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July 19, 2010

Pathology Quiz Case 1: Diagnosis

Arch Otolaryngol Head Neck Surg. 2010;136(7):746-747. doi:10.1001/archoto.2010.85-b

Diagnosis: Nasopharyngeal tuberculosis

Tuberculosis in the head and neck region is often diagnosed, and several presentations of head and neck tuberculosis have been described. However, solitary nasopharyngeal tuberculosis is an uncommon entity and, to our knowledge, has rarely been reported in the literature. A 10-year retrospective study among 1315 tuberculosis cases in Bradford, England, resulted in 128 patients with head and neck tuberculosis.1Most of these patients (n = 111 [87%]) had cervical tuberculous lymphadenitis. Only 1 patient (a 36-year-old Asian man) presented with bilateral middle ear effusions and was diagnosed as having nasopharyngeal tuberculosis after nasal biopsy. Eighty-nine percent of the patients (n = 114) were of Asian origin, and 10.2% (n = 13) were white. Nalini and Vinayak2described 117 patients with head and neck tuberculosis, 111 of whom (95%) were diagnosed as having cervical lymphadenopathy. They also reported cases of tuberculosis of the larynx, oropharynx, cervical spine, and ear. Nasopharyngeal tuberculosis was not reported.

Most of the available literature about nasopharyngeal tuberculosis involves series of cases and individual case reports of patients with varying symptoms, of which cervical lymphadenopathy is the most common. Waldron et al3described 10 patients with nasopharyngeal tuberculosis between 1985 and 1989. Seven patients presented with enlarged cervical nodes. Other symptoms were nasal obstruction, weight loss, cough, decreased hearing, secretory otitis media, and general malaise. In 8 cases, the chest x-ray films showed no abnormalities.

Srirompotong et al4published a retrospective study involving 23 patients in Thailand with nasopharyngeal tuberculosis between 1991 and 2000. Again, cervical lymphadenopathy was most commonly reported as the main symptom (91.3%). Other symptoms were weight loss and fever (30.4%), epistaxis (13.1%), nasal obstruction (8.7%), and hearing loss (4.3%). The observed nasopharyngeal abnormalities consisted of an irregular surface, ulcerations, or a nasopharyngeal mass. A chest x-ray film that was suggestive of pulmonary tuberculosis was found in 44.4% of the cases. Tse et al5reported 17 cases of nasopharyngeal tuberculosis. Ten patients presented with cervical lymphadenopathy and 2 patients with hearing loss. Other symptoms were otalgia, tinnitus, nasal obstruction, and postnasal drip. Two patients also had fever, night sweats, and weight loss. Chan et al6described 3 patients who developed solitary nasopharyngeal tuberculosis after they completed radiotherapy for nasopharyngeal carcinomas. They raised the possibility of local tissue damage after irradiation creating a portal of entry for infection through the inhalation of tuberculosis. It should be pointed out that the patients lived in geographical areas with a high incidence of tuberculosis.

In the absence of cervical lymphadenopathy or other evident clinical abnormalities, it is difficult to discriminate between nasopharyngeal tuberculosis and a malignant nasopharyngeal tumor.7One patient without cervical lymphadenopathy and normal findings on the chest x-ray film presented with snoring as the only complaint.8Only mucosal edema and hyperemia of the nasopharynx were found. Köktener and Köktenera9described a patient who presented with headache as the only symptom. This patient was diagnosed as having nasopharyngeal tuberculosis after a nonspecific nasopharyngeal lesion was observed on magnetic resonance imaging, followed by biopsy. King et al10described 2 patterns that could be used to identify nasopharyngeal tuberculosis on magnetic resonance images: polypoid mass of the adenoids and a diffuse thickening of the mucosal wall of the nasopharynx. However, only 3 cases were included and compared with available literature.

Our 92-year old white patient presented with minor dysphagia-related symptoms. An observed ulcerating and granulating nasopharyngeal lesion was clinically highly suggestive of a nasopharyngeal carcinoma. Retrospectively, our patient's medical history revealed long-term contact with a patient who had pulmonary tuberculosis. The minor irregularity and mild enhanced signal intensity that were observed on the T2-weighted magnetic resonance image were not specific for either inflammation or a nasopharyngeal carcinoma.

