Candidiasis

A 33-year-old woman who was a professional singer came to the office with a 1-month history of progressively worsening hoarseness, dysphagia, and a globus sensation. She had been treated previously with systemic corticosteroids without relief, and she had been forced to cancel several performances.

Our evaluation found that her voice was pressed, moderately hoarse, and breathy. Examination of the larynx demonstrated what might be interpreted as severe leukoplakia of her true vocal folds, arytenoids, and some supraglottic structures (figure). There was a moderate amount of mucosal edema and erythema involving her entire larynx. Strobovideolaryngoscopy revealed that the vibratory margin was irregular and glottic closure was incomplete. There were also marked stiffness, decreased mucosal wave, and an asymmetric weakness. Supraglottic hyperfunction was also present. In addition, there was evidence of gastroesophageal reflux with posterior laryngeal cobblestoning and erythema. Her chest x-ray was normal.

The woman was diagnosed with laryngeal candidiasis, reflux, muscle tension dysphonia, and vocal abuse. We treated her for 4 weeks with fluconazole, relative voice rest, and aggressive antireflux therapy. She was also counselled on smoking cessation and vocal hygiene.

On followup, the patient exhibited complete resolution of her candidiasis and control of her reflux. Her voice quality had improved substantially, but she remained slightly hoarse. Videostroboscopy revealed an excellent recovery of her vocal fold function. A small scalloped area and stiffness remained in the midportion of her left vocal fold. This scar was responsible for her persistent dysphonia.

Disease characteristics

Candida is a yeast that is present in the oral cavity, ears, and other body surfaces. When host immune mechanisms and the protective mucosal barrier are impaired, Candida overgrowth can lead to infections of the larynx. Candidiasis and other fungal infections are relatively common in immunocompromised patients, but they have also been described in healthy individuals. [1]

Predisposing factors for laryngeal candidiasis include immunodeficiency syndromes, immunosuppressive medications (e.g., chemotherapeutic agents and corticosteroids), nutritional deficiencies, diabetes, previous antibiotic therapy, inhaled corticosteroid therapy, radiation therapy, smoking, reflux disease, trauma, and chemical or thermal injury. Many patients have multiple predisposing factors.

A high index of suspicion is necessary to make the diagnosis. Laryngeal candidiasis typically exhibits initial symptoms of dysphonia and dysphagia. Examination of the larynx often reveals a characteristic white or gray pseudomembrane, although some patients have erythema alone. Mucosal edema, erythema, and ulceration can also be present.

Strobovideolaryngoscopy provides important information. Our patient had significant vocal fold irregularity and stiffness, no mucosal wave, and incomplete glottic closure. After aggressive medical management and relative voice rest, these symptoms and signs were alleviated, The small scar that remained on the left vocal fold might have been present prior to or as a result of infection.

Previous reports have outlined the importance of biopsy in making the diagnosis of laryngeal candidiasis [1,2] We feel this is not necessary in most cases because clinical findings and treatment response can confirm the diagnosis. Furthermore, a premature biopsy of this infection might cause vocal fold scarring, which can be extremely difficult to treat. [3] Indications for biopsy include an incomplete response to adequate therapy or a reasonable suspicion of a malignancy or other serious systemic disease. In borderline cases, laryngeal cultures and cytology can be obtained easily by bronchoscope brushings.

Recommended treatment

The first step in treatment is often to eliminate the predisposing factors. Implementing good vocal hygiene, eliminating gastroesophageal reflux, and increasing hydration should be routine. In certain cases, voice therapy is necessary, either during or after primary treatment. Topical nystatin (as a mouthwash) for 3 weeks might be adequate in some cases. Systemic therapy with fluconazole at 100 to 400 mg/day for 3 to 4 weeks is necessary in immunocompromised patients, in those with severe disease or systemic involvement, or when topical therapy fails.' We also use it as a primary therapy in most cases. Finally, intravenous treatment with amphotericin B might be necessary in refractory cases.

Early recognition and treatment of this disease is important to prevent the spread of infection and systemic involvement. In the professional singer or actor, misdiagnosis, inadequate treatment, or premature biopsy can lead to an impaired ability to perform, cancelled shows, and even perhaps the end of a career. Appropriate conservative management should lead to rapid and effective control of the infection and an improvement in vocal function for most patients.

From the Department of Otolaryngology--Head and Neck Surgery, Thomas Jefferson University, Philadelphia (Dr. Neuenschwander, Dr. Spiegel, Dr. Lyons, and Dr. Sataloff); the American Institute for Voice and Ear Research, Philadelphia (Ms. Cooney); and the Department of Otolaryngology--Head and Neck Surgery, the Graduate Hospital, Philadelphia (Dr. Spiegel and Dr. Sataloff).

References

(1.) Forrest LA, Weed H. Candida laryngitis appearing as leukoplakia and GERD. J Voice 1998;12:91-5.

(2.) Tashjian LS, Peacock JE Jr. Laryngeal candidiasis. Report of seven cases and review of the literature. Arch Otolaryngol 1984;110:806-9.

(3.) Sataloff RT. Vocal fold scar. In: Sataloff RT, ed. Professional Voice: The Science and Art of Clinical Care. San Diego: Singular Publishing Group, 1997:555-7.

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