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 Table of Contents  
CASE REPORTS
Year : 2021  |  Volume : 9  |  Issue : 1  |  Page : 36-38

Fungal laryngitis


1 Department of ENT, AFMC, Pune, Maharashtra, India
2 Department of ENT, MH Kirkee, Pune, Maharashtra, India
3 Department of Pathology, MH Kirkee, Pune, Maharashtra, India
4 Department of ENT, 159 GH, Ferozepur, Punjab, India

Date of Submission11-Jan-2021
Date of Decision27-May-2021
Date of Acceptance02-Jun-2021
Date of Web Publication18-Nov-2021

Correspondence Address:
Vikas Sharma
Department of ENT, MH Kirkee, Pune, Maharashtra.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/dypj.DYPJ_3_21

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  Abstract 

Fungal laryngitis is a rare clinical entity in an immunocompetent patient. This case report describes the case of a 50-year-old singer who presented with hoarseness. The patient underwent microlaryngoscopy with excision of cyst. Primary laryngeal lesion with no tissue invasion, no systemic fungal manifestations immunocompetent state of the patient and a good response to surgery is characteristic of fungal laryngitis.

Keywords: Aspergillus, fungal infection, fungal laryngitis, microlaryngeal surgery, vocal nodule


How to cite this article:
Ujval M, Sharma V, Fatima SS, Dangwal VD, Nitin S. Fungal laryngitis. D Y Patil J Health Sci 2021;9:36-8

How to cite this URL:
Ujval M, Sharma V, Fatima SS, Dangwal VD, Nitin S. Fungal laryngitis. D Y Patil J Health Sci [serial online] 2021 [cited 2021 Nov 27];9:36-8. Available from: http://www.dypatiljhs.com/text.asp?2021/9/1/36/331111




  Introduction Top


Fungal infection of the respiratory tract is a common entity in immunocompromised individuals.[1] However, the fungal infection of the larynx is infrequent.[2] It may be present in immunocompetent and immunocompromised individuals presenting as acute or chronic laryngitis. The symptoms are nonspecific, including hoarseness, foreign body sensation in the throat, odynophagia, and dysphagia. Conditions known to predispose fungal etiology of laryngitis may be laryngopharyngeal reflux (LPR), inhaled corticosteroids, and prolonged antibiotic usage.[1]Aspergillus, Candida, Cryptococcus, Histoplasma, and Blastomyces are the organisms generally attributable to fungal laryngitis. These may go undiagnosed and treated inappropriately.[3] We report a case of fungal laryngitis presenting with hoarseness in an immunocompetent patient.


  Case Report Top


A 50-year-old male singer presented with complaints of hoarseness of 2-year duration to our ear, nose, and throat outpatient department in a tertiary care hospital. He had similar complaints in the past and was operated on for a vocal nodule in 2013. He is a known case of chronic rhinosinusitis with polyps and had undergone endoscopic sinus surgery in 2017. Postoperatively, he has been using intranasal corticosteroids for the same. He was also being managed for LPR with proton-pump inhibitors. The patient is not immunocompromised and does not have any comorbidity. His general physical and systemic examination was normal.

Videolaryngoscopy revealed a solitary smooth nodule in the anterior part of the left true vocal cord [Figure 1]b. Arytenoids were edematous with interarytenoid pachyderma. Both vocal cords were mobile. The rest of the larynx was normal. There was no significant lymphadenopathy. VHI and GRBAS score was 45 and 5, respectively. Nasal endoscopy revealed a postoperative status of the nasal cavity with no mass, polyp, or mucopus. Contrast-enhanced computed tomography neck was done, radiological features were suggestive of a benign nodule, and no features of malignancy were seen [Figure 1]a.
Figure 1: (a) (a) Noncontrast computed tomography of neck showing radiologically benign lesion on left true vocal cord. (b) Videolaryngoscopy using Hopkins 90° endoscope showing solitary smooth nodule on left true vocal cord (Vocal cords seen in abduction) (c) Videolaryngoscopy using Hopkins 90° endoscope showing solitary smooth nodule on left true vocal cord (Vocal cords seen in adduction)

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He underwent microlaryngoscopy and excision of the nodule under general anesthesia, and the tissue was sent for histopathological examination [Figure 1]c. On visualization of fungal elements on the smear, potassium hydroxide mount and fungal culture revealed Aspergillus. Postoperative period was uneventful. There was no residual nodule on videolaryngoscopy post operatively as seen in [Figure 2]a. VHI and GRBAS score measured on the post op day 30 was 26 and 3, respectively.
Figure 2: (a) Postoperative videolaryngoscopy – Postoperative status, no nodule, VC adducted position. (b) Aspergillus on histopathological examination. Hematoxylin- and eosin-stained smear – fragments of septate fungal hyphae with dichotomous branching at an angle

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Fragments of septate fungal hyphae with dichotomous branching as seen in [Figure 2]b were revealed on Histopathological examination of hematoxylin and eosin (H and E) stained smear from the excised tissue sample.


