Volume 5, Issue 2 , Pages 91-92, March 2010
Primary oropharyngeal tuberculosis causing destruction of uvula—A rare presentation
Article Outline
Abstract
Despite the contact of pulmonary secretions and the mucous membranes of the upper respiratory tract with a high bacillary load, tuberculosis of the head and neck area, excluding laryngeal forms, is exceptional and constitutes only 2–6% of extra pulmonary tuberculosis and 0.1–1% of all forms of tuberculosis. Oral cavity tuberculosis is uncommon, out of which primary pharyngeal tuberculosis is extremely rare. We present a case of an ulcerative lesion in a 7-year-old female subsequently proven to be primary oropharyngeal tuberculosis. There was an erosion of uvula and posterior soft palate. There was also an ulcerated area on adjacent area of left tonsillar fossa with slough over posterior pharyngeal wall.
Keywords: Tuberculosis, Oropharyngeal, Uvular destruction
1. Introduction
Despite the contact of pulmonary secretions and the mucous membranes of the upper respiratory tract with a high bacillary load, tuberculosis of the head and neck area, excluding laryngeal forms, is exceptional and constitutes only 2–6% of extra pulmonary tuberculosis and 0.1–1% of all forms of tuberculosis. Oral cavity tuberculosis is uncommon, out of which primary pharyngeal tuberculosis is extremely rare. We present a case of an ulcerative lesion in a 7-year-old female subsequently proven to be primary oropharyngeal tuberculosis.
2. Case report
A 7-year-old female patient presented to the Otolaryngology outpatient department with the chief complaint of cough for one and half years, especially at night. She also complained of pain during deglutition (odynophagia) for the same period. There was associated loss of appetite. She also suffered from nasal regurgitation of food for the last 6 months.
Examination of the oropharynx revealed pooling of saliva and congestion of gums. There was erosion of uvula and posterior soft palate. There was also an ulcerated area on adjacent area of left tonsillar fossa with slough over posterior pharyngeal wall (Photo 1). There were also multiple bilateral matted cervical lymph nodes in levels 1b, 2, 3, 4. On indirect laryngoscopy, larynx was normal. Examination of nose on anterior rhinoscopy showed no abnormality.
Photo 1.
Photograph showing erosion of uvula and soft palate with slough adjacent to left tonsillar fossa.
General examination revealed that the patient weighed 12
kg and was mildly anemic. Laboratory findings revealed Hb-8 gm%; TLC 10,000, N 48, L46, M 2, E 4, B 0; ESR 100mm/h in first hour. Chest skiagram was normal. Patient was started on a course of antibiotics (amoxycillin–clauvulanate in appropriate dosage), initially for 7 days. This was later continued for another 7 days.
However, as there was no significant improvement, biopsy was taken from the posterior soft palate region because of suspicion of malignancy. Histopathological examination showed epithelioid cell granuloma with Langhan's and foreign body type giant cells indicating tubercular inflammation. Subsequently Tuberculin test showed induration of 22mm.
The patient was started on Category 3 Anti tubercular drugs (2HRZE+4HR) after which the patient improved significantly with gradual resolution of the ulcers.
3. Discussion
Primary pharyngeal tuberculosis is extremely rare even in endemic areas [2]. Usually, pharyngeal tuberculosis is more commonly seen in association with pulmonary tuberculosis [1]. Primary disease has been reported in small numbers, in the area of nasopharynx and palatine tonsil but reported as extremely rare manifestation in area of posterior oropharyngeal wall and soft palate.
Tuberculosis of oral cavity and oropharynx is unusual because of protective mechanism in the upper respiratory tract [3]. Saliva, containing saprophytes with phagocytic property and epithelium of oral cavity, inhibit growth and multiplication of tuberculosis bacilli. Any breach in the mucosa due to chronic irritation or inflammation can predispose to tuberculosis. Poor dental hygiene, leukoplakia and dental extraction are other predisposing factors. Even if there is no breach in mucosa, Mycobacterium tuberculosis crosses mucosal barriers by endocytosis within mucosal lymphoepithelial sites. These entry sites commonly include oropharyngeal and nasopharyngeal tonsils and Peyer's patches. Phagocytes containing intracellular mycobacteria disseminate infection to other parts of the body and also probably migrate back onto mucosal surface to shed bacilli [3].
The oropharynx may be the site of primary infection in childhood and results in an asymptomatic primary focus of pharynx with cervical lymphadenopathy. It has been postulated that such infections are acquired by inhalation, with harboring of disease in Waldeyer's ring [4]. At the time of presentation, it usually mimics malignancy presenting mostly with odynophagia or dysphagia and ulceroproliferative lesions; thus causing problems in diagnosis.
Differential diagnosis of oral and pharyngeal tuberculosis includes traumatic ulcers, aphthous ulcers, hematological disorders, actinomycosis, syphilis, midline granuloma, Wegner's disease and malignancy [4]. Diagnosis of oropharyngeal tuberculosis is based on histopathological findings and the identification of tubercle bacilli. Treatment is in the form of anti-tuberculosis therapy.
In this patient, the erosion of uvula and posterior soft palate and ulcerated area on adjacent left tonsillar fossa evoked suspicion of malignancy. Hajioff et al. reported a case of primary tuberculosis of posterior oropharyngeal wall, presented as sore throat, fever and malaise [1]. However oropharyngeal tuberculosis causing erosion of the uvula or soft palate is rare.
4. Conclusion
Tuberculous lesions of the oral cavity have become so infrequent that it is virtually a forgotten clinical entity. Prevalence of tuberculous lesions in nose, mouth and pharynx even at the peak period in 1930 were reported only in an average of 0.66% [2]. Usually, on first or primary presentation, they appear like neoplasms. But in ulceroproliferative lesions of oropharynx or oral cavity not responding to antibiotic therapy, diagnosis of tuberculosis should be suspected. The clinician should remain alert to the possibility of tuberculosis especially in developing countries like India where the incidence of tuberculosis is high.
References
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- A. Shah, A. Pande, I.M. Vora, S.B. Ugale, Primary lupus vulgaris of the pharynx (a case report), 36 (2) (1990) 106–108.
- . Primary pharyngeal tuberculosis. Lung Ind. 2005;22:127–129
- . Tuberculosis of tonsil with unusual presentation. Ind. J. Tub. 2001;48:223
PII: S1871-4048(09)00025-2
doi:10.1016/j.pedex.2009.04.001
© 2009 Elsevier Ireland Ltd. All rights reserved.
Volume 5, Issue 2 , Pages 91-92, March 2010
