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Year : 2020  |  Volume : 13  |  Issue : 5  |  Page : 465-469  

Extranodal tuberculosis of the head and neck: Our experiences at a tertiary care teaching hospital of East India

1 Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha 'O' Anusandhan University (Deemed to be), Bhubaneswar, Odisha, India
2 Medical Research Laboratory, IMS and SUM Hospital, Siksha 'O' Anusandhan University (Deemed to be), Bhubaneswar, Odisha, India
3 Division of Microbiology, ICMR-National Institute of Occupational Health, Ahmedabad, Gujarat, India

Date of Submission13-Jun-2019
Date of Decision01-Oct-2019
Date of Acceptance20-Dec-2019
Date of Web Publication7-Sep-2020

Correspondence Address:
Santosh Kumar Swain
Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha 'O' Anusandhan University (Deemed to be), Bhubaneswar, Odisha
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.mjdrdypu_168_19

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Introduction: Extranodal tuberculosis of the head-and-neck area is a rare clinical entity and constitutes a less common type of extrapulmonary tuberculosis. It often creates challenges among head-and-neck physicians for its diagnosis and treatment. Objective: The aim of the study is to discuss the clinical presentations, diagnostic challenges, and treatment of extranodal tuberculosis of the head-and-neck area. Materials and Methods: There are 22 patients of extranodal locations of tuberculosis in the head-and-neck region managed at our teaching hospital between December 2014 and January 2019. Results: The sinonasal tract affected in 5 cases, the tonsils in 4 cases, the middle ear cleft in 4 cases, the nasopharynx in 3 cases, and the larynx in 3 cases. The parotid gland affected with tuberculosis in 2 cases and 1 case in the thyroid gland. The clinical presentations, imaging, and endoscopic pictures are not specific, whereas the diagnosis is based on histopathological examination. All the patients treated with antitubercular therapy. All patients showed favorable results after 1-year follow-up. Conclusion: Extranodal tuberculosis is a rare clinical entity and has no specific clinical features. It is often a differential diagnosis of head-and-neck malignancies and chronic infective or noninfective ulcers. Early diagnosis and its treatment may avoid complications and needless major surgery.

Keywords: Antitubercular treatment, extranodal, head, neck, tuberculosis

How to cite this article:
Swain SK, Mohanty JN, Sahu MC. Extranodal tuberculosis of the head and neck: Our experiences at a tertiary care teaching hospital of East India. Med J DY Patil Vidyapeeth 2020;13:465-9

How to cite this URL:
Swain SK, Mohanty JN, Sahu MC. Extranodal tuberculosis of the head and neck: Our experiences at a tertiary care teaching hospital of East India. Med J DY Patil Vidyapeeth [serial online] 2020 [cited 2020 Oct 24];13:465-9. Available from: https://www.mjdrdypv.org/text.asp?2020/13/5/465/294342

  Introduction Top

Tuberculosis is a major health problem in developing countries. Tuberculosis is a chronic granulomatous infectious disease of the human being caused by intracellular acid-fast bacilli Mycobacterium tuberculosis known since antiquity.[1] Although there is a tremendous advancement in the treatment and prevention of tuberculosis, still it is a major cause of disability and death in developing and underdeveloped countries.[2] Tuberculosis has a worldwide presence and no part of the human organ is immune to it, and the most common primary site being involved is lungs. Lymph nodes are the most common location in the head-and-neck area to be affected. Although extranodal parts of the head-and-neck area are rare, often compromised and misdiagnosed in clinical practice. The clinical presentations, endoscopy, and imaging are not enough for proper diagnosis. It often creates misdiagnosis with head-and-neck malignancies and other chronic infective and noninfective lesions. The aim of this study is to discuss the clinical presentations, diagnostic problems, and treatment of extranodal tuberculosis in the head-and-neck region.

