Extra pulmonary TB in the head and neck region most frequently occurs in the cervical lymph nodes (>90%), followed by the larynx (2% to 6%) [
8,
9]. Involvement of the temporal bone, sinonasal cavity, eye, pharynx, thyroid and skull base are even less frequently observed [
4,
8,
9]. The characteristics of laryngeal TB have changed over the years and it has become a challenge for otolaryngologists to distinguish this disease from others. In the past, laryngeal TB typically affected young people in the second or third decade of life with advanced pulmonary TB. Symptoms were cough, haemoptysis, fever, weight loss and night sweats. An ulcerative, granulomatous lesion was generally positioned on the posterior part of the larynx due to accumulation of sputum in the arytenoid region in bed-bound patients. Today, laryngeal TB mainly involves people in their 50 s or 60 s presenting first and foremost with hoarseness (80% to 100%). Other symptoms are odynophagia (50% to 67%) and to a lesser extent, dysphagia, dyspnoea, stridor, cough and haemoptysis.
Systemic symptoms have become rare [
2,
4‐
7,
9,
11]. Laryngeal TB can involve all parts of the larynx and there is no longer an unmistakable association with pulmonary TB. The larynx becomes infected either by a direct spread from the lungs, or by a haematogenous spread from sites other than the lungs [
5,
11,
12]. The former mechanism is most common and probably relevant for the patient in our case. In the case of a haematogenous spread, there is no evidence of pulmonary disease [
3,
7,
9]. The distinction between laryngeal TB and chronic laryngitis or laryngeal carcinoma in particular has become difficult. Odynophagia is described as an important discriminating symptom, since it is considered rare in laryngeal cancer [
2,
5‐
7,
11]. Yet, from experience we know that painful dysphagia is a well-known symptom reported among patients suffering from a supraglottic laryngeal carcinoma. In a physical examination, the true vocal cords are most frequently affected by laryngeal TB, followed by the epiglottis, false vocal cords and ventricles, arytenoids, posterior commissure and the subglottic area [
4,
7,
12]. Laryngeal TB can manifest as oedema, hyperaemia or ulcerative lesions, but can also present as a nodule, an exophytic mass or obliteration of an anatomical structure [
12]. Aside from chronic laryngitis and laryngeal carcinoma, these various presentations give rise to a comprehensive differential diagnosis including cat-scratch disease, syphilis, sarcoidosis, Wegener's granulomatosis and fungal infections [
8]. Since pathognomonic characteristics indicative of laryngeal TB do not exist and the fact that it is an uncommon disease in industrialised countries, the infection is easily mistaken for the more frequently occurring laryngeal carcinoma [
3,
6,
8]. Our patient had a long-standing history of heavy smoking, and had symptoms of hoarseness and odynophagia. Laryngoscopy revealed an oedematous tumour with decreased mobility of the vocal cord. The clinical signs, supported by the findings on the initial CT scan of the larynx, led us to the diagnosis of a laryngeal carcinoma. Laryngeal TB, however, can have the exact same symptoms. In the majority of cases, there is an association with pulmonary TB [
2,
4]. Therefore, an anomalous chest X-ray, if not compatible with pulmonary metastasis, should alert the radiologist and otolaryngologist to the possibility of TB, especially when former chest X-rays were normal.
Laboratory techniques for detecting TB infections include histopathological tissue examinations with Ziehl-Neelsen histochemical staining for acid-fast bacilli and identification of
M. tuberculosis by polymerase chain reaction or bacterial culture. The latter method, although time-consuming, is considered the reference standard [
13]. A CT of the neck cannot definitively identify laryngeal TB since, as in a chest X-ray, it can imitate many other diseases. Antituberculous agents are the primary treatment for laryngeal TB. The improvement of dysphagia and resolving of cavernous lung lesions are expected to occur within several weeks [
6,
12,
14,
15]. If not treated early, laryngeal TB can result in (sub)glottic stenosis, muscular involvement and vocal cord paralysis when the cricoarytenoid joint or recurrent laryngeal nerve are invaded [
5,
12].