J R Soc Med 2005;98:267-269
doi:10.1258/jrsm.98.6.267
© 2005 Royal Society of Medicine
4 years' experience of head and neck tuberculosis in a south London hospital
N Choudhury BSc MRCS 1
G Bruch MD 1
P Kothari FDSRCS 1
G Rao FRCPath 2
R Simo FRCS 1
1 Department of Otorhinolaryngology and Head and Neck Surgery, University
Hospital Lewisham, London, UK
2 Department of Microbiology, University Hospital Lewisham, London, UK
Correspondence to: Ms Natasha Choudhury, West Middlesex University Hospital,
Twickenham Road, Isleworth TW7 6AF, UK E-mail:
natashamasood1{at}aol.com
 |
SUMMARY
|
|---|
In a south London department of otorhinolaryngology and head
and neck
surgery, 33 cases of tuberculosis were diagnosed in
4 years. The most common
presentation was cervical adenitis
(58%) and in some cases the initial
investigations suggested
malignant disease. Most of the patients were of
non-British
origin but none proved to be HIV seropositive. Fine-needle
aspiration
was positive for tuberculosis in 7 of 19 patients. 21 patients
required
a surgical procedure for diagnosis.
|
INTRODUCTION
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|---|
Tuberculosis (TB) is the world's leading cause of death from
a single
infective agent and a rising incidence has caused the
World Health
Organization to declare the disease a global
emergency.
1,2
Among
the factors associated with the reversal of a previous decline
are
increased global travel and a rising prevalence of immunodeficiency
through
HIV infections or drug therapy. In the UK, pulmonary
tuberculosis is the most
common manifestation but extrapulmonary
disease is likewise increasing. Here
we review four years' experience
of head and neck tuberculosis—a
condition that can present
diagnostic and therapeutic challenges.
|
METHODS
|
|---|
We retrospectively reviewed the case notes of all patients with
proven
extrapulmonary tuberculosis seen in the Otorhinolaryngology
and Head and Neck
Department of University Hospital Lewisham
from December 1999 to January 2004.
(All patients had then been
referred to a TB clinic in the Department of Chest
Medicine
for further management.) Routine tests included full blood count,
C-reactive
protein and a chest X-ray. Patients with neck, thyroid and salivary
gland
masses underwent ultrasound-guided fine-needle aspiration, with
cytological
and microbiological examination including staining for acid-fast
bacilli
(Ziehl-Neelsen). Where tuberculosis was suspected, sputum samples
were
obtained for Ziehl-Neelsen staining. In patients with inconclusive
results
further biopsies were taken for microbiological analysis,
including culture on
Löwenstein-Jensen medium, and histological
assessment. Patients with
proven TB were subsequently counselled
and tested for HIV at the chest
clinic.
|
RESULTS
|
|---|
33 patients were seen over the study period, 21 male 12 female,
mean age 40
years (range 21-75). 15 had a history of previous
TB contact. 18 were of South
Asian origin and only 'Caucasian'.
In 19 patients (58%), the
presenting feature was cervical lymphadenitis.
In addition, 9 had salivary
gland TB, 2 laryngeal TB, and 1
each nasopharyngeal, hypopharyngeal and ear
TB. 21 patients
required some sort of surgical procedure for diagnosis
(
Figure 1).
In 12 patients the
disease was producing constitutional
symptoms such as fever, weight loss or
night sweats. None of
the patients proved to be HIV positive. 16 had evidence
of TB
on their chest X-ray.
The modes of microbiological and histopathological assessment
were
Ziehl-Neelsen stain 12/33,
Mycobacterium tuberculosis culture
18/29
and histopathology 21/21. No patient had an atypical mycobacterial
infection
but in 2 the organism was resistant—in one case
to streptomycin and in
the other to isoniazid.
To highlight some of the diagnostic dilemmas we describe three of the
cases.