  Materials and Methods Top

We carried out a 5-year retrospective study of 22 cases of extranodal locations of tuberculosis managed by the department of otorhinolaryngology and head-and-neck surgery of a tertiary care teaching hospital of East India during December 2014–January 2019. This study was approved by the Institutional Ethics Committee (IEC) (letter no: IMS/CRL/IEC/73, Date: August 18, 2014). The patients were of the age from 11 to 65 years. Details of patients' clinical presentations, diagnostic methods, treatment and outcomes were analyzed. Routine blood tests such as total white cell count, differential cell count, and erythrocyte sedimentation rate were done in all cases. The diagnosis of extranodal tuberculosis was based on pathological and microbiological findings of the biopsy specimen collected from the different locations of tubercular lesions. The diagnosis was confirmed by histopathological examinations with chronic granulomatous inflammatory exudates with or without caseating necrosis and Langhans giant cells surrounded by lymphocytes. As the microbial study with smear (Ziehl–Neelsen staining) and culture was difficult in extranodal tuberculosis of the head-and-neck region, here the diagnosis was confirmed by histopathological study. Ziehl–Neelsen staining method is used to stain acid-fast bacilli such as Mycobacterium species which is the quickest and easiest technique done to identify the acid-fast bacilli. In cases of histopathology picture showing the absence of caseations, the diagnosis was confirmed by recovery of the patients under antitubercular therapy (ATT). Computed tomography (CT) was done in sinonasal and nasopharyngeal tuberculosis. Magnetic resonance imaging (MRI) was done in parotid and laryngeal tuberculosis. Chest X-ray of the lungs was done in all cases.

  Results Top

There were 12 male and 10 female patients aged from 11 to 65 years, with a mean age of 39 years. The disease affecting the locations in the head-and-neck region was 5 cases in the sinonasal area, 4 in the tonsils, 4 in the middle ear cleft, 3 in the nasopharynx, 3 in the larynx, 2 in the parotid gland, and 1 in the thyroid gland. Three cases had a family history of tuberculosis. The mean duration of symptoms was 6 months. Clinical presentations were varied as per site of involvement [Table 1]. In sinonasal tuberculosis [Figure 1], patients were presenting with nasal discharge, nasal obstruction, and mild swelling of the cheek and orbit. Imaging like CT scan [Figure 2] is helpful for assessing the size of the lesions and spread of the disease in sinonasal tuberculosis. In nasopharyngeal tuberculosis, the diagnostic nasal endoscopy showed bulged and irregular mucosa at the posterosuperior part of the nasopharynx. CT scan is helpful to find the exact site of the lesion and its spread of nasopharyngeal tuberculosis [Figure 3]. Patients of laryngeal tuberculosis presented with chronic hoarseness of voice and ulcerative lesions over the vocal cords. Parotid tuberculosis presented with swelling of the infra-aural area where the examination confirmed a mass of the parotid gland with neither any inflammatory feature nor facial weakness. One patient of thyroid gland tuberculosis presented with a 2-cm lump over the anterior part of the neck which moves upon swallowing. Routine blood investigations such as total white cell count and differential count were within normal limits in all cases. Tuberculin test was done in 7 cases and positive in 3 cases. Ultrasound of the neck was done in one case of thyroid tuberculosis and two cases of parotid tuberculosis. Clinical presentations and imaging are nonspecific and often mislead to diagnosis. The diagnosis is mainly based on the histopathological examination. Biopsy and histopathological examinations were done in all of our cases. Two cases of sinonasal cases had undergone endoscopic sinus surgery. One case of tuberculosis otitis media with facial palsy had undergone mastoid exploration and facial nerve decompression. Tonsillectomy was done in 3 cases, two patients had undergone superficial parotidectomy, whereas one case had undergone lobo-isthmectomy of the thyroid gland. Histopathology report was positive for tuberculosis in all the cases. The report showed epithelioid granuloma with or without caseating necrosis [Figure 4]. All the diagnosed cases of extranodal tuberculosis of the head-and-neck region sent to integrated counseling and testing center for HIV but found negative. All the cases received antitubercular treatment. Four drugs such as rifampicin, isoniazid, ethambutol, and pyrazinamide were given in the intensive phase for 2 months followed by isoniazid and rifampicin in a continuation phase for 6–8 months. All patients showed favorable results, and no one had recurrence during 1-year follow-up period.
Table 1: Clinical presentation in extranodal tuberculosis of the head and neck

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Figure 1: Diagnostic nasal endoscopy showing multiple reddish-to-pinkish mass in the nasal cavities along with cheesy materials in the floor of the nose

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Figure 2: Computed tomography scan of the nose and paranasal sinuses showing diffuse mucosal thickening of the right maxillary and ethmoidal sinuses

