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A Case of Nasal Tuberculosis

Mimicking
Malignancy

Dr. Santhosh Kumar P.

Introduction
Tuberculosis of the nose was first described by Professor Giovanni
Morgagni in Italy, when conducting an autopsy of a young man
with pulmonary tuberculosis
Primary nasal tuberculosis is said to be much rarer than
spontaneous nasal tuberculosis
There has been a steady rise in the number of tuberculosis
cases in the last two decades-AIDS epidemic,
-increase in drug resistance &
-more international travel

Primary nasal tuberculosis


Rare- head & neck TB
Routes- direct inoculation- nose picking or finger
nail trauma,
-open pulmonary TB
- haematogenous
F:M - 3:1
3 Types (ONODI) - ulcerative, proliferative &
infiltrative
Upper respiratory tract TB- 1.8% Pts OF TB
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Case report

A 45 yr old female patient presented to the


outpatient department with complaints of
Nasal obstruction- 2months( initially left side)
Recurrent epistaxis- spontaneous, bilateral
On examination of the nasal cavity, a smooth exophytic
growth nearly filling both nasal cavities was seen
A nasal endoscopy was done and the clinical findings
of a nasal mass in both nasal cavities were confirmed

Endoscopic image of mass in right and


left nasal cavity
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CT scan

Showed an ill
defined soft
tissue
attenuation
arising from
the nasal
septum
extending into
both nasal
cavities, more
on the left side
Perforation of

Histopathology

Showed caseating
granulomatous
lesions and
epitheloid cells
suggestive of
tuberculosis

Treatment
She was immediately started on category I
antitubercular therapy (for extra pulmonary
tuberculosis)
Declared cured after completion of 6
months of treatment

Discussion
Tuberculosis causes about 2 billion deaths per year
worldwide
The increase of tuberculosis in the recent years has
been associated with features such as
o emergence of multidrug resistance,
o atypical manifestations with aggressive progression
of disease in patients infected with the HIV virus
Increased incidence in the 25-44 yr old age group of
extra pulmonary tuberculosis which constitutes two
thirds of reported cases
9

Despite the resurgence of tuberculosis, primary nasal


tuberculosis continues to remain a rare clinical entity
The nose is least liable to invasion by acute tuberculosis
because of
the structure of mucosa,
respiratory movements of the cilia and
bactericidal secretion

10

Antoni B, Anna R, Ewa O et. al. Tuberculosis of the


head and
neck epidemiological and clinical presentation. Jan
2013

35.6% patients with lymph node


tuberculosis,
27.4% with laryngeal tuberculosis
13.7% with oropharyngeal tuberculosis
12.3% with salivary gland tuberculosis
4.1% with tuberculosis of paranasal sinuses
4.1% with aural tuberculosis
2.7% with skin tuberculosis

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The involvement of the cartilaginous part of the


septum or inferior turbinate and floor are
most common
The lesions may lead to septal perforation
but bony septum is not involved
The patient usually presents with nasal
obstruction, crusting, discharge and epistaxis
Bilateral presentation has also been
documented but all involved septal lesions

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Differential diagnosis

Wegeners granulomatosis, sarcoidosis


leprosy, mycoses
malignancy
rhinoscleroma, rhinosporidiosis
foreign body

The diagnosis is difficult as CT and MRI


findings are non specific. They may show soft
tissue mass with or without bone destruction
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Definitive diagnosis is established by tissue biopsy


which shows characteristic epitheloid
granulomas. Occasionally caseation and acid fast
bacilli may also be present
Microbiological diagnosis is established by culture
of the bacteria. This is highly specific but lacking in
sensitivity
The sensitivity can be increased by polymerase
chain reaction
The culture can be accelerated with technology
such as BACTEC
Manteaux test may corroborate the diagnosis

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Pulmonary tuberculosis cultures have


the highest sensitivity of identification
In nasal tuberculosis, however, previous
studies have shown that initial solid
biopsy cultures and acid fast bacilli
staining tend to be negative
This may be due to the paucity of
bacilli in extra pulmonary sites with
culture negativity rates as high as 50-75%

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The first line of management is a four


drug regimen
Isoniazid, rifampicin, pyrazinamide and
ethambutol for 2 months followed by
isoniazid and rifampicin for 4 months
It must also be borne in mind that nasal
tuberculosis can be associated with
tuberculosis involving other sites in the
head and neck region.
Therefore detailed examination of the
ears, larynx and neck must be done
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Conclusion
Nasal tuberculosis
can resemble other disorders
such as malignancy
A biopsy with tubercular bacilli culture must be
done in all cases presenting with atypical
nasal masses
Diagnosis is made by an assessment of the
history, clinical findings and histological findings
Once the diagnosis is made the appropriate
regimen of antitubercular therapy must be
started immediately
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REFERENCES

[1] Waldman SR, Levin HL, Sebek BA et.al. Nasal tuberculosis : a forgotten entity.
Laryngoscope:1981; 91:11-16.
[2] Goguen LA,Karmody CS. Nasaltuberculosis. Otolaryngol Head Neck Surg1995; 113:131135
[3] Butt AA. Nasal tuberculosis in the 20th century: Am J Med Sci. 1997 Jun;313(6):332-335
[4] Chamberlain WB. Nasal tuberculosis. Ann Laryngol Rhinol Otol 1922;31:423-429.
[5] Prasad BK, Kejriwal GS, Sahu SN. Case report: Nasopharyngeal tuberculosis. Indian J Radiol
Imaging 2008; 18(1): 6365.
[6] Hale RG, Tucker D Head and neck manifestations of tuberculosis. Oral Maxillofac Surg Clin
North Am. 2008 Nov; 20(4):635-642.
[7] Mohan K, RS Anand K, Sathiya M et.al. Primary nasal tuberculosis: a case report. Indian
journal of otolaryngology head and neck surgery. Jan-Mar 2006; 59(1): 87-89.
[8] Ramakant D, Lokendra. Primary Nasal Tuberculosis. Lung India. Apr-Jun; 25(2):102-103.
[9] Goldberg B. Clinical tuberculosis. Philadelphia: FA Davis Company Publishers; 1946.
[10] Antoni B, Anna R, Ewa O et. al. Tuberculosis of the head and neck epidemiological and
clinical presentation. Jan 2013.
[11] Chodosh PL, Willis W .Tuberculosis of the upper respiratory tract. Laryngoscope 1970; 80:679
696.

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THANK YOU

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