Case 1
A man of 32 sought advice after two weeks with an enlarging neck mass and
hoarseness. The mass was hard and fixed, measuring 6 cm x 6 cm, and he
had a right vocal cord paresis. The mass was sampled by fine-needle aspiration
which yielded no help. CT showed a large necrotic mass in the right side of
the neck (Figure 2) and also an
apical right lung mass; the appearance suggested a malignant Pancoast type
tumour (Figure 3). Bronchoscopy
and lavage did not confirm this suspicion. A subsequent Heaf test was strongly
positive (grade 4). Incision biopsy of the neck mass then yielded material
that was positive for TB on microscopy, culture and histology.
Case 2
A man of 45 reported six months of dysphagia and odynophagia and four
months of anorexia, weight loss, night sweats and dysphonia. At initial
oesophagogastroduodenoscopy, gastroenterologists identified a large abnormal
supraglottic and hypopharyngeal mass that was suspicious of carcinoma;
however, multiple gastric biopsies showed no evidence of metaplasia, dysplasia
or malignancy. On referral to our department he underwent panendoscopy and
biopsy of the supraglottic and piriform sinus mass. Hypopharyngeal and
laryngeal TB was evident on microscopy, culture and histology. He also had
pulmonary TB, with a positive sputum smear and culture. Initially nasogastric
feeding was required because of his rigid larynx, but he eventually
recovered.
Case 3
A man aged 63 reported the sudden onset of unilateral hearing loss,
tinnitus and acute vertigo. His pure-tone audiogram showed a 70 dB left
sensorineural hearing loss. He had also been troubled by headaches and nausea,
ataxia and dysarthria. CT showed mild hydrocephalus and cerebrospinal fluid
was positive for TB on staining and culture. MRI identified a large cerebellar
abscess that was likewise due to TB. Twelve months' therapy was initially
recommended, but the treatment was extended to 2 years owing to disease
reactivation.
|
DISCUSSION
|
|---|
In UK inner-city areas such as ours, the resurgence of TB is
most evident
in the growing immigrant
population.
1 Most of
our
33 patients were from South Asia.
HIV infection is a risk factor, but none was found in the present series.
Our experience of extrapulmonary TB is, however, typical in showing a high
rate of cervical
adenitis.3,4
Historically, tuberculous cervical lymphadenitis has been more common in
children and young adults but the peak age range has now shifted to 20-40
years.5
In such cases, clinical differentiation from lymphoma or secondary
metastasis can be difficult. The simplest initial investigation is fine-needle
aspiration cytology, but in our series this was positive for acid-fast bacilli
in only 7 of 19 patients. Definitive diagnosis depends on a combination of
microbiology and histology. Single-organ TB (e.g. salivary gland) can be
particularly challenging to diagnose, and 21 of our patients (61%) required
some form of surgical procedure for diagnosis, including superficial
parotidectomy and submandibular gland excision.
Conventional techniques for isolation and identification of TB can be
time-consuming and delay treatment. Molecular investigation by means of the
polymerase chain reaction allows rapid diagnosis and subtyping of the
mycobacteria,6,7
and an even quicker technique with a specific DNA-probe can be applied to the
small clinical specimen collected by fine-needle
aspiration.8
However, these techniques are not yet routinely available in most UK
otolaryngology and head and neck centres.
The present series illustrates some of the diagnostic dilemmas presented by
extrapulmonary TB. Differentiation from neoplastic or other inflammatory
conditions can be difficult, particularly in mucosal TB involving the larynx,
hypopharynx and nasopharynx. Within our patient cohort, the original suspected
diagnosis included nasopharyngeal carcinoma and an occult primary tumour.
Conversely, we had a patient with a suspected recurrence of cervical TB that
proved to be a lymphoma. These patients need the services of a
multidisciplinary team of surgeons, chest physicians, microbiologists and
community nurses.
|
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SUMMARY
INTRODUCTION
