|Year : 2012 | Volume
| Issue : 2 | Page : 88-91
Primary tuberculosis of the nasopharynx: A rare case and literature review
Emine Elif Altuntas1, Canan Filiz Karakus1, Kasim Durmus1, Ismail Önder Uysal1, Suphi Müderris1, Sahende Elagöz2
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 Publication||6-Sep-2012|
Emine Elif Altuntas
Department of Othorhinolaryngology, Faculty of Medicine, University of Cumhuriyet, Sivas
Source of Support: None, Conflict of Interest: None
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 2020 Sep 30];18:88-91. Available from: http://www.indianjotol.org/text.asp?2012/18/2/88/100732
| Introduction|| |
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. 
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. , 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. 
We report one patient with proved primary mycobacterium tuberculosis of the nasopharynx and presenting similar cases by the reviewing literature.
| Case Report|| |
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|| |
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. ,
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.,  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, , 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. ,,
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. 
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.  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  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. 
The most frequent manifestation of head and neck tuberculosis (95%) is cervical lymphadenitis.  Vayýsoðlu et al .  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.  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 .  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.  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|| |
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.
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[Figure 1], [Figure 2]