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 Table of Contents  
CASE REPORT
Year : 2012  |  Volume : 18  |  Issue : 2  |  Page : 88-91

Primary tuberculosis of the nasopharynx: A rare case and literature review


1 Department of Otorhinolaryngology, Faculty of Medicine, University of Cumhuriyet, Sivas, Turkey
2 Department of Pathology, Faculty of Medicine, University of Cumhuriyet, Sivas, Turkey

Date of Web Publication6-Sep-2012

Correspondence Address:
Emine Elif Altuntas
Department of Othorhinolaryngology, Faculty of Medicine, University of Cumhuriyet, Sivas
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-7749.100732

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  Abstract 

The isolated pulmonary involvement as well as upper respiratory tract involvement is declining in consequence of anti-tuberculosis treatment and vaccine programs. However, the incidence of tuberculosis is increasing in less developed and in some developed cities. A 56-year-old woman presented with 5-6 years history of nasal obstruction, sleep with open mouth, and snoring. The mass of the nasopharynx biopsy was performed under local anesthesia. The biopsy material's histopathological examination showed features of tuberculosis and diagnosis confirmed as tuberculosis by the pathologists. Primary nasopharyngeal tuberculosis without the lung involvement is very rare; otorhinolaryngologists should keep in mind the possibility of tuberculosis in the differential diagnosis of nasopharyngeal mass as the incidence of tuberculosis in developed countries is steadily increasing.

Keywords: Differential diagnosis, Casopharynx, Tuberculosis


How to cite this article:
Altuntas EE, Karakus CF, Durmus K, Uysal IÖ, Müderris S, Elagöz S. Primary tuberculosis of the nasopharynx: A rare case and literature review. Indian J Otol 2012;18:88-91

How to cite this URL:
Altuntas EE, Karakus CF, Durmus K, Uysal IÖ, Müderris S, Elagöz S. Primary tuberculosis of the nasopharynx: A rare case and literature review. Indian J Otol [serial online] 2012 [cited 2019 Sep 21];18:88-91. Available from: http://www.indianjotol.org/text.asp?2012/18/2/88/100732


  Introduction Top


The incidence of tuberculosis is increasing in less developed and in some developed cities. The World Health Organization (WHO) Statistical Information System (WHOSIS) reported that India has the highest incidence of tuberculosis in the world. Approximately 25% of these cases create extra pulmonary tuberculosis and of which 10-35% are found in the head and neck region. [1]

The isolated pulmonary involvement as well as upper respiratory tract involvement is declining in consequence of anti-tuberculosis treatment and vaccine programs. Oral cavity, tonsils, tongue, ears, nose, epiglottis, larynx, and pharynx may be involved in the upper respiratory tract. Nasopharynx and middle ear involvement is rare. Nasopharyngeal tuberculosis is an uncommon disease and usually occurs in the princes of active pulmonary or systemic infections. Although the prevalence of nasopharyngeal tuberculosis has decreased after the wide use of anti-tuberculous agents, the number of reports for the disease has slightly increased recently in accordance with advances in the diagnostic tools. Diagnosis of nasopharyngeal tuberculosis often overlooked. Nasopharyngeal tuberculosis has a similar clinical presentation to that of nasopharyngeal carcinoma; both can present with cervical lymphadenopathy, nasal discharge, or nasal obstruction. [2],[3] Cervical lymphadenopathy, together with the nasopharyngeal symptoms related to the mass or mucosal irregularity, makes the differential diagnosis from carcinoma difficult; and thus makes histopathologic evaluation necessary for diagnosis. [4]

We report one patient with proved primary mycobacterium tuberculosis of the nasopharynx and presenting similar cases by the reviewing literature.


  Case Report Top


A 56-year-old woman presented with 5-6 years history of nasal obstruction, sleep with open mouth, and snoring.

Right middle turbinate hypertrophic and pale appearance, nasal septum deviated to the right side and nasal based also has a crest were detected at an anterior rhinoscopy. Vegetative mass with smooth surface was protruding from the nasopharynx into the right nasal passage that was seen with endoscopic examination [Figure 1]. Ear and throat examination and blood investigations were normal. Sputum microscopy and culture were negative. No evidence of active tuberculosis in the chest and no systemic tuberculosis were observed.
Figure 1: Vegetative mass with smooth surface was protruding from the nasopharynx into the right nasal passage

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The patient's age was advanced, and mass was located one-sided of the nasopharynx for the differential diagnosis of the nasopharyngeal pathology, nasopharynx computerized tomography (CT) was planned. On computed tomography of nasopharynx, the massive space occupying lesions was detected.

