Head and Neck Manifestations

Tuberculous Lymphadenitis (Scrofula). This represents the most common form of extrapulmonary TB (13), and in 80% to 90% of cases, it is the only site of infection. In HIVnegative patients, it is usually bilateral and posterior cervical in location, presenting as an erythematous, painless mass along the anterior border of the sternocleidomastoid, typically without systemic symptoms (11). The tuberculin skin test (TST) is positive in more than 75% of patients. In HIV-positive patients, multiple sites may be involved, often with mediastinal and intra-abdominal lymphadenopathy, pulmonary or other organ involvement, and systemic symptoms. The TST is often negative in these patients. Of the patients, 10%

present with a fluctuant mass and 5% with sinus tract draining serosanguinous discharge. Chest radiographs are indicative of past or active infection in less than 20%.

Fine needle aspiration (FNA) may reveal granulomas, but the cultures and smears are rarely positive in HIV-negative patients. The opposite occurs in HIV-infected patients, where cytohistologic findings are not often typical, but the FNA yield of acid-fast smears and cultures is higher. Excisional biopsy is required for definitive diagnosis if the FNA is inconclusive, basically to exclude lymphoma or other infectious agents (atypical mycobacteria or fungi). Drains are not required to avoid fistula formation.

Complications of cervical lymph node involvement are node enlargement with pain, suppuration, sinus formation, and appearance of new nodes. These occur in 25% to 30% of patients, even during or postchemotherapy, and do not necessarily indicate failure of drug treatment. While some do not recommend surgical excision of scrofulous nodes, there are many who do, justifying it with the 25% to 30% drug-failure rate.

Pregnant patients with TB lymphadenitis are managed with topical care and aspiration of fluctuant collections until after delivery, due to concerns of teratogenicity. Antibacterial treatment can be initiated postpartum.

Ocular TB. TB produces various ocular syndromes, including choroidal tubercles, uveitis (Chapter 6), iritis, and episcleritis. In suspected cases, a prompt referral to an ophthalmologist should be made.

Tuberculous Otitis. Tuberculous otitis media is rare and usually represents hematogenous spread. Roughly one-half of the cases have no other evidence of present or past TB. The classic clinical picture is painless otorrhea with multiple tympanic perforations, exuberant granulation tissue, early severe hearing loss, and mastoid bone necrosis (see Chapter 25 for further discussion of otorrhea). The finding of multiple tympanic membrane perforations is most likely TB, possibly pathognomonic. Nonetheless, the diagnosis is difficult, even when tissue is available. Tuberculous otitis may be complicated by facial nerve paralysis, which is discussed in detail in Chapter 29. Response to drug therapy is excellent, and surgery usually is not required.

Nasal TB. Tuberculomas with destructive characteristics in the nasal cavity can be seen and are part of the differential for nasal destructive lesions, companions to Wegener's granulomatosis and lymphoma (these are discussed in Chapters 8 and 17, respectively). Polyps can also be seen in the inferior turbinate. A positive AFB smear from the nasal cavity needs to be followed with culture to rule out infection from M. leprae, since nasal infection is common in lepromatous leprosy.

Pharyngeal TB. The most common sites are the adenoids, posterior pharynx and the tonsils. Most of those infections are primary infections. They were more common in the past, associated with ingestion of nonpasteurized milk that was infected with M. bovis. No specific characteristics are present and in many cases, biopsies are performed to rule out cancer; however, response to anti-TB therapy is prompt, and resolution is the rule.

Tuberculous Sialadenitis. The parotid and submandibular glands are most commonly infected and can be the sole site of disease. Minor salivary glands have also been involved (15). In most cases, computed tomography (CT) imaging, FNA, and culture have not been helpful. Surgical excision is recommended if medical treatment fails and/or diagnostic confirmation is required. Pathology will show granulomatous inflammation and nucleic acid amplification testing (NAAT) by polymerase chain reaction (PCR) will be positive. Postoperatively, nine months of anti-TB therapy is recommended.

Tuberculous Laryngitis. The pathogenesis of TB laryngitis has changed with the implementation of active chemotherapy. In the preantibiotic era, TB laryngitis was often encountered in advanced disease, along with oral and epiglottic lesions, tonsillar ulcers, otitis media, and bronchogenic spread. Once diagnosed with laryngeal TB, patients respond promptly to antibacterial therapy; the prevalence of laryngeal TB has decreased dramatically since the introduction of this therapy; and most of the laryngeal cases now seen are due to hematogenous dissemination (9,11).

TB laryngitis is highly contagious, due to the effective aerosolization of bacilli-laden secretions during speaking, sneezing, or coughing. Lesions vary from erythema to ulceration and exophytic masses resembling carcinoma. The most common initial symptom is hoarseness. Systemic symptoms of weight loss, fever, night sweats, and fatigue are often present; cough, wheezing, hemoptysis, dysphagia, odynophagia, and otalgia are the dominant local symptoms. Stridor may develop secondary to subglottic fibrosis and narrowing, local tumor mass, or vocal cord paralysis.

Sputa samples reveal AFB in up to 30% of cases. If biopsy is performed to rule out carcinoma, the tissue should be sent for AFB culture. Histology will reveal granulomatous inflammation. Appropriate respiratory precautions should be taken to avoid aerosol formation and occupational exposure of health-care personnel.

Oral and Esophageal TB. Nonhealing ulcers of the tongue or oropharynx and nonhealing sockets after tooth extraction may be due to TB. The esophagus can be eroded by an adjacent caseous node, which leads to stricture with obstruction or tracheoesopha-geal fistula formation, and rarely, fatal hematemesis from an aortoesophageal fistula.

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