Otorhinolaryngology and tuberculosis

Dr Stephen Antony, Director, Divine Medical Centre and Dr Monica M Michael, ENT Surgeon Divine Medical Centre, Bengaluru elaborate on the various forms of TB and its manifestations

Tuberculosis, a communicable disease caused by the Mycobacterium tuberculosis, has the potential to affect any tissue in the body causing mass lesions and loss of function. It can manifest from a localised lesion to systemic, disseminated TB. Treating TB is imperative as it is a progressive disease and remains a major global public health problem. It is estimated that about one-third of the world’s population is infected with TB. In India, it was earlier thought that TB was more common in the lower socio-economic sections of the population. But, recently its incidence is rising in affluent society also due to increase in immunocompromised states like diabetes, chronic kidney disease, heart disease and increased prevalence of HIV etc.  The various challenges in the control of TB are attributed to increased poverty and drug addiction, lack of TB chemotherapy, development of resistant strains, immigration from TB-affected areas, and decreased immunisation coverage. Ear, nose and throat (ENT) localisations of TB are also increasing due to these risk factors. Hence, it is also vital for otolaryngologists to keep an open mind and evaluate the condition extensively in case of doubtful cases, while diagnosing.

Types of TB: Primary TB occurs during primary infection, evolving from pulmonary focus or by haematogenic dissemination. From primary infection, approximately five per cent of the infected cases can develop the active disease. While pulmonary TB is the most common presentation, extrapulmonary TB (EPTB) is also an important clinical problem. This includes tuberculosis of organs other than the lungs, such as lymph nodes, abdomen, genito-urinary tract, skin, joints and bones, meninges, etc. Though ear, nose and larynx involvement in TB is relatively rare, they pose significant clinical and diagnostic challenge being the most common among the granulomatous infections. They are generally clinically primitive forms and typically affect young people with a slight prevalence among females.

TB of ear, nose, throat (ENT): TB affecting the ear, nose, throat region presents in the form of tuberculous cervical lymphadenopathy, laryngeal TB, tuberculous otitis media (TBOM) and nasal TB.

Cervical lymphadenopathy: The otorhinolaryngeal manifestation of TB is most commonly cervical lymphadenopathy which presents as a neck swelling and may progress to suppuration forming a cold abscess. Fever if present, is of low grade. It can be diagnosed with fine needle aspiration cytology. In early stages it can be treated with antitubercular drugs (ATT), and in later stages non-dependent incision and drainage can be done.

Laryngeal TB: The second most common manifestation is laryngeal TB and it usually is secondary to pulmonary TB. Patients suffer from dysphonia together with clinical outbreaks related to the pulmonary localisation. It presents with change of voice, causes ulcerative lesions, turban epiglottis and mouse nibbled vocal cords. It can involve the entire larynx. It can be diagnosed by direct laryngoscopy and biopsy. The treatment for it is with ATT.

Nasal TB: The nose is least liable to invasion by acute TB of any part of the respiratory tract, because of the structure of mucosa, respiratory movements of the cilia and bactericidal secretions. Nasal TB can be due to direct inoculation or haematogenous spread. It presents as three entities – nodular form (lupus vulgaris), ulcerative form or sinus granuloma.  Lupus vulgaris is the most common form. It is caused by direct inoculation, involving the skin and mucosa, with nodules (apple jelly nodules). Ulcerative form presents with ulcers over the cartilaginous part of the nasal septum, presenting with nasal obstruction and may progress to septal perforation. Sinus granuloma presents with a mass in the paranasal sinuses.

TB in oral cavity: Involvement of oral cavity is a rare entity.  Predisposing factors for primary oral TB include poor dental hygiene, dental extraction, periodontitis and leukoplakia. It presents with painless irregular ulcers over mucosa anywhere in the oral cavity. The site commonly involved is the tongue, followed by palate, gums and lips, whereas tonsillar TB is a rare localisation. It is crucial to exclude malignancy. The management involves confirmation with biopsy and ATT.

Aural TB: Aural TB is a very rare disease entity. Modes of spread are nasopharyngeal spread through eustachian tube into middle ear or haematogenous spread. It presents with chronic serous/ blood stained painless otorrhea, otalgia and conductive hearing loss. Multiple perforations in the tympanic membrane is considered the hallmark of the disease. Pre-auricular adenopathy with postauricular fistula – pathognomonic for tuberculous otitis media. It is evaluated with aural swab, HRCT temporal bone and treated with ATT.  In case of intracranial complications or mastoid abscess, surgical intervention is required.

Symptoms and diagnosis of ENT TB: The characteristic features of TB are low grade evening rise in temperature, night sweats, weight loss, chronic cough and hemoptysis. But very few patients have the presence of these classic symptoms. Hence, the presence of pulmonary TB should be evaluated in any case of doubt. Emphasis should be on chronic ear discharge, persistent swelling in the neck. General physical and local ear, nose and throat examination need to be carried out on all the patients. In addition to routine investigations, all the patients need to be subjected to chest X-rays. Radiological examination of the soft tissue neck, cervical spine and the mastoids should also be carried out. Endoscopic examination will include nasopharyngoscopy, direct laryngoscopy and bronchoscopy. Histopathological examination not only helps a clinician to reach a definitive diagnosis and further management but also aids in documentation for medico-legal purposes. Fine needle aspiration cytology will be useful on suspected neck swellings. Investigations like culture and sensitivity and AFB staining of the sputum, pus from discharging sinuses, laryngeal secretions and ear discharge should be included.

It is essential for the general population to be aware of the symptoms of TB in various regions and present early to the out-patient department. Early diagnosis is of prime importance in TB otolaryngology as it saves time, energy and expenses for the patient and helps in starting appropriate management. Early management is mostly medical with anti-tubercular drugs. Surgical management is required only as a last resort in some conditions like the presence of abscess or as a part of diagnostic procedure.

References:
Nasopharyngeal tuberculosis, Col R.K. Mishra, Col B.K. Prasad, Maj Sunil Mathew, Medical journal armed forces india, Elsevier 71(2015) S586eS589.
Primary Nasal Tuberculosis Revisited: Case Reports, Manish Chandra and *Rajeev Krishna Gupta, Indian Journal of Medical Case Reports, 2015 Vol. 4 (2) April-June, pp.33-35.
Laryngeal Tuberculosis: A Rare Case Report, Yadlapalli AK, Veeranjaneyulu P, Krishna SB,Haseena Md, Mahajan A, Laryngeal Tuberculosis: A Rare Case Report. J Pharm Biomed Sci 2014; 04(06): 497-501.
CASE STUDY- EXTRANODAL ENT TUBERCULOSIS, Dr. D. Sridhara Naryanan1* and Dr. Dhanya T2, Dr. S. Anusha, World Journal of Pharmaceutical Research, Volume 5, Issue 01, 1376-1381