Nasopharynx tissue samples were obtained under local anesthesia, which showed feature of chronic caseous granulomatous infection, non-necrotizing granulomas under the ciliated respiratory epitelium on the surface of lymphocytic nasopharyngeal mucosa [Figure 2]a, giant granuloma containing coagulation necrosis and Langhans type giant cells in the center [Figure 2]b, and crypt that was lined with ciliated epithelium and granulomas [Figure 2]c. No malignant cells were observed. Therefore, the biopsy material's histopathologic examination showed features of tuberculosis, and diagnosis confirmed as tuberculosis by the pathologists.
Figure 2: (a) The ciliated respiratory epithelium, lymphocytic strom a , and non-necrotizing granulomas (H and E; ×10). (b) Giant granuloma containing coagulation necrosis and Langhans type giant cells in the center (H and E; ×10). (c) Cryp that was lined with ciliated epithelium and granulomas (H and E; ×10)

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Patient was treated with medical therapy (isoniazid, rifampisin, pirazinamid, and etambutol) for 9 months. Significant clinical improvement was observed in the third month of the treatment, and the nasopharyngeal mass resolved after a 3 months anti-tuberculous therapy.


  Discussion Top


Tuberculosis, one of the oldest diseases in man, is even today a leading cause of human suffering and loss of life. After the implementation of modern anti-tuberculosis treatment, incidence of tuberculosis has been decreased in developed countries up to the mid-1980 s; the incidence of tuberculosis has been increasing steadily in many countries during the last two decades. This is especially related to the increased population of immunocompromised patients. Not only tuberculosis of the lungs, but also the extra pulmonary forms, including head and neck tuberculosis, has increased disproportionately. [5],[6]

Nasopharyngeal tuberculosis usually appears as a complication of pulmonary tuberculosis. Usually, as a result of upper respiratory tract contact with the lung secretions, infection spreads to the upper respiratory tract. Nasopharyngeal tuberculosis appears in 1.9% of patients with pulmonary tuberculosis. However, primary nasopharyngeal tuberculosis without the lung involvement is very rare. According to Rohwedder et al., [7] only 0.1% nasopharyngeal involvement were detected in primary active pulmonary tuberculosis patients. However, the nasopharynx is a relatively silent region, and the disease may be more common than suspected, [3],[2] especially in endemic areas and with an increase in HIV.

Nasopharyngeal tuberculosis is seen most commonly in women and in 5 th - 6 th decades. Among smokers and people with low socio-economic status, the prevalence of the nasopharyngeal tuberculosis is increased. [8],[9],[10]

Cervical lymphadenopathy, nasal obstruction, rhinorrhea, epistaxis, serous otitis media, and hearing loss are the most common clinical symptoms of the nasopharyngeal tuberculosis. [11,12]

Symptoms and signs of the nasopharyngeal tuberculosis are not typical; diagnosis of this clinical entity is very difficult. Diagnosis of the nasopharyngeal tuberculosis was based on the pathological and microbiological examination of the biopsy specimen. Nasopharyngeal tuberculosis, because of location and clinical symptoms, can mimic nasopharyngeal cancer. Nasopharyngeal cancer in the surrounding tissues may cause granulomatous reactions; for definitive diagnosis, repeated biopsies should be done. Epitheloid giant cells and granulomatous inflammation that was characterized by caseous necrosis were the pathological findings of the tuberculosis. Isolation of acid-phase bacilli and produce mycobacterium tuberculosis in the culture is very difficult procedure in the nasopharyngeal tuberculosis. [4]