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Figure 3: Computed tomography showing enhanced soft-tissue area in the nasopharynx

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Figure 4: (a) Histopathological examination showing granuloma formation with caseous necrosis. (b) Ziehl–Nielsen staining from biopsy specimen showing acid-fast bacilli

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  Discussion Top

Tuberculosis is one of the most devastating bacterial diseases of the human being and caused by M. tuberculosis. There are 8.7 million new cases of tuberculosis, and 1.4 million people died from tuberculosis.[3] This chronic granulomatous infection can affect any organ of the body. Due to advancement in the ATT, the incidence is decreasing significantly. However, there is a resurgence of extrapulmonary tuberculosis including the tubercular lesions of the head and neck. This may be due to human immunodeficiency virus.[4] Primary sinonasal tuberculosis is a rare clinical entity which often mimics other rhinosinusitis, so frequently missed by a clinician, delay in diagnosis and its treatment.[5] The pathological changes of sinonasal tuberculosis are often three types. The infection is confined to mucosa of the sinonasal area and leads to polyp formation. The second type affects the bony wall and often leads to fistula formation. The third type is associated with hyperplastic changes in the sinonasal mucosa and leads to the formation of the tuberculoma. Sinonasal tuberculosis often leads to complications of septal perforation, nasal stenosis, or atrophic rhinitis if not treated in time.[6] In this study, five cases have sinonasal tuberculosis without such complications. Tuberculosis of the oral cavity and oropharynx is often rare. Tuberculosis of the tonsils usually presents with sore throat and odynophagia. Tuberculosis of the tonsil is suspected when there are unequal sizes of the two tonsils and often associated with jugulodigastric node enlargement. All of the patients with tonsillar tuberculosis in this study presented with odynophagia. The predisposing factors for primary tuberculosis of the oral cavity are HIV infection, poor dental hygiene, alcoholism, dental extraction, periodontitis, and leukoplakia.[7] The differential diagnosis of tonsillar tuberculosis is traumatic ulcers, aphthous ulcers, syphilis, actinomycosis, malignancy, midline granuloma, hematological disorders, and Wegner's granuloma.[8] Tuberculosis of the otitis media is a rare clinical entity in the human being.[9] It constitutes 0.04%–0.90% of all types of suppurative otitis media in developed countries, whereas its incidence is steadily rising in the endemic areas of tuberculosis.[10] Tuberculous otitis media is characterized by painless ear discharge of insidious onset which fails to respond with antibiotic treatment, single or multiple perforations in the tympanic membrane, pale granulation tissue inside the middle ear cavity and mastoid, and hearing loss out of proportion to clinical findings.[11] Profound hearing loss is often seen in tuberculous otitis media which may be conductive, sensorineural, or mixed type depending the extent of the disease-causing tympanic, ossicular, or bony destruction.[12] Single perforation is often seen than multiple perforations in the eardrum. The pale, polypoidal, edematous granulations are seen in the middle ear cleft.[13] In this study, tubercular otitis media patients presented with painless ear discharge, hearing loss, facial nerve paralysis, and tympanic membrane showing multiple perforations. Surgery is often advised in primary aural tuberculosis for preventing facial nerve palsy and intracranial spread, although in the present day, the ATT is paramount in managing aural tuberculosis like pulmonary. One case of tuberculous otitis media with facial nerve palsy had undergone mastoid exploration with facial nerve decompression followed by ATT. The nasopharynx is one of the basic destinations in head and neck to be influenced by tuberculosis. These are (1) aviation route, either through direct nasal ventilation or optionally by canalized bacillary expectoration and (2) hematogenous or lymphatic channel, from essential area, as a rule from aspiratory. The lymphatic nasopharyngeal pollution is better clarified by the abundant lymphatic system of the Waldeyer's ring.[14] The clinical introductions in nasopharyngeal tuberculosis are nasal block, rhinorrhea, epistaxis, cervical lymphadenopathy, serous otitis media, and hearing loss.