Variable Presentations of Oropharyngeal Tuberculosis
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International Medical Journal Vol. 28, No. 1, pp. 124 - 126 , February 2021 CASE REPORT Variable Presentations of Oropharyngeal Tuberculosis Wan Nabila Wan Mansor 1) , Carren Sui-Lin Teh 2) , Lye Meng Hon 2) , Intan Kartika Kamarudin 3) ABSTRACT Purpose: In this report, we present three (3) cases of oropharyngeal tuberculosis which have different clinical presentations with its own diagnostic challenges in the spate of a year. Discussions: Tuberculosis is a multisystemic disease and is one of the commonest infectious diseases in South East Asia. Oropharyngeal tuberculosis is a rare disease comprising of 0.5-5% of all tuberculosis cases and is usually secondary to laryngeal involvement in pulmonary tuberculosis. However, oropharyngeal tuberculosis can be an isolated manifestation without larynge- al or lungs involvement with a myriad of presentations, from ulcers to tonsillar hypertrophy. Conclusions: Oropharyngeal tuberculosis may manifest itself in the least expected manner such as in an acute upper airway obstruction or a simple peritonsillar abscess. While oropharyngeal cases are rare, histopathological and microbiological analysis are important for diagnosis and treatment especially in endemic countries. KEY WORDS tuberculosis, oropharyngeal, diagnosis Received on May 28, 2020 and accepted on August 13, 2020 1) Department of Otorhinolaryngology-Head and Neck Surgery, Universiti Kebangsaan Malaysia Jalan Yaacob Latif, Jalan Tun Razak, 56000, Batu 9 , Cheras, Kuala Lumpur, Malaysia 2) Department of Otorhinolaryngology- Head and Neck Surgery, Hospital Sungai Buloh Jalan Hospital, 47000, Sungai Buloh, Selangor, Malaysia 3) Department of Otorhinolaryngology, Faculty of Medicine, Universiti Teknologi Mara Jalan Hospital, 47000, Sungai Buloh, Selangor, Malaysia Correspondence to: Wan Nabila Wan Mansor (e-mail: [email protected]) 124 INTRODUCTION Tuberculosis (TB) is a chronic infectious granulomatous disease caused by Mycobacterium tuberculosis. It remains a major health chal- lenge in the world, especially in endemic regions 1,2) . Involvement of the oropharynx by TB can either present itself as primary or commonly sec- ondary to pulmonary TB 3) . The lesions of primary oropharyngeal TB generally occur in younger patients, however, secondary oropharyngeal involvement is more commonly spread via infected sputum 1,4) . Histopathological and microbiological analysis are the mainstay for diagnosis 2,3) . Oropharyngeal TB is rare and consists of only 0.05-5% of total tuberculosis cases globally 1) . Nevertheless, we would like to pres- ent three cases which occurred within a year. CASE 1 A 34-year-old woman admitted to the Emergency Department with worsening shortness of breath, sore throat and dysphagia for a month. She had both loss of weight and appetite. There was audible inspiratory stridor with multiple cervical lymphadenopathy at levels I, II, III and IV. Intraoral examination showed fibrotic webbing of the oropharynx with laryngopharyngeal fibrosis obstructing the airway. Tracheostomy and direct laryngoscopy were performed, which revealed the soft palate, pharyngeal arches and uvula plastered to the posterior pharyngeal wall with a small opening to the nasopharynx (Figure.1). A large broad fibrotic band with surrounding granulation tissue was observed at the tongue base and hypopharynx. A small opening to the airway was visu- alized. Intraoperatively, the large fibrotic band was incised to widen the small airway. The fibrotic and granulation tissues were then sent for his- topathological examination and was reported as granulomatous inflam- mation with occasional multinucleated giant cells with no central necro- sis. Ziehl-Neelsen (ZN) stain was tested negative. Chest X-ray showed cavitation over the right upper lung zone. Erythrocyte sedimentation rate was 40 mm/hour. Her tracheal aspirate also yielded negative stain for AFB and mycobacterium culture. X-ray of neck lateral soft tissue demonstrated soft tissue density thickening of the oropharynx and hypopharynx (Figure. 2). CT scan revealed soft tissue density and vocal cord thickening at the glottic and subglottic regions, with multiple calcified lung granulomas observed in both lung apices. Based on the radiological and histopatho- logical findings, the diagnosis of secondary tuberculosis of the orophar- ynx with extension to the hypopharynx was established. Anti- tuberculosis treatment was commenced and after a total duration of 4 weeks treatment with anti-tuberculosis drugs, a repeated CT scan of the neck revealed a markedly reduced soft tissue thickening at the orophar- ynx and hypopharynx with improvements in the airway patency (Figure.3). The patient was seen after completing 9 months of antituber- culosis treatment and is well with minimal scarring over the orophar- ynx. C 2021 Japan University of Health Sciences & Japan International Cultural Exchange Foundation
Transcript of Variable Presentations of Oropharyngeal Tuberculosis
International Medical Journal Vol. 28, No. 1, pp. 124 - 126 , February 2021
CASE REPORT
Variable Presentations of Oropharyngeal Tuberculosis
Wan Nabila Wan Mansor1), Carren Sui-Lin Teh2), Lye Meng Hon2), Intan Kartika Kamarudin3)
ABSTRACTPurpose: In this report, we present three (3) cases of oropharyngeal tuberculosis which have different clinical presentations
with its own diagnostic challenges in the spate of a year. Discussions: Tuberculosis is a multisystemic disease and is one of the commonest infectious diseases in South East Asia.
