This document discusses tuberculosis (TB) of the head and neck region. It notes that TB in this area usually presents as lymphadenopathy or chronic inflammation not responding to antibiotics. It also discusses specific sites that can be involved like the oral cavity, larynx, ear, nose and paranasal sinuses. Diagnosis involves demonstration of M. tuberculosis by smear, culture or biopsy. Imaging may show thickening but is nonspecific. Treatment is with anti-tubercular therapy for at least 6 months, with surgery sometimes needed for complications or resistant cases.

1. TUBERCULOSIS IN ENT
DR.GAUTHAM
FIRST YEAR PG
DEPARTMENT OF ENT

2. INTRODUCTION
• TB IN HEAD AND NECK REGION USUALLY PRESENT WITH LYMPHADENOPATHY
OR CHRONIC INFLAMMATION THAT DO NOT RESPOND TO ANTIBACTERIAL THERAPY.
• IN PRE-CHEMOTHERAPEUTIC PATIENTS WITH ACTIVE TB OFTEN DEVELOPED
LARYNGEAL, OTOLOGIC, NASAL & PARANASAL INVOLVEMENT.
• RESURGENCE OF TB AS A CONSEQUENCE OF HIV INFECTION& AIDS HAS BROUGHT
ENT TB INTO FOCUS ONCE AGAIN

3. • MODE OF INFECTION IN HEAD & NECK REGION
• 1) DIRECT SPREAD BY CONTAMINATED SPUTUM FROM A PULMONARY FOCUS
• 2) HEMATOGENOUS
• 3) LYMPHATIC
• CERVICAL LYMPH NODE INVOLVEMENT IS THE MOST COMMON FORM OF LYMPH NODE
TB & ALSO THE MOST FREQUENT H&N MANIFESTATION OF TB.
• TB OF CERVICAL SPINE MAY PRESENT AS TORTICOLLIS, STIFFNESS OF NECK MUSCLES.
• RETROPHARYNGEAL/PARAVERTEBRAL ABSCESS MAY PRESENTWITH
DYSPHAGIA/DYSPNOEA/STRIDOR

4. TB OF ORAL CAVITY
• ORAL CAVITY IS AN UNCOMMON SITE OF TB INVOLVEMENT. THE INTACT MUCOSA
OF ORAL CAVITY IS RELATIVELY RESISTANT TO INVASION & SALIVA HAS INHIBITORY
EFFECT ON GROWTH OF MYCOBACTERIA
• .INFECTION IS USUALLY THROUGH INFECTED SPUTUM COUGHEDOUT BY A PATIENT
WITH OPEN PULMONARY TB.IT CAN ALSO BE THROUGH HEMATOGENOUS ROUTE
• TONGUE IS THE MOST COMMON SITE(50%) AND LESIONS ARE USUALLY OVER THE
TIP, BORDERS, DORSUM & BASE OF TONGUE.
• IT MAY BE SINGLE/MULTIPLE, PAINFUL/PAINLESS. USUALLY WELL CIRCUMSCRIBED,
BUT CAN BE IRREGULAR.

5. • LESIONS SOMETIMES BEGIN AS NODULES/FISSURES/PLAQUES.
• INITIAL PICTURE RESEMBLES MALIGNANCY
• HISTOPATHOLOGY CONFIRMS DIAGNOSIS OF TB.
• SECONDARY INVOLVEMENT OF DRAINING LYMPH NODESMAY OCCUR
• MAJORITY OF PATIENTS HAVE PULMONARY TB.
• OTHER SITES OF INVOLVEMENT INCLUDE FLOOR OF MOUTH,SOFT PALATE,
ANTERIOR PILLARS & UVULA

6. TB OF LARYNX
• CLASSICALLY DEVELOPS DