Nasopharyngeal tuberculosis can arise from both a primary infection and a secondary spread via the lymphatic or hematogenous system from a primary pulmonary lesion. Primary nasopharyngeal tuberculosis is rare and difficult to detect earlier because of the nonspecific presentations of the disease. As upper airway tuberculosis can be contagious, early initial diagnosis and suspicion of the physicians are needed in clinical practice. Recently, we successfully diagnosed and treated the disease by antitubercular medications of two cases of primary nasopharyngeal tuberculosis. Herein, we report our experience with a literature review.
Tuberculosis (TB) has maintained as one of the world’s oldest and deadliest communicable diseases. It can mostly affect the lung (pulmonary) but also other sites (extrapulmonary) as well. The proportion of extrapulmonary TB has been gradually increasing since 2001 and status of extrapulmonary TB in South Korea accounts for about 11%–17% [
A 56-year-old female presenting with purulent rhinorrhea and postnasal drip of 2-month duration visited the outpatient clinic. Endoscopic examination of the nasopharynx revealed irregular mucosal necrotic ulceration diffusely extending from the opening of Eustachian tube to the soft palate (
A 34-year-old female who had a one-month history of sore throat, sputum, and mild cough visited the outpatient clinic. On the endoscopic exam, necrotic mucosa was noted on the nasopharynx which was not sucked out (
Extrapulmonary TB has a relatively low prevalence compared to pulmonary TB, and NPTB is particularly rare. The clinical manifestations of NPTB vary greatly, but most common symptom is cervical lymph node enlargement which was presented in many previous studies. In addition, there are nasal congestion (10%), neck pain, tinnitus, hearing loss, otalgia, and postnasal drip [
The most characteristic finding of the NPTB is the lesion, somewhat in resemblance of melted cheese, not detached from the underlying mucosa through repeated suctioning. Additionally, for diagnosis, it is essential to check the presence or absence of TB in patients or their family history, and close contact with an active TB patient through history taking, and tests such as tissue biopsy, smear, culture, and TB-PCR [
Although there was a previous report that surgical excision was performed from the beginning, as in NPTB, surgery is not necessary and only antitubercular medical treatment is sufficient. Surgical treatment should be considered only for NPTB in severe cases of obstruction or multidrug resistant TB unresponsive to medical treatment.
For NPTB, the minimal duration of antitubercular treatment is six months. There were a few previous reports that stated the antitubercular medical treatment started by two months of INH, RFP, EMB, and PZA followed by INH and RFP for 4 to 7 months. However, the preferred regimen of treatment was various according to the clinicians and the course of the disease [
In conclusion, NBTB shows various clinical features in the ear, nose, and neck. So even if the patient visits to the hospital for ear symptoms or cervical lymph node problems, if necrosis of the nasopharyngeal mucosa is found on nasal endoscopy, although it is not common, attention should always be paid to the possibility of NPTB. If diagnosis and treatment are delayed, it can spread to others and leave serious sequelae. Accurate diagnosis and prompt treatment through deep and multiple site endoscopic biopsy can reduce sequelae and improve quality of life.
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The authors have no potential conflicts of interest to disclose.
None
Initial nasopharynx endoscopic and CT findings of case 1. A: Endoscopic finding: melted cheese like necrotic tissue with purulent discharge on right posterior wall of nasopharynx. B: Neck CT: peripheral rim enhancing mucosal thickening of right posterior nasopharynx extended to Eustachian tube (arrow).
Ziehl–Nielsen staining from biopsy specimen with acid-fast bacilli.
Follow-up nasopharyngeal examination after 6 months of antitubercular treatment.
Initial nasopharynx endoscopic and CT findings of case 2. A: Endoscopic finding: necrotic tissue like melted cheese with purulent discharge on posterior nasopharynx. B: Neck CT: mucosal thickening and increased enhancement of nasopharynx (arrow) with 0.9 cm lymph node in right retropharyngeal area (arrow head).
Follow-up ear endoscopic and CT findings before antitubercular treatment. A: Endoscopic finding: tympanoscopic examination showed a right tympanic membrane perforation and otorrhea. B: Temporal CT: soft tissue density in right mastoid cavity and middle ear (circle).
Follow-up endoscopic examination which was performed 5 months after antitubercular treatment started. A: Nasopharynx. B: Right tympanic membrane.