Invasive Fungal Laryngotracheitis Causing Laryngotracheal Separation

Fungal laryngotracheitis (FLT) is rare, and the diagnosis can be challenging, as its presentation lacks specificity and may resemble other conditions such as granulomatous disease, gastroesophageal reflux, or malignancy. FLT can be very invasive, causing complete laryngotracheal separation, leading to a non-functioning larynx. We report a 39-year-old Indian woman with diabetes who presented to the emergency department with a sore throat, hoarseness, dysphagia, and stridor for two days. Initially treated for diabetic ketoacidosis due to acute tonsillopharyngitis, she required intubation for airway obstruction and severe metabolic acidosis. Fourteen days post-intubation, an airway assessment revealed bilateral vocal fold edema and pus in the subglottic and cervical trachea. CT imaging showed circumferential fluid around the trachea and a distorted larynx. Examination under anesthesia and neck exploration revealed pus around the thyroid gland and trachea, leading to a tracheostomy and sample collection. Histopathology indicated a fungal infection, confirmed as Candida guillermondii with Escherichia coli. The patient was treated with oral fluconazole and intravenous cefuroxime for four weeks. Despite treatment, a repeat CT indicated a non-functioning larynx, prompting a proposal for a total laryngectomy. After a multidisciplinary discussion, it was decided to continue antifungal therapy due to the patient's clinical improvement. At follow-up a month later, she was stable, tolerating oral intake with a double-lumen tracheostomy tube. This case underscores the importance of a high index of suspicion for FLT and the need for patient-specific decisions regarding total laryngectomy in a non-functioning larynx.