Journal Reading

Tuberculosis in Otorhinolaryngology: Clinical Presentation and Diagnostic Challenges

Rajiv C.Michael1 and Joy S.Michael2

Tutor : dr. Tris Sudyartono, Sp. THT-KL dr. Agus Sudarwi, Sp. THT-KL dr. Afif Zjauhari, Sp.THT-KL Present by: Rossy Triana Trisnawaty Wijaya Reyjen Wijayakusuma

ABSTRACT
TB otorhinolaryngeal
5 culture-proven 7 histology-proven 1 sputum-positive pulmonary TB.

TB affects all tissues of the body 80% pulmonary TB TB

Clinical laboratory

and

Diagnose

INTRODUCTION

Mycobacterial smear

TB
80% pulmonary TB Extra pulmonary TB

Diagnosis

Culture

Histopathological chronic/caseating granuloma

Lymphadenitis

TB otorhinolaryngeal 1. Laryngeal TB 2. The mastoid air cells and the middle ear TB

MATERIALS AND METHODS

Retrospective analysis Signs and symptoms suggestive otorhinolaryngeal TB

Biopsy histopathological and or microbiological Blood investigations total and differential white blood cell count and ESR

Patients with cervical adenitis were not included in this study

Laryngeal Tuberculosis
Indirect laryngoscopy/ fibroptic laryngoscopic diffuse erythema and granulomatous or polypoidal changes of the vocal cords.

Hoarseness Odynophagia Dysphagia Loss of weight Loss of appetite.

Diagnosis BIOPSY

Tuberculosis of the Middle Ear

Otorrhea Otalgia Hearing loss Facial palsy

Physical abundant avascular tissue

examination polypoid or pale granulation

Tuberculosis of the Nasal and the Paranasal Region

Nasal obstruction Blood-stained rhinorrhoea Epistaxis Headache.

Granular nasal and nasopharyngeal lesions rigid nasal endoscopy and biopsy.

Mycobacterial smear, culture, and DST.

Concurrent pulmonary tuberculosis 3 consecutive sputum samples mycobacterial smear and culture.

Histopathological haematoxylineosin stains.

Pathognomonic : chronic granulomatous inflammatory exudates, with or without caseation

Table 1 Suspected TB nasopharynx (18/36), larynx (13/33), and middle ear/mastoid cavity (46/51). 5 histopathological and culture-proven Tb One each from the nasopharynx and larynx Three from the middle ear cleft 7 histopathological : chronic granulomatous inflammation strongly suggestive of tuberculosis 77 non-specific inflammatory appearance on histology and culture negative Table 2 Table 3 Histopathological strongly suggestive of tuberculosis, but mycobacterial smear and culture of the tissue were negative. One patient with laryngeal tuberculosis had sputum smearpositive pulmonary tuberculosis. The ESR ranged from 5mm to 50mm.

RESULT

Five patients culture positive and histology suggestive of tuberculosis. Erythrocyte sedimentation rate (ESR) indirect indicator of inflammation marker for tuberculosis 15mm to 45 mm/hour None of these five patients had coexistent pulmonary tuberculosis.

TB granulomatous infections otorhinolaryngeal region advent of antituberculosis chemotherapy incidence has come down significantly, but there is a resurgence of extrapulmonary TB including primary otorhinolaryngeal TB due to HIV.

DISCUSSION

In our series over a period of 3 years, 12 of 121 patients had TB with only 5 being culture and histopathology proven and the remaining 7 with only histopathology strongly suggestive of tuberculosis. Only 1 patient had concomitant pulmonary TB. Laryngeal and middle ear tuberculosis have been historically associated with coincidental pulmonary tuberculosis only one of our patients with histopathology-proven laryngeal tuberculosis had coexistent pulmonary tuberculosis

HIV-infected persons increased risk for primary or reactivation of TB especially extrapulmonary TB increased risk of otorhinolaryngeal TB In our series, none of our patients with culture- or histopathologically-proven otorhinolaryngeal TB had HIV infection.

ESR values >10mm TB Our patients mean ESR : 20cumm/hour ESR nonspecific inflammatory marker (diagnostic workup TB)

Smear microscopy detect acid fast bacilli and culture

Culture drug susceptibility testing Molecular techniques, such as polymerase chain reaction detect DNA or RNA

Catagory I Revised National Tuberculosis Programme (RNTCP) Guidelines

intensive phase (2 months) Isoniazid Rifampicin Pyrazinamide Ethambutol

12 patients

DOTS clinics

continuation phase (4 month) Isoniazid Rifampicin

In conclusion, although the otorhinolaryngeal manifestations of tuberculosis are less common than those in the past, a high index of suspicion is necessary given the similarity in clinical presentation and appearance particularly to head and neck malignancies and other chronic noninfective and infective pathological conditions.

All specimens from suspected cases of otorhinolaryngeal tuberculosis representative biopsies histopathological examination as well as mycobacterial culture and sensitivity.