In the absence of cervical lymphadenopathy and abnormal findings on the chest-x-ray film, histopathologic examination of the nasopharyngeal lesion showed an active granulomatous infection without evidence of malignant tissue. The histologic features can be confused with those of several pathologic entities. Infection with Mycobacterium tuberculosisis probably the best-known cause of a necrotizing granulomatous inflammation. Similar histologic changes can also be identified in infections with nontuberculous mycobacteria, although necrosis is not often present in those cases. The granulomas found in sarcoidosis are mostly well organized, with minimal or no necrosis. Sometimes, Schaumann and asteroid bodies are present. A granulomatous inflammation can also be seen in vasculitides, such as Wegener granulomatosis or Churg-Strauss syndrome.

In this case, the multiple foci of necrosis were not typically located in the center of the granulomas, which would be expected in a classic tuberculosis case. A Ziehl-Neelsen stain was negative for acid-fast bacilli. Nevertheless, neither the atypically located necrosis nor the negative result on the Ziehl-Neelsen stain could exclude the presence of M tuberculosis. Microbiological cultures of the mouth, nose, and lesion showed only common flora. An additional periodic acid–Schiff diastase stain did not show fungi or spores. Finally, molecular polymerase chain reaction analysis was performed on the formalin-fixed, paraffin-embedded biopsy material. The findings confirmed infection with M tuberculosis. Computed tomography with contrast showed no other signs of systemic tuberculosis.

Standard quadruple therapy was limited to isoniazid, 300 mg/d, and rifampicin, 600 mg/d, because of possible liver enzyme disorders. After the first month of therapy, the nasopharyngeal lesion was substantially reduced. The recovery of the patient was monitored during a monthly checkup at our outpatient department. The minimal treatment period for extrapulmonary tuberculosis is 6 months,4,7but it can be extended.7In cases with adequate treatment, the prognosis of nasopharyngeal tuberculosis is good.4,7

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Menon  KBem  CGouldesbrough  DStrachan  DR A clinical review of 128 cases of head and neck tuberculosis presenting over a 10-year period in Bradford, UK.  J Laryngol Otol 2007;121 (4) 362- 368PubMedArticle
Nalini  BVinayak  S Tuberculosis in ear, nose, and throat practice: its presentation and diagnosis.  Am J Otolaryngol 2006;27 (1) 39- 45PubMedArticle
Waldron  JVan Hasselt  CASkinner  DWArnold  M Tuberculosis of the nasopharynx: clinicopathological features.  Clin Otolaryngol Allied Sci 1992;17 (1) 57- 59PubMedArticle
Srirompotong  SYimtae  KJintakanon  D Nasopharyngeal tuberculosis: manifestations between 1991 and 2000.  Otolaryngol Head Neck Surg 2004;131 (5) 762- 764PubMedArticle
Tse  GMMa  TKChan  AB  et al.  Tuberculosis of the nasopharynx: a rare entity revisited.  Laryngoscope 2003;113 (4) 737- 740PubMedArticle
Chan  ABMa  TKYu  BKKing  ADHo  FNTse  GM Nasopharyngeal granulomatous inflammation and tuberculosis complicating undifferentiated carcinoma.  Otolaryngol Head Neck Surg 2004;130 (1) 125- 130PubMedArticle
Percodani  JBraun  FArrue  P  et al.  Nasopharyngeal tuberculosis.  J Laryngol Otol 1999;113 (10) 928- 931PubMedArticle
Aktan  BSelimoglu  EUcuncu  HSutbeyaz  Y Primary nasopharyngeal tuberculosis in a patient with the complaint of snoring.  J Laryngol Otol 2002;116 (4) 301- 303PubMedArticle
Köktener  AKöktenera  A Nasopharyngeal tuberculosis.  Eur J Radiol 2001;39 (3) 186- 187PubMedArticle
King  ADAhuja  ATTse  GMvan Hasselt  ACChan  AB MR imaging features of nasopharyngeal tuberculosis: report of three cases and literature review.  AJNR Am J Neuroradiol 2003;24 (2) 279- 282PubMed