Case study
Primary Rhinopharyngeal Tuberculosis: An Unusual Location
Tuberculosis rinofaríngea primaria: una localización infrecuente
Alfonso Martínez
, Ángel Lede, José A. Fernández
Corresponding author
Servicio de Otorrinolaringología, Hospital da Costa, Burela (Lugo), Spain
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Fernández" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Alfonso" "apellidos" => "Martínez" "email" => array:1 [ 0 => "alfonso_m_f@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Ángel" "apellidos" => "Lede" ] 2 => array:2 [ "nombre" => "José A." "apellidos" => "Fernández" ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Servicio de Otorrinolaringología, Hospital da Costa, Burela (Lugo), Spain" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tuberculosis rinofaríngea primaria: una localización infrecuente" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 993 "Ancho" => 993 "Tamanyo" => 89995 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Mass on the posterior nasopharyngeal wall that captures gadolinium on MRI (sagittal section).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Up to 10% of tuberculosis (TB) cases have some manifestation in the head and neck region.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> Although the upper respiratory tract is the entry point of <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span>, its involvement is rare (less than 2%)<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and a nasopharyngeal location is exceptional and generally isolated, with no pulmonary or systemic involvement.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The most frequent form of presentation is high jugular adenopathy (50%–90%), followed by nasal obstruction, snoring, rhinorrhoea, serous otitis, hearing loss, tinnitus, and otalgia.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,4,5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Endoscopy can present a varied range, from an apparently normal mucosa, to an evident mass, or a mucosa with an adenoid or swollen appearance, ulcers, leukoplakic areas, and various combinations thereof.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Radiologically, there are 2 patterns: either a polypoid mass or a diffuse thickening of the nasopharyngeal walls. Extension to the prevertebral musculature, skull base bone, etc. is infrequent.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The symptoms (high cervical adenopathy and rhinopharyngeal mass) and the radiological findings make it difficult to distinguish from undifferentiated carcinoma, especially in areas where both are endemic, such as Southeast Asia, making it necessary to carry out a biopsy for histological and bacteriological studies.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,7</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Clinical Case</span><p id="par0030" class="elsevierStylePara elsevierViewall">We present the case of a female patient, 72 years old, with no history of interest, with an incidental finding on an MRI performed due to headaches (finally diagnosed as tension headache), of an asymptomatic mass on the posterior rhinopharyngeal wall. The mass had cystic areas, post-contrast enhancement, and no deep invasion (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). No cervical adenopathy was observed on the MRI scan. The patient did not present systemic or pulmonary symptoms and the chest X-ray was normal.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Nasofibroscopy revealed a polypoid lesion occupying the entire rhinopharynx, with mucosa of normal appearance (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Biopsy under local anaesthesia and the subsequent anatomopathological analysis of the tissue showed granulomas with histiocytic, epithelioid, and giant multinucleated Langhans cells, as well as caseous necrosis (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). Ziehl-Neelsen staining was positive for acid-fast bacilli (AFB). After the patient received a positive intradermal tuberculin test, we introduced treatment with rifampicin, isoniazid, and pyrazinamide for 6 months, after which the endoscopy was normal and the biopsy showed unaltered respiratory epithelium.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Radiological and immunological tests carried out on the patient's close contacts revealed no other TB cases in any localisations, so it was not considered necessary to administer treatment to these individuals.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0050" class="elsevierStylePara elsevierViewall">To date, only 4 series (including between 7 and 17 cases) and the odd case of rhinopharyngeal TB have been described in the English-language literature,<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8–10</span></a> mainly in young patients and endemic areas.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The presentation form in over 50% of cases is the presence of cervical adenopathy, followed by other nasal symptoms (airway obstruction, rhinorrhoea, snoring, etc.) or otological symptoms (hearing loss, autophony, and sensation of blockage). In our patient, we did not detect any of the commonly referred symptoms or signs because, as explained, a chance discovery led to the performance of the various tests leading to the final diagnosis.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Pulmonary or systemic involvement associated to this location is rare (25%–30%)<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and was absent in the case of this patient. Conversely, rhinopharyngeal involvement is very unusual in pulmonary TB.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,11</span></a> Nasopharyngeal TB is consequently generally considered primary (by direct inhalation of <span class="elsevierStyleItalic">Mycobacterium</span>). In the rest of the upper aerodigestive tract (such as the larynx), lung involvement is very high (95%), because spread takes place through sputum from the pulmonary lesions.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">The most frequent endoscopic image is the combination of over-elevated areas accompanying a frank mass (70%–75%).<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> In our case, the mass occupied the entire space of the cavum, without areas of other type.