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Indian Medical Gazette — JANUARY 2013 39

Case Report

Primary Nasopharyngeal Tuberculosis


Apoorva Kumar Pandey, Assistant Professor,
Virendra Pratap Singh, Professor and Head,
Tripti Maithani, Assistant Professor
— Department of E.N.T, Shri Guru Ram Rai Institute of Medical & Health Sciences,
Dehradun, Uttarakhand.
Aparna Bhardwaj, Assistant Professor,
Department of Pathology, Shri Guru Ram Rai Institute of Medical & Health Sciences,
Dehradun, Uttarakhand.

Abstract last century, before the advent of appropriate chemotherapy,


1.4% of all adenoids and 6.5% of all tonsils specimen
Tuberculous infection of the upper respiratory tract is
removed surgically from asymptomatic patients were
an uncommon clinical condition and in that nasopharyngeal
proved to be tuberculous2. During past few years there has
involvement is struck with rarity per se. This condition is
been a resurgence of pulmonary tuberculosis as well as its
often prevalent in people of low socioeconomic strata living
extrapulmonary manifestations. High defaulter rate,
in endemic areas, especially in developing countries. It has
malnutrition, migration of people, emergence of drug
a silent and indolent course and most commonly mimicks
resistance, and increased incidence of HIV infection
nasopharyngeal carcinoma in its clinical presentation. In
coexisting with tuberculosis might all be contributing factors
absence of concurrent pulmonary involvement, it is often
behind resurgence. Increased incidence of extrapulmonary
misdiagnosed or diagnosed only after the biopsy has been
tuberculosis is reported, particularly, in cases with
taken. Nevertheless, high index of suspicion is required on
transplants, taking immunosuppressive drugs, in cirrhotics,
part of the clinician to diagnose this comparatively rare
and in chronic renal failure1. It usually occurs in cases with
entity.
active pulmonary infection, secondary form, and it spreads
via hematogenous or lymphatic route3. Conversely, primary
Keywords
nasopharyngeal tuberculosis is exceedingly rare and is
Nasopharyngeal tuberculosis, anti-tuberculous treatment believed to occur from direct infection of upper respiratory
(ATT), acid fast bacilli (AFB), Ziehl-Neelsen stain (ZN), tract 3 . There are very few reports of primary
human immunodeficiency virus (HIV) nasopharyngeal tuberculosis in medical literature4-5.

Introduction Case Report


Extrapulmonary tuberculous sites affected in A 35 years old male patient came to our out-patient
otorhinolaryngologic domain are cervical glands, larynx, department with chief complaint of bilateral nasal
pharynx, tongue, gum, palate, palatine tonsils, nasal cavity, obstruction and mucoid rhinorrhea for 4 years. Nasal
paranasal sinuses, temporal bone, and salivary glands1. In obstruction was initially left sided and then progressively
Address for correspondence: Dr Apoorva Kumar Pandey, Asst. Prof., ENT, House No. 1, Main Street, Ashiward Enclave, Dehradun - 248 001,
Uttarakhand. E-mail: pande.apoorva@gmail.com
40 Indian Medical Gazette — JANUARY 2013

became bilateral. It was more pronounced on lying down


posture. There were no associated complaints of excessive
sneezing, headache, and nasal bleeding. He was a non-
alcoholic and a non-smoker There was no history of
diabetes, hypertension ,tuberculosis or any other major
medical or surgical illness in past. He did not have any
significant personal and family history. Patient had been
consulting a doctor for this problem, elsewhere, since last
year but got no relief. On anterior rhinoscopy there was no
septal deviation, turbinate hypertrophy or nasal mass.
However, posterior rhinoscopy revealed a polypoidal mass
in nasopharynx. Ear and throat were normal and neck
examination did not reveal any significant lymphadenopathy.
Nasal endoscopy findings were consistent with posterior
rhinoscopy; a soft, polypoidal mass was present in
nasopharynx completely occluding both posterior choana
(Fig. 1). Audiometry revealed normal hearing. Routine blood
and urine investigations were within normal limits except

Fig. 2
CT nasopharynx showed a mass in nasopharynx
blocking both posterior chaona.Mass was mildly
enhancing with no bony erosion

Granulomas featured central caseous necrosis surrounded


Fig. 1 by epithelioid histiocytes and outermost collar of
Nasal endoscopy revealed a soft polypoidal mass in lymphocytes with many Langhan’s giant cells , consistent
nasopharynx occluding right and left posterior with tuberculosis (Fig. 3). However, ZN stain for AFB was
choana respectively negative. Enquiring the patient retrospectively and examining
further, there was no history of contact with tuberculosis.
an elevated ESR (12 mm/Ist hr). HIV and HBsAg were There were no complaints like cough, hemoptysis, weight
negative. X-ray chest was clear. CT scan of nasopharynx loss, fever, night sweat, loss of appetite, and weakness.
revealed minimally enhancing soft tissue mass in His 3 consecutive sputum tests were negative. ELISA for
nasopharynx without any bony invasion (Fig. 2). tuberculosis revealed IgM positive. There was no systemic
Endoscopic biopsy showed lymphoid tissue forming involvement elsewhere in the body. ATT was started. The
lymphoid follicles lined by stratified squamous epithelium. patient was put on Isoniazid, Rifampicin, Pyrazinamide,
A few fragments of ciliated pseudostratified columnar and Ethambutol for two months during initial phase (2HRZE)
epithelium along with fibroblastic proliferation and necrosis and on Isoniazid and Rifampicin for four months of
was also present. No evidence of malignancy was seen continuous phase (4HR). Patient is in regular follow-up
and report was consistent with features of chronic and after 4 months of treatment, he is symptom free. Repeat
adenoiditis. nasal endoscopy did not show any evidence of nasal
Patient underwent shaving of the mass with regrowth.
microdebrider under general anesthesia .The histopathology
report showed numerous subepithelial well formed Discussion
granulomas in tissue sections lined by respiratory epithelium. Upper respiratory tract involvement is found in
Indian Medical Gazette — JANUARY 2013 41

