Ulcerative fungal laryngitis. (Laryngoscopic Clinic).

We evaluated a 52-year-old woman who had a history of chronic fatigue syndrome, exercise-induced asthma, and depression. She also had a 1- to 2-pack/day cigarette addiction. Two years earlier, she had undergone a video-stroboscopic examination and was diagnosed with Reinke's edema and a mild-to-moderate left vocal fold paresis.

Four months prior to our examination, the patient had experienced an acute onset of severe hoarseness after shouting at a concert. Her voice continued to deteriorate over the next few months until she became virtually aphonic. Empiric steroid and antibiotic therapy prescribed by her primary care physician resulted in only a partial restoration of her voice. It was then that she came to our office for further evaluation.

On examination, the patient was severely hoarse. Her voice was low-pitched and somewhat pressed. Strobovideolaryngoscopy revealed that a large ulcer and surrounding glossy leukoplakia had occupied much of the middle third of the right true vocal fold (figure 1). The remainder of the vocal fold was erythematous and exhibited dilated vessels. Other findings included left-sided Reinke's edema and uncontrolled laryngopharyngeal reflux. We prescribed amoxicillin/clavulanate and prednisone to treat the presumed bacterial ulcer and a protonpump inhibitor and an [H.sub.2] blocker to treat the reflux. We also strongly suggested that she stop smoking.

Follow-up strobovideolaryngoscopy one month later revealed only minimal improvement in the patient's ulcer. Because broad-spectrum antibiotic therapy had failed to treat the ulcer and because a pharyngeal culture obtained at the initial visit grew yeast, we considered a diagnosis of ulcerative fungal laryngitis. We prescribed a 3-week course of oral fluconazole with the understanding that the patient would require an operative biopsy if no improvement ensued. On re-examination 1 week later, the patient did exhibit improvement in the leukoplakia and some healing of the ulcer (figure 2). However, considerable inflammation remained, which was manifested by the presence of persistent erythema and injected vessels.

Following the completion of antifungal therapy, a third strobovideolaryngoscopy detected no residual leukoplakia or ulceration of the right true vocal fold (figure 3). The right vocal fold was stiff and exhibited a diminished mucosal wave. The vasculature on the right side remained prominent, and the left Reinke's edema was unchanged. There was no Reinke's edema on the right, although the stroboscopic examination 2 years earlier had shown that the edema in the vocal folds was bilateral and symmetrical. The patient was happy with her voice, and she had considerably reduced her smoking.