  Discussion Top


Fungi are a rare cause of chronic laryngitis. Presentation of fungal laryngitis is varied, but most commonly, people present with hoarseness. Several case reports have been seen regarding leukoplakia with fungal etiology.[4 This may mimic malignancy and warrant a biopsy.[5] Histopathology and fungal culture are key in confirmation of diagnosis.[1]

Aspergillus infection is very rare and generally occurs in immunocompromised patients like poorly controlled diabetes mellitus.[3] Infections in immunocompetent patients, like in our patient, typically are confined to the mucosa. Aspergillus infections can have several manifestations in the aerodigestive tract.[6] Hematogenous spread following vascular invasion often accompanies, resulting in microthrombosis of the tissues.[7] Manifestation of Aspergillus infection is often observed as tracheobronchial aspergillosis seen as pulmonary lesions and may be seen in paranasal sinuses too resulting in bony destruction.[8] In atopic patients, allergic fungal sinusitis as a result of aspergillosis is a chronic disease state.[7]

Although fungal spores like Aspergillus are present in the inhaled air, the incidence of fungal laryngitis is very rare and colonization of fungi in the larynx is uncommon.[5] It may, most of the time, be seen in immunocompromised individuals with chronic pulmonary diseases.[9] Normal clinical examination and chest X-ray ruled out pulmonary infection in our patient. Diagnosis mainly depends upon the clinical examination, but final diagnosis can only be made on the basis of histopathology and culture. Histopathological examination by standard H and E stain usually reveals Aspergillus hyphae, but stains like Grocott’s silver and periodic acid–Schiff increase the sensitivity and must be carried out if there is a strong suspicion of a fungal infection. Making diagnosis by culture is traditional and the most accepted modality in any fungal infection.[10]

Recently, polymerase chain reaction has also been used. Our patient was immunocompetent which was supported by normal laboratory investigations, HIV seronegativity, and clinical absence of any infections. Factors altering the mucosal barrier of the larynx predispose to fungal infections in the absence of immunodeficiency, which include prolonged antibiotic therapy, radiation to the neck, LPR, inhaled corticosteroids, and smoking.[5] Hence, the use of long-term inhalational corticosteroids, or proton-pump inhibitors, or surgical trauma can serve as possible explanations for the cause in our patient. In the postoperative follow-up, the patient was asymptomatic, with improved voice quality and better VHI and GRBAS scores.

Treatment should be entirely based on our clinical acumen. Immunocompetent individuals with mild symptoms can be managed conservatively. In our case, we had a singer who had a cyst that was not resolved by conservative management in the form of voice rest and vocal hygiene, and we had to intervene surgically and excise the cyst as his profession demands a good voice quality.

Primary laryngeal lesion with no tissue invasion and no systemic involvement, immunocompetent state of the patient and a good response to surgical treatment were the notable features in our case of fungal laryngitis. If we are dealing with chronic laryngeal pathologies, we may have to keep fungal laryngitis on our cards even if the patient is immunocompetent and has lesions mimicking common pathologies.


  Conclusion Top


Primary laryngeal lesion, no tissue invasion, no systemic involvement, immunocompetent state, good response to surgical treatment was the notable feature in our case. If we are dealing with chronic laryngeal pathologies, we may have to keep fungal laryngitis on our cards even if the patient has obvious lesions and immune competent. The contributing factors may be the use of oral steroids, inhalational steroids, proton-pump inhibitors, and long-term antibiotics. However, there is no current consensus about the use of antifungal as treatment for this etiology.

Informed consent

Informed consent was obtained from the patient.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Klein AM, Tiu C, Lafreniere D. Malignant mimickers: Chronic bacterial and fungal infections of the larynx. J Voice 2005;19:151-7.  Back to cited text no. 1
    
2.
Mehanna HM, Kuo T, Chaplin J, Taylor G, Morton RP. Fungal laryngitis in immunocompetent patients. J Laryngol Otol 2004;118:379-81.  Back to cited text no. 2
    
3.
Liu YC, Zhou SH, Ling L. Aetiological factors contributing to the development of primary laryngeal aspergillosis in immunocompetent patients. J Med Microbiol 2010;59:1250-3.  Back to cited text no. 3
    
4.
Ravikumar A, Prasanna Kumar S, Somu L, Sudhir B. Fungal laryngitis in immunocompetent patients. Indian J Otolaryngol Head Neck Surg 2014;66:375-8.  Back to cited text no. 4
    
5.
Swain SK, Nahak B, Sahu MC. Fungal laryngitis in asthmatic boy treated with inhalatory corticosteroids: A case report. Pediatr Pol 2017;92:453-6.  Back to cited text no. 5
    
6.
Brandwein M. Histopathology of sinonasal fungal disease. Otolaryngol Clin North Am 1993;26:949-81.  Back to cited text no. 6
    
7.
Benson-Mitchell R, Tolley N, Croft CB, Gallimore A. Aspergillosis of the larynx. J Laryngol Otol 1994;108:883-5.  Back to cited text no. 7
    
8.
Sher TH, Schwartz HJ. Allergic Aspergillus sinusitis with concurrent allergic bronchopulmonary Aspergillus: Report of a case. J Allergy Clin Immunol 1988;81:844-6.  Back to cited text no. 8
    
9.
Wittkopf J, Connelly S, Hoffman H, Smith R, Robinson R. Infection of true vocal fold cyst with Aspergillus. Otolaryngol Head Neck Surg 2006;135:660-1.  Back to cited text no. 9
    
10.
Gavito-Higuera J, Mullins CB, Ramos-Duran L, Sandoval H, Akle N, Figueroa R. Sinonasal fungal infections and complications: A pictorial review. J Clin Imaging Sci 2016;6:23.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2]



 

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