[15] In this study, patients of nasopharyngeal tuberculosis presented with blood-stained nasal discharge and nose block. Diagnostic nasal endoscopy demonstrates mucosal thickening, ulcerations, or polypoidal mass. Nasopharyngeal tuberculosis regularly copies to other nasopharyngeal maladies such as lymphoma, nasopharyngeal carcinoma, minor salivary organ carcinoma, Wegener's granulomatosis, parasitic contamination, angiofibroma, sarcoidosis, periarteritis nodosa, infection, syphilis, and Castleman's illness.[16],[17] Laryngeal tuberculosis often presents with hoarseness of voice (80%–100%) and odynophagia (50%–67%). It can affect any part of the larynx.[18] The vocal cords of the larynx are commonly affected in laryngeal tuberculosis. Laryngeal tuberculosis is characterized by edema, hyperemia, or ulcerative lesions in the larynx. In our study, all the patients of laryngeal tuberculosis presented with hoarseness of voice, and endoscopic findings showed small ulcerative lesions in the vocal folds. The difference between laryngeal carcinoma and laryngeal tuberculosis is often difficult. Previously laryngeal tuberculosis is due to complications of pulmonary tuberculosis, but in the present time, isolated laryngeal tuberculosis is increasing. In our case, the lesions in the larynx were not due to pulmonary tuberculosis.[19] Thyroid gland tuberculosis constitutes 0.1%–0.4% of all types of tuberculosis affecting the body parts.[20] Thyroid tuberculosis often presents with thyroid nodule or as multinodular goiter. Sometimes, it forms fistula with its orifice. Hence, the diagnosis of thyroid tuberculosis is suspected when goiter occurs in context to tuberculosis or immunosuppression. In this case, fine-needle aspiration cytology confirms the diagnosis and it is better to avoid thyroidectomy.[20] The parotid gland is the most common salivary gland to be affected by tuberculosis. Tuberculosis of the parotid gland often presents with unilateral swelling or abscess formation in the parenchyma of the gland. The fistula formation in the parotid gland often suggests the diagnosis. The differential diagnosis of parotid gland tuberculosis is neoplastic lesions of the parotid and sarcoidosis. Early diagnosis by fine-needle aspiration will avoid major surgery of the parotid gland as it is a medically treatable lesion.[21] The diagnosis of extranodal tuberculosis of the head and neck is confirmed by histopathological examination which reveals granulomatous inflammation with epithelioid giant cells and caseous necrosis. Ziehl–Neelsen staining may directly show acid-fast bacilli. The microbiological culture and drug sensitivities of the infective strain are not usually done in practice, whereas the multiple repeated biopsies are often used for confirming the diagnosis and starting the treatment.[22] The polymerase chain reaction (PCR) test is often used for the diagnosis of tuberculosis. The detection of M. tuberculosis is increased from 2% to 17% on culture to 89%–100% in PCR.[23] In cases of strong clinician suspicion of tuberculosis with negative cultures, samples can be sent for PCR test.[24] In this study, diagnosis was confirmed by biopsy from the lesion and histopathological examination. CT scan is advised to show either a large mass, a lobulated mass, or an irregular soft tissue in the head-and-neck region.[14] MRI is useful in case of soft granulomatous mass. In MRI, nasopharyngeal tuberculosis is either seen as polypoidal mass of the adenoids or diffuse thickening of the mucosa at the nasopharynx.[25] As per the WHO guidelines, extrapulmonary tuberculosis should be treated by four-drug regimen in the first 2 months followed by two drugs for the next 4 months.[26] The main treatment of extrapulmonary tuberculosis is antituberculous therapy, whereas the surgery is often done to establish an early diagnosis and start early treatment of the patient.[27],[28] All of the patients in this study had taken ATT. The absence of characteristic clinical presentations and the rare occurrence of head-and-neck extranodal tuberculosis often create challenges among physicians and may lead to misdiagnosis and delayed treatment. Hence, otorhinolaryngologists and head-and-neck physicians should be alert regarding its clinical presentations and diagnostic challenges for early treatment and to avoid its complications.

  Conclusion Top

Extranodal tuberculosis of the head-and-neck region is a rare occurrence and often leads to misdiagnosis of the disease. The diagnosis is often accidental or surprise during the evaluation of head and neck lesions. Histopathological confirmation is the most important in the diagnostic procedure for these lesions. Antitubercular treatment is the treatment of choice for extranodal tuberculosis of the head-and-neck region. Early diagnosis and its treatment may avoid complications of extranodal tuberculosis and needless major surgery.

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