As acid-fast bacilli are found in only 10% of tuberculosis specimens by direct examination and as culture takes several weeks, there is a need for additional rapid and sensitive tests to differentiate granulomas in these two conditions. For this reason, Arnold et al. [13] investigated the use of tuberculostearic acid (TBSA) detection in tissue biopsy specimens for the diagnosis of nasopharyngeal tuberculosis. This study has shown that the detection of tuberculostearic acid in formalin fixed, paraffin wax-embedded tissue specimens is useful for the rapid diagnosis of tuberculosis infections. Also, MRI and PET may be useful for nasopharynx cancer and tuberculosis differential diagnosis. Kim [14] report a case of primary nasopharyngeal tuberculosis that resembled a malignant tumor due to clinical presentation and elevated uptake of 18-F FDG that were highly suggestive of malignancy. However, these studies are single case studies and it may show false-positive findings on F-18 FDG PET/CT scan and this point also should not be ignored. The differential diagnosis of nasopharyngeal tuberculosis must include the other causes of granulomatous pharyngitis, fungal diseases, sarcoidosis, Wegener's granulamatosis, carcinomas, and sarcomas. [15]

The most frequent manifestation of head and neck tuberculosis (95%) is cervical lymphadenitis. [5] Vayýsoðlu et al . [16] reported a series of 40 patients with tuberculosis in the head and neck region. Forty-one patients had cervical lymphadenopathy, 2 patients had parotid gland tuberculosis, 2 patients had nasopharyngeal tuberculosis, and 3 patients were diagnosed as tongue, tonsil, and larynx tuberculosis, respectively. Choudhury et al. [17] reported a series of 33 patients with tuberculosis in the head and neck region who were diagnosed in 4 years period. In 19 patients (58%), the presenting feature was cervical lymphadenitis, 9 had salivary gland, 2 laryngeal and 1 each nasopharyngeal, hypopharyngeal and ear tuberculosis. 21 patients required some sort of surgical procedure for diagnosis. Altuntaş et al . [18] reported 4 patients' primary head and neck region tuberculosis; 1 patient had larynx tuberculosis, 1 patient had parotid gland tuberculosis, 1 patient had paranasal sinus tuberculosis, and 1 patient was diagnosed as nasal tuberculosis, respectively. In all of these studies, diagnosis was confirmed by excisional biopsy in all patients, and lesions were resolved after anti-tuberculosis chemotherapy. As in the literature, the diagnosis of tuberculosis in our patient was based on a histopathological examination, demonstrating a granulomatous reaction with typical caseous necrosis and treatment with anti-tuberculosis drugs have done.

The standard treatment of tuberculosis requires the application of different drugs. Patients are 2-month treated with 4 drugs (isoniazid, rifampicin, pyrazinamide, and ethambutol), followed by 4-month treated with two drugs (isoniazid and rifampicin). The treatment for extra pulmonary tuberculosis is the same as for pulmonary tuberculosis. [19] The prognosis of the nasopharynx tuberculosis is pretty good with anti-tuberculosis therapy if treatment duration is not less than 6 months. Clinical improvement in patients with this treatment as soon as possible and provide healing without sequelae. In our case, clinical improvement was started at the third month and treatment was terminated at the ninth month.


  Conclusions Top


As a result, nasopharyngeal tuberculosis is a rare disease; it usually occurs in the presence of active pulmonary and systemic infections. Usually, nasopharyngeal tuberculosis is limited to a single patient who is published in the literature.

Tuberculosis of the nasopharynx is a rare condition, even in endemic areas. In patients with unexplained upper respiratory tract complaints, with detected masses in the nasopharynx, tuberculosis should be considered in the differential diagnosis of the ulcerated lesions. There are few data on isolated primary tuberculosis of the nasopharynx [Table 1]. Even though nasopharyngeal tuberculosis cases are rare, otorhinolaryngologists should keep in mind the possibility of tuberculosis in the differential diagnosis of nasopharyngeal mass as the incidence of tuberculosis in developed countries is steadily increasing
Table 1: Literature review on primary tuberculosis of the nasopharynx

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.