radiography may reveal pulmonary involvement in less than


20% of cases8, while evident hilar lymphadenopathy in
50% of cases9. Radiologically nasopharyngeal tuberculosis
can exhibit 2 patterns as defined by magnetic resonance
imaging: 1) polypoidal mass formation in nasopharynx, and
2) diffuse mucosal thickening at that level 3. Hence,
differential diagnosis can vary according to above-
mentioned 2 patterns. For the polypoidal presentation, it
includes lymphoid hyperplasia, nasopharyngeal carcinoma,
lymphoma, and Castleman’s disease. Diffuse mucosal
thickening includes early local stage of nasopharyngeal
carcinoma, lymphoma, minor salivary gland tumours,
wegener’s granuloma, syphilis, fungal infection, and
leprosy3.
Fig. 3 Histopathological examination of lesion reveals
Photomicrograph showing many well formed granulomas
granulomatous inflammation showing epitheliod cells,
composed of epithelioid cells and surrounded by collar of
lymphocytes beneath pseudostratified columnar epithelium langhan’s giant cell with or without caseation11. Definite
(H & E stain,X100). (Inset) Epithelioid cells and well formed diagnosis can be established by demonstrating AFB or
Langhan’s giant cells(arrow) (H & E stain, X 400) positive culture for mycobacterium tuberculosis11. Drug
susceptibility testing must be done after the bacillus is
isolated, to identify resistant bacilli. Detection of
approximately 1.8% of all tuberculous cases6. Nasopharynx tuberculostearic acid in histopathological specimen is said
is the least common site in the upper respiratory tract to be
to be more sensitive for diagnosing nasopharyngeal
afflicted by tuberculosis5. The more common sites involved
tuberculosis as compared to conventional methods 12.
are nasal septum near mucocutaneous junction and posterior
Tuberculostearic acid is a structural component of the cell
end of nasal septum5.
walls of mycobacteria and detection of it yields results with
The most common clinical picture observed in sensitivity of 83% and specificity 98%12 .Tuberculosis and
nasopharyngeal tuberculosis comprises neck mass, nasal nasopharyngeal carcinoma may often coexist together,
obstruction, rhinorrhoea, epistaxis, otalgia and hearing particularly in a compromised setting where a patient is
loss2,7-9. Other complaints described are cough, sore throat, being treated by radiotherapy or chemotherapy12. It is
increased expectoration, tinnitus, and headache 10 . important to mention here that in all patients with
Constitutional symptoms occur in 12-30% of cases of tuberculosis, it is necessary to rule out human
nasopharyngeal tuberculosis 7-8. Direct visualization of immunodeficiency virus infection, particularly in cases of
nasopharynx may show 3 main patterns of involvement: extrapulmonary tuberculosis and with no apparent
1) normal nasopharynx, 2) diffuse inflammation and immunodeficiency state 1. Antituberculous therapy
ulceration of respiratory mucosa, and 3) polypoidal mass invariably remains the mainstay of treatment having a
lesion arising at the site of adenoids3. Rarely nasopharyngeal remarkable response.
tuberculosis can invade directly to cavernous sinus or skull
Conclusively it can be said that failure to diagnose this
base, resulting in third or sixth cranial nerve palsy11.
entity may be due to absence of respiratory and
Extension outside the nasopharynx involving adjacent
constitutional symptoms, non-specific clinical presentation,
prevertebral muscle has also been reported3.
and low index of suspicion. Tuberculous infection must be
Importance of detailed history taking and eliciting a borne in mind when a patient presents with mass in
history of exposure is indubitable and may clinch the nasopharynx with evidence of active pulmonary infection.
diagnosis. A thorough and assiduous search should be made Histopathological examination is mandatory to establish the
for the primary focus of tuberculous infection. Chest definite diagnosis as well as to rule out other conditions.
42 Indian Medical Gazette — JANUARY 2013

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Tuberculosis of the nasopharynx: a rare entity
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4. Savic D., Kosanovic M., Crejia D. — Isolated
tuberculosis of the nasopharynx. Srpski Arh Celok 11. Sithinamsuwan P., Sakulsaengprapha A., Chinvarun
Lek. 89:99, 1961. Y. — Nasopharyngeal tuberculosis : A case report
presenting with diplopia. J Med Assoc Thai. (10):1442-
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French G.L. — Diagnosis of nasopharyngeal
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Intern Med. 80:708-713, 1974. specimens. J Clin Pathol. 41: 1334-1336, 1988.

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