Oropharyngeal tuberculosis is a rare disease comprising of 0.5-5% of all tuberculosis cases and is usually secondary to laryngeal involvement in pulmonary tuberculosis. However, oropharyngeal tuberculosis can be an isolated manifestation without larynge-al or lungs involvement with a myriad of presentations, from ulcers to tonsillar hypertrophy.
Conclusions: Oropharyngeal tuberculosis may manifest itself in the least expected manner such as in an acute upper airway obstruction or a simple peritonsillar abscess. While oropharyngeal cases are rare, histopathological and microbiological analysis are important for diagnosis and treatment especially in endemic countries.
KEY WORDStuberculosis, oropharyngeal, diagnosis
Received on May 28, 2020 and accepted on August 13, 20201) Department of Otorhinolaryngology-Head and Neck Surgery, Universiti Kebangsaan Malaysia Jalan Yaacob Latif, Jalan Tun Razak, 56000, Batu 9 , Cheras, Kuala Lumpur, Malaysia 2) Department of Otorhinolaryngology- Head and Neck Surgery, Hospital Sungai Buloh Jalan Hospital, 47000, Sungai Buloh, Selangor, Malaysia3) Department of Otorhinolaryngology, Faculty of Medicine, Universiti Teknologi Mara Jalan Hospital, 47000, Sungai Buloh, Selangor, MalaysiaCorrespondence to: Wan Nabila Wan Mansor(e-mail: [email protected])
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INTRODUCTION
Tuberculosis (TB) is a chronic infectious granulomatous disease caused by Mycobacterium tuberculosis. It remains a major health chal-lenge in the world, especially in endemic regions1,2). Involvement of the oropharynx by TB can either present itself as primary or commonly sec-ondary to pulmonary TB3). The lesions of primary oropharyngeal TB generally occur in younger patients, however, secondary oropharyngeal involvement is more commonly spread via infected sputum1,4). Histopathological and microbiological analysis are the mainstay for diagnosis2,3). Oropharyngeal TB is rare and consists of only 0.05-5% of total tuberculosis cases globally1). Nevertheless, we would like to pres-ent three cases which occurred within a year.
CASE 1
A 34-year-old woman admitted to the Emergency Department with worsening shortness of breath, sore throat and dysphagia for a month. She had both loss of weight and appetite. There was audible inspiratory stridor with multiple cervical lymphadenopathy at levels I, II, III and IV. Intraoral examination showed fibrotic webbing of the oropharynx with laryngopharyngeal fibrosis obstructing the airway. Tracheostomy and direct laryngoscopy were performed, which revealed the soft palate,
pharyngeal arches and uvula plastered to the posterior pharyngeal wall with a small opening to the nasopharynx (Figure.1). A large broad fibrotic band with surrounding granulation tissue was observed at the tongue base and hypopharynx. A small opening to the airway was visu-alized.
Intraoperatively, the large fibrotic band was incised to widen the small airway. The fibrotic and granulation tissues were then sent for his-topathological examination and was reported as granulomatous inflam-mation with occasional multinucleated giant cells with no central necro-sis. Ziehl-Neelsen (ZN) stain was tested negative.
Chest X-ray showed cavitation over the right upper lung zone. Erythrocyte sedimentation rate was 40 mm/hour. Her tracheal aspirate also yielded negative stain for AFB and mycobacterium culture. X-ray of neck lateral soft tissue demonstrated soft tissue density thickening of the oropharynx and hypopharynx (Figure. 2).
CT scan revealed soft tissue density and vocal cord thickening at the glottic and subglottic regions, with multiple calcified lung granulomas observed in both lung apices. Based on the radiological and histopatho-logical findings, the diagnosis of secondary tuberculosis of the orophar-ynx with extension to the hypopharynx was established. Anti-tuberculosis treatment was commenced and after a total duration of 4 weeks treatment with anti-tuberculosis drugs, a repeated CT scan of the neck revealed a markedly reduced soft tissue thickening at the orophar-ynx and hypopharynx with improvements in the airway patency (Figure.3). The patient was seen after completing 9 months of antituber-culosis treatment and is well with minimal scarring over the orophar-ynx.
