Hoarseness Beyond Cancer: Laryngeal Presentation of Tuberculosis

Introduction: Tuberculosis (TB) remains a leading infectious disease worldwide, with Ethiopia among the highest-burden countries. Laryngeal tuberculosis is rare, accounting for less than 1%-2% of TB cases and typically affects the posterior glottis and true vocal cords. However, atypical involvement of the subglottic region is uncommon and can closely resemble laryngeal carcinoma both clinically and radiologically, posing a significant diagnostic challenge. Case Presentation: We report a 64-year-old man with a 1-year history of progressive hoarseness. Neck CT demonstrated asymmetric mucosal thickening and enhancement of the glottis with anterior subglottic extension, along with a rim-enhancing necrotic prelaryngeal node which are findings highly suggestive of malignancy. Chest CT revealed right upper lobe cavitation, nodularity and tree-in-bud opacities consistent with active pulmonary tuberculosis. GeneXpert MTB/RIF confirmed Mycobacterium tuberculosis, and laryngeal biopsy revealed caseating granulomatous inflammation with acid-fast bacilli. A diagnosis of concomitant pulmonary and laryngeal tuberculosis was established, and the patient was started on standard first-line anti-tubercular therapy. Discussion: Laryngeal tuberculosis typically involves the posterior glottis, but in this case, anterior subglottic disease with necrotic nodal involvement created strong radiologic overlap with carcinoma. Recognition of such atypical patterns is crucial, especially in endemic regions, as misdiagnosis may lead to unnecessary surgical interventions. Conclusion: Persistent hoarseness with mass-like laryngeal lesions should prompt consideration of tuberculosis in endemic settings. Radiologists play a key role in identifying suggestive features and integrating them with pulmonary imaging and microbiologic results to ensure accurate diagnosis and timely treatment.