Nasopharyngeal Tuberculosis

Vega Pratiwi Puri RSUD Purworejo

Anamnesis
Name : Muntofingah Age : 25 years old Sex : female Weight /height : 46 Kg / 152cm Chief complaint : bilateral neck mass History of current illness : patient had bilateral small neck mass since she was child , but the mass began more apparent in last 3 years. No tenderness.

Dysphagia (-) , odinophagia (-), breath difficulty (-), hoarseness (-), nasal congestion (-), discharge (-), hearing and ear complaint (-), epistaxis (-), cough (-), fever (-), sweating (-), anorexia (-) , difficulty in weight gain (+)

Anamnesis
History of past illness : patient had tonsilitis since she was 5 years old and never been treated. Patient had small cervical lymphadenopathy and it was getting bigger especially during past 3years. 2 years ago patient got bleeding cough. She went to doctor , doing sputum examination for TB and chest X-ray, but the result was negative. She does not have any history of allergy. History of family illness : no history of TB or prolonged cough , allergy , and malignancy

Examination
Physical examination Supporting examination

Neck region :Palpable neck mass 6x4x4 cm in left side and 5x3x3cm in right side . Mobile (+) , painless , solid , warm (-), distict border Oral cavity : normal Nasal cavity : normal Ear cannal : -

Endoscopy Nasopharyngeal biopsy : stroma as tubelcle , consist of lymphocyte, epitheloid histiocyte and hatia langhans. No sign of malignancy. Granulomatous inflamation,, high possibility of TB infection FNAB Lab examination Chest Xray Sputum tuberculosis examination

Nasopharyngeal tuberculosis
Tuberculosis can spread to any organ especially the lung. immunosupresive patient (aging, HIV, ogran transplan) tend to get exrapulmonary manifestation of tuberculosis infection 0.1% patient of active pulomonary TB got nasopharyngeal TB Nasopharyngeal primary TB 0.12% of all TB patient. Infection of TB in upperr respiratory tract is very rare, especially nasopharyx

Nasopharyngeal tuberculosis
The most important symptom cervical lymphadenopathy (91.3%) (superior nd media), followed by discharge and nasal obstruction Diagnosing nasopharyngeal TB is very difficult biopsy should be done to confirm diagnosis Upper respiratory track involvement of tuberculosis are larynx, pharynx, tonsil soft palate , middle ear and nasopharynx

Sign and symptom

Cervical lymphadeopathy (most common) Hearing loss Tinnitus Otalgia Nasal obstruction Pot nasal drip Epistaxis Otitis media Sore throat Cough Snoring and diplopia (few report) Osteomyelitis of clivus

Nasopharyngeal Tuberculosis

 Direct examination of nasopharyx revealed the main pattern :

Normal nasopharyx Iregularty and uleration of mucosa Mas lession that may cause bulging of the wall or a polypoid mass The mass may arise at the site of adeoid with appearance of mass or adeoid hyerplasia.

Biopsy

Case report
58 years old male snoring. Rhinoscopy anterior and oropharyngeal examination was normal. Edoscopy : edema and hyperemia of nasopharyngeal mocosa . No cervical lymphadenopathy. Tuberculin test (-). Histopatology examination from biopsy support the diagnosis of tuberculosis. After antituberculosis administration, the symptom were regress. 33 years old female superior and media lymphadenopathy, no tenderness since 2months ago. Fever (-) , sweating (-), chest Xray was normal, neck USG: multiple bilateral solid mass. Endoscopy : swelling of left lateral nasopharynx. PA : epitheloid cell granuloma with caseous necrosis and multinucleated giant cell .

Case report
61 years old M post nasal drip, lnn cervical (-), MRI : mild diffuse mucosal thickening in the left side of the roof. No extention otside nasopharynx. No lymphadenopathy. Biopsy : granuomatous inflamation and AFB with ziehl neelson staining. No evidence of pukmonary or sysemic tuberculosis.

Case report
33 years old M binocular horizontal diplopia. Progressive within 2years. Epistaxis (-), running nose (-), post nasal drip (-), nasal obstruction (-), chronic chough (-) fever (-), night sweat (-), anorexia (-). Lnn cervical (+). Abnormal neurological sign rectus muscle palsy , increase ICP (-), meningeal sign (-). MRI nasopranyx mass with extension to sphenoid sinus and cavernosus sinus . Endoscopy irregular mucosa ad bulging mass of the roof of nasopharynx. Biopsy granulomas made upof epitheloid cell and caseous necrosis but AFB (-).

Case report
40 yearsold F foul smelling nasal discharge. Nasal endoscopy was normal except irregular nasopharyngeal mucosa. Biopsy was taken which indicated nasopharyngeal TB. Patient refused antituberculotic treatment , 2 months later came with bilateral neck nodes. 17 years old F swelling of bothside of the neckk and hearing loss. Endoscopic examination revealed nasopharynx mass, and biospy was taken. The result : caseating granulomatous inflamation compatible with tuberculosis.

Nasopharyngeal lesion
Cancer (SCC, lymphoma) Fungal infection (aspergilusm mucomycosis) Granulomatous inflamation (sarcoidosis, leprosy, syphilis, tuberculosis) Autoimmune diseases (polyarteritis nodosa, chrug strauss and wegeners granulomatosis.

Treatment
Principle of tuberculosis treatment :
Antituberculosis should be administered in cobimbination, adequate dosage and appropriate with the patients problem. Antituberculosis should be devided into two phase (intensive and advance)

Caterory 1
New pulmonary TB patient with BTA Pulmonary Tb patient with BTA but Chest Xray + Extrapulmonary Tuberculosis