C 2021 Japan University of Health Sciences & Japan International Cultural Exchange Foundation
Wan Mansor W. N. et al. 125
CASE 2
A 33-year-old man admitted for sore throat and fever for 5 days. Intraoral examination revealed a bulging at the left peritonsillar region and uvula has deviated to the right. Thus, aspiration was done followed by incision and drainage. A total of 4 ml of pus was drained and sent for microbiological analysis including mycobacterium culture, staining and TB polymerase chain reaction. Pus culture yielded Streptoccocus pyo-genes. The result was positive stain for acid-fast bacilli. Further investi-gations revealed a positive Mantoux test of 18 mm. The sputum culture for mycobacterium was negative. Chest X-ray findings was normal. Based on the results, the diagnosis of primary oropharyngeal tuberculo-sis with concomitant infection was established instead of left peritonsil-lar abscess. The patient had complete recovery after six months of anti-tuberculosis treatment.
CASE 3
A 19-year-old lady was admitted for throat discomfort. Oral exam-ination revealed an asymmetrical grade 3 and grade 1 left and right ton-sillar hypertrophy respectively. She had left submandibular swelling with bilateral level II cervical lymphadenopathy. Chest examination was normal. Computed tomography (CT) of the neck was performed which revealed bilateral cervical and right supraclavicular necrotic lymphade-nopathy. With the presence of asymmetrical tonsillar hypertrophy and lymphadenopathy, diagnostic tonsillectomy was performed to rule out lymphoma. Histopathology of the left enlarged tonsil was normal. Interestingly, her right tonsil revealed multiple granuloma of epithelioid histiocytes with multinucleated giant cells of Langhan's type, which was characteristic of tuberculosis. The Ziehl-Neelsen (ZN) stain was tested negative for acid fast bacilli. The patient had defaulted on her follow-up and was uncontactable for further treatment.
DISCUSSIONS
Tuberculosis of the upper aerodigestive tract which includes the oral cavity and oropharynx is a rare disease which may either be primary or secondary infections1). Tuberculosis of the oral cavity commonly affects the tongue, however, other oral sites such as gingiva and mucobuccal folds can also be affected as well1,2).
Piasesk (1987) explains that oropharyngeal and oral cavity mucosa are generally resistant to infection by Mycobacterium tuberculosis due to the protection by the presence of salivary enzymes but a compro-mised protective layer of the mucosa lining may provide a route of infection4). Furthermore, inflammatory conditions such as tooth extraction or poor oral hygiene may predispose to tuberculosis infection in both oral cavity and oropharynx1,4).
Oropharyngeal TB may manifest itself with non-specific symptoms such as sore throat, fever, malaise, decreased appetite, weight loss, and odynophagia1,3). Due to the location, the signs and symptoms are vari-
Figure 1: Fibrotic appearance of the oropharynx as seen using fibreoptic laryngoscope.
Figure 2: This image depicts the appearance of thick soft tissue at the oropharynx as seen from the lateral neck X-ray.
Figure 3: Sagittal view of the CT Neck revealed soft tissue densi-ty at the hypopharynx.
Oropharyngeal Tuberculosis126
able and non-specific. Literature has shown the oropharyngeal manifes-tation may consist of satellite ulcers with undermined edges and a gran-ulating floor4). However, not all lesions appear as ulcers. Some may be present with nodules, fissures, tuberculomas or granulomas which are often found in secondary oropharyngeal tuberculosis2). Other findings may include tonsillar enlargement with surface ulceration or ulceropro-liferative growth mimicking a malignancy5). Our three patients did not present as what was suggested in the literature but instead the first case presented with an acute upper airway emergency secondary to the fibrotic webbing of the oropharynx, second case with a peritonsillar abscess and third a fibrotic tonsil. Each had their own list of possible diagnoses but tuberculosis was unexpected.
Malaysia is an endemic area for tuberculosis with 92 active TB cases per 100, 000 population in 2018 and we have had three cases in a year. We suggest countries who are also tuberculosis-endemic to have a higher degree of suspicion of oropharyngeal tuberculosis even when encountering regular cases such as peritonsillar abscesses or asymmetri-cal tonsillar enlargement6).
CONCLUSIONS
Oropharyngeal tuberculosis may manifest itself in the least expected
manner such as in an acute upper airway obstruction or a simple peri-tonsillar abscess. While oropharyngeal cases are rare, histopathological and microbiological analysis is important for diagnosis and treatment especially in endemic countries.
REFERENCES
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