 
  References Top

1.WHO report 2008: Global tuberculosis control d surveillance, planning, financing. Core Health Indicators. Available from: http://www.who.int/tb/publications/global report/2008/pdf/fullreport.pdf. [Last accessed on 09 Mar 05].  Back to cited text no. 1
    
2.King AD, Ahuja AT, Tse GM, van Hasselt AC, Chan AB. MR Imaging Features of Nasopharyngeal Tuberculosis: Report of Three Cases and Literature Review. AJNR Am J Neuroradiol 2003;24:279-82.  Back to cited text no. 2
[PUBMED]    
3.Waldron J, van Hasselt CA, Skinner DW, Arnold M. Tuberculosis of the nasopharynx: Clinicopathological features. Clin Otolaryngol Allied Sci 1992;17(1):57-9.  Back to cited text no. 3
    
4.Özkırıº M, Kubilay U, Aydin E, Özkiriº F, Kayabaºoðlu G, Ünver ª. Primary nasopharyngeal tuberculosis. KBB-Forum 2005;4[online].  Back to cited text no. 4
    
5.Rieder HL. Epidemiology of tuberculosis in Europe. Eur Respir J Suppl 1995;20:620-32.  Back to cited text no. 5
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6.Nalini B, Vinayak S. Tuberculosis in ear, nose, and throat practice: Its presentation and diagnosis. Am J Otolaryngol 2006;27:39-45.  Back to cited text no. 6
[PUBMED]    
7.Rohwedder JJ. Upper respiratory tract tuberculosis: Sixteen cases in a general hospital. Ann Intern Med 1974;80:708-13.  Back to cited text no. 7
[PUBMED]    
8.Sharma HS, Kurl DN, Kamal MZ. Tuberculoid granulomatous lesion of the pharynx: Review of the literature. Auris Nasus Larynx 1998;25:187-91.  Back to cited text no. 8
[PUBMED]    
9.Yılmaz YF, Tezer MS, Titiz A, Özlügedik S, Yalçin F, Ünal A. Snoring and obstructive sleep apnea due to Nasopharyngeal tuberculosis. Gazi Medical Journal 2005:16:47-9.  Back to cited text no. 9
    
10.Percodoni J, Brown F, Yardeni E, Murris-Espin M, Serrano E, Arrue P, et al. Nasopharyngeal tuberculosis. J Laryngol Otol 1999;113:928-31.  Back to cited text no. 10
    
11.Civelek ª, Sayın Ý, Ercan Ý, Çakýr BÖ, Turgut S, Baþak T. Nasopharyngeal tuberculosis: A case report. Turk Arch Otolaryngol 2008;46:53-7.  Back to cited text no. 11
    
12.Tse GM, Ma TK, Chan AB, Ho FN, King AD, Fung KS, et al. Tuberculosis of the nasopharynx: A rare entity revisited. Laryngoscope 2003;113:737-40.  Back to cited text no. 12
    
13.Arnold M, Chan CY, Cheung SW, van Hasselt CA, Frencht GL. Diagnosis of nasopharyngeal tuberculosis by detection of tuberculostearic acid in formalin fixed, paraffin wax embedded tissue biopsy specimens. J Clin Pathol 1988;41:1334-6.  Back to cited text no. 13
    
14.Kim KS. Primary Nasopharyngeal Tuberculosis Mimicking Carcinoma A Potentially False-Positive PET/CT Finding. Clin Nucl Med 2010;35:346-8.  Back to cited text no. 14
    
15.Cleary KR, Batsakis JG. Mycobacterial disease of the head and neck: Current perspective. Ann Otol Rhinol Laryngol 1995;104:830-3.  Back to cited text no. 15
    
16.Vayısoðlu Y, Unal M, Ozcan C, Görür K, Horasan ES, Sevük L. Lesions of tuberculosis in the head and neck region: A retrospective analysis of 48 cases. Kulak Burun Bogaz Ihtis Derg 2010;20:57-63.  Back to cited text no. 16
    
17.Choudhury N, Bruch G, Kothari P, Rao G, Simo R. 4 years' experience of head and neck tuberculosis in a south London hospital. J R Soc Med 2005;98:267-9.  Back to cited text no. 17
    
18.Altuntaº EE, Doðan M, Müderris S, Elagöz ª. Extranodal tuberculosis of head and neck: A report of four cases. Cumhuriyet Med J 2009;31:60-5.  Back to cited text no. 18
    
19.Helbling CA, Lieger O, Smolka W, Iizuka T, Kuttenberger J. Primary tuberculosis of the TMJ: Presentation of a case and literature review. Int J Oral Maxillofac Surg 2010; 39:834-8.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1]


This article has been cited by
1 Isolated nasopharyngeal tuberculosis in a 12?year old boy – A case report
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[Pubmed] | [DOI]



 

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