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Diagnosis is based on the histological finding of granulomas of Langhans cells with caseous necrosis or the detection of AFB in Ziehl-Neelsen staining (less common).</p><p id="par0075" class="elsevierStylePara elsevierViewall">Other causes of granulomas to be considered are sarcoidosis, Wagener's disease,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> fungal infections, reactions to carcinomas, lymphomas (especially Hodgkin's) and radiotherapy, among others. Finding AFB in Lowenstein culture or staining distinguishes them.</p><p id="par0080" class="elsevierStylePara elsevierViewall">We conclude that it is necessary to consider TB in the differential diagnosis of nasopharyngeal lesions (even when asymptomatic and without lymph node involvement, as in this case). As indicated above, it should mainly be distinguished from undifferentiated carcinoma and the granulomatosis mentioned, by biopsy and histological and bacteriological studies.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of Interests</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:2 [ "identificador" => "xres94819" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec81970" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres94818" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec81971" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinical Case" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflict of Interests" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2010-04-20" "fechaAceptado" => "2010-06-02" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec81970" "palabras" => array:3 [ 0 => "Tuberculosis" 1 => "Rhinopharynx" 2 => "Caseous necrosis" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec81971" "palabras" => array:3 [ 0 => "Tuberculosis" 1 => "Rinofaringe" 2 => "Necrosis caseosa" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">We describe a primary rhinopharyngeal tuberculosis case in a woman who presented with an asymptomatic mass found incidentally on a MRI scan. Histopathological examination of the biopsy specimen showed granulomatous inflammation and caseous necrosis. Anti-tuberculosis therapy was applied for a 6-month period, after which nasopharyngeal examination was normal. This case supports the necessity of including tuberculosis in the differential diagnosis for a rhinopharyngeal mass.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Describimos un caso de tuberculosis primaria rinofaríngea, como el hallazgo casual en un examen por resonancia magnética de una masa asintomática. El estudio anatomo-patológico tras biopsia mostró granulomas con necrosis caseosa. Se instauró tratamiento antituberculoso de 6 meses, tras el cual la endoscopia rinofaríngea fue normal. Este caso plantea la necesidad de incluir la tuberculosis en el diagnóstico diferencial de las masas de rinofaringe.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Martínez A, et al. Tuberculosis rinofaríngea primaria: una localización infrecuente. Acta Otorrinolaringol Esp. 2011;62:401–3.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 993 "Ancho" => 993 "Tamanyo" => 89995 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Mass on the posterior nasopharyngeal wall that captures gadolinium on MRI (sagittal section).</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 780 "Ancho" => 975 "Tamanyo" => 118799 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Endoscopic view of the rhinopharyngeal mass.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 731 "Ancho" => 975 "Tamanyo" => 260365 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Granulomas with central necrosis, giant multinucleated Langhans cells, epithelioid histiocytes and peripheral mononuclear inflammatory infiltrate (original, haematoxylin–eosin, ×400.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:12 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A clinical review of 128 cases of head and neck tuberculosis presenting over a 10-year period in Bradford, UK" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "K. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2023 March | 1 | 1 | 2 |
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| 2020 December | 0 | 2 | 2 |
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| 2020 May | 0 | 1 | 1 |
| 2020 March | 17 | 1 | 18 |
| 2020 February | 17 | 11 | 28 |
| 2020 January | 19 | 4 | 23 |
| 2019 December | 17 | 11 | 28 |
| 2019 November | 18 | 5 | 23 |
| 2019 October | 15 | 3 | 18 |
| 2019 September | 17 | 3 | 20 |
| 2019 August | 12 | 4 | 16 |
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| 2019 June | 73 | 18 | 91 |
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| 2018 April | 5 | 1 | 6 |
| 2018 March | 8 | 0 | 8 |
| 2018 February | 15 | 2 | 17 |
| 2018 January | 6 | 0 | 6 |
| 2017 December | 10 | 0 | 10 |
| 2017 November | 10 | 1 | 11 |
| 2017 October | 10 | 4 | 14 |
| 2017 September | 7 | 1 | 8 |
| 2017 August | 14 | 3 | 17 |
| 2017 July | 21 | 2 | 23 |
| 2017 June | 30 | 14 | 44 |
| 2017 May | 32 | 2 | 34 |
| 2017 April | 35 | 2 | 37 |
| 2017 March | 23 | 31 | 54 |
| 2017 February | 34 | 2 | 36 |
| 2017 January | 19 | 1 | 20 |
| 2016 December | 24 | 5 | 29 |
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| 2016 October | 47 | 6 | 53 |
| 2016 September | 55 | 9 | 64 |
| 2016 August | 45 | 1 | 46 |
| 2016 July | 15 | 2 | 17 |
| 2016 June | 24 | 9 | 33 |
| 2016 May | 36 | 16 | 52 |
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| 2015 December | 27 | 15 | 42 |
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| 2015 September | 20 | 9 | 29 |
| 2015 August | 46 | 4 | 50 |
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| 2015 June | 25 | 1 | 26 |
| 2015 May | 50 | 6 | 56 |
| 2015 April | 53 | 10 | 63 |
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| 2015 February | 20 | 6 | 26 |
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| 2014 December | 51 | 12 | 63 |
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| 2014 August | 23 | 6 | 29 |
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| 2014 March | 24 | 2 | 26 |
| 2014 February | 22 | 5 | 27 |
| 2014 January | 20 | 5 | 25 |
| 2013 December | 24 | 3 | 27 |
| 2013 November | 33 | 6 | 39 |
| 2013 October | 61 | 4 | 65 |
| 2013 September | 31 | 8 | 39 |
| 2013 August | 12 | 4 | 16 |
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