all
patients,
of whom seven (58%) had bilateral
lesions. The
extent of the pulmonary
lesion was minimal
in three patients
(25%), moderately
advanced
in six patients
(50%), and far

MOON

448

advanced
in three patients
(25%). The radiographic
findings
were those of active TB such as poorly defined nodules
(n =
12), patchy consolidation
(n = 5), and cavities (n = 3) (Fig. 2D).
No patient had findings of primary TB (i.e., segmental
consolidation or mediastinal
Iymphadenopathy).
Of the 1 0 patients
in whom follow-up
assessment
was
done, all but one was clinically
improved,
with laryngoscopic
evidence
of partial (n = 3) or complete
(n = 6) resolution
of
the lesions with little fibrosis.
In one patient, laryngeal
stenosis and fibrosis
involving
the vocal cords persisted
oven the
2-year
follow-up
period.
Slow
but substantial
nadiologic
improvement
was seen on chest madiographs
in all patients.

Laryngeal
TB affecting
older patients
has been emphasized as the new expression
of this disease
[10-i 3]. However, the majority
of the patients
are still young adults. More
than half (n = 7; 58%) of our patients were in their 30s on 40s
and had both laryngeal
and pulmonary
complaints.
The
remaining
patients
(n = 5; 42%) were in their 605 or 70s and
complained
of progressive
hoarseness
and odynophagia
but
symptoms.

It was

in these

older

patients

that

biopsies
were performed
to mule out a malignant
tumor.
Virtually all patients with laryngeal TB have active pulmonary
TB. The sputum-positive
mate is usually 90-95%
in patients
with laryngeal
TB [4, 5]; it was 67% among
our patients.
Although
minimal
pulmonary
lesions could be seen in some
patients,
studies with large numbers
of patients [1 0-i 3] have
shown that most patients with laryngeal TB had advanced
pulmonary lesions. Likewise,
nine of the 12 patients (75%) in our
study had moderately
or fan advanced
pulmonary
TB. Howeven, cavitary

lung

lesions,

which

are frequently

reported

in the

literature
[4, 13], were less common
in our patients (25%). In
our study, the common
radiographic
findings
were those of
reactivation
TB. Primary TB laryngitis
is name [1].
The radiographic
appearance
of laryngeal
TB depends
on
the stage and extent of the disease.
In the acute phase, the
lesion is frequently
exudative
and diffuse [1 , 3]. In our study,
most of the patients
younger
than 50 (6 of 7; 86%) were in
this stage of the disease.
On the CT scans, bilateral
and diffuse thickening
of the vocal cords and epiglottis
was usually
seen without formation
of a definite focal mass. The diagnosis of TB could be indicated
by the diffuse
nature of the
laryngeal
involvement
in these young patients
with pulmonary TB. In the chronic phase, the lesion is usually localized
and the gmanulomatous
mass is frequently
confused
with
carcinoma
[5]. All our patients
older than 50 were in this
stage of the disease
and initially were considered
to have
laryngeal
carcinoma.
On CT scans,
a focal thickening
on
mass was seen in the vocal cords or epiglottis
but, charactenistically,
there was diffuse
asymmetric
thickening
of the
contralateral
vocal cord, epiglottis,
and panalaryngeal
tissue.
These findings
are consistent
with those of other studies.
Rarely, a single mass, either sessile or pedunculated,
may
be encountered
[1].
The most important
differential
diagnosis
is primary
lanyngeal carcinoma.
The conventional
radiographic
appearances
of laryngeal
TB are varied and nonspecific
and cannot differ-

AJR:166,

February

1996

entiate
this disease
from a diffuse
infiltrating
cimcumglottic
carcinoma.
However,
we found several CT findings
that suggested the possibility
of TB. First, laryngeal
TB appears
as
diffuse and bilateral,
but not necessarily
symmetric,
even in
patients
with a focal mass. The paralaryngeal
spaces
are
almost always involved
bilaterally.
Second,
the fundamental
integrity
of the laryngeal
architecture
is preserved
in lamyngeal TB. On CT scans,
no sclerosis
or destruction
of the
laryngeal
cartilages
was observed
in any patient.
Gross
alteration
of the structures
by a laryngeal
mass favors a neoplastic condition.
Third, laryngeal
TB rarely extends
to the
hypopharynx
or subglottic
areas, which is not true in carcinoma or non-TB
inflammatory
lesions
[2]. In our patients,
subglottic

Discussion

few pulmonary

ET AL.

extension

of the

lesion

was

suspected

in only

one

patient.
Five patients
(42%)
had cervical
lymphadenitis.
Although
theme is some overlap
between
TB and malignant
metastatic
lymph nodes, CT features
favoring
TB lymphadenitis are nodes with a central,
low-density
and peripheral
rim enhancement
[14]. Other conditions
in the differential
diagnosis
are sarcoidosis,
syphilis,
leprosy,
lethal midline
granuloma,
fungal diseases,
and chronic nonspecific
laryngitis [6]. Acute
inflammatory
diseases
and postradiation
changes
also merit consideration.
Radiographic
evaluation
of the larynx complements
the
clinical examination.
CT scans can show the size and extent
of the disease
process
and detail the cross-sectional
area
and adequacy
of the airway
[6]. Compared
with laryngoscopic findings,
CT scans more accurately
demonstrated
the
diffuse nature of disease
and the involvement
of the paralamyngeal spaces in most of our patients
(n = 9; 75%). Interestingly, even
in patients
who had bilateral
paralaryngeal
diseases,
vocal cord mobility was namely impaired.
CT scans
may fail to show superficial
ulcers,
but ulcerative
lesions
have been reported
to be uncommon
[1 1]. Calcification,
a
common
finding of TB elsewhere
in the body, was not found
in our patients,
but it has been reported
in one case studied
by CT scanning
[8]. Focal
low-attenuation
areas
in the
lesion, which are relatively
uncommon
in squamous
cell cancinoma
of the larynx, were seen in one of our patients
and
were probably
indicative
of caseation
necrosis
[7].
The response
of laryngeal
TB to anti-TB chemotherapy
is
excellent
[10-13].
After appropriate
treatment,
the lesion and
the patients
symptoms
usually
disappear
in 1-2 months,
leaving little residual fibrosis.
However,
irreversible
laryngeal
stenosis
or cnicoarytenoid
fixation can occur with inadequate
treatment
on in patients
with multidrug-resistant
strains
of
Myobacterium
tuberculosis
[1 2]. In our patients,
fibrotic
stenosis
of the vocal cords and tmacheobmonchial
tree was
present
in one patient who had inadequate
treatment.
In the
remaining
patients,
follow-up
laryngoscopic
examination
showed marked improvement
of the laryngeal
lesion.
Because
of the high infectivity
of laryngeal
TB, early diagnosis is important.
Any patient with known or suspected
pulmonany
TB who
develops
a laryngeal
mass
must
be
considered
to have laryngeal
TB unless proved otherwise.
The role of the radiologist
is to alert the clinician to the possibility of this disease,
outline the extent of the disease,
and
assess
the patients
response
to treatment.
CT scanning
may be the most useful technique
for this task.

AJR:166,

February

LARYNGEAL

1996

TUBERCULOSIS:

In summary,
laryngeal
TB manifested
as a diffuse bilateral
lesion with or without
a focal mass and was always associated with active pulmonary
TB. Although
the CT appearances
may not be specific,
the possibility
of TB should be raised
when a bilateral and diffuse laryngeal
lesion is seen without
destruction
of the laryngeal
architecture
in patients
with pulmonamy TB. Direct laryngoscopy
and biopsy are mandatory
to
establish
a definitive
diagnosis.

laryngeal tuberculosis. J Laryngol 1981:95:393-398

5. Soda A, Rub,o H, Salazar M, Ganem J, Beilanga D, Sanchez A.Tubercuksis

8. Aspestrand
F, Kolbenstvedt
A, Boysen M. CT findings
in benign expansions of the larynx. J Comput Assist Tomogrl989;13:222-225
9. Braunwald E. Harrisons
principles
of internal
medicine,
11th ed. New

1987:627

10. Yarnal

JA, Golish JA, Kuyp F. Laryngeal

tuberculosis
presenting
noma. Arch Otolaryngol 1981:107:503-509
11 . Bull TA. Tuberculosis of the larynx. Br MedJ 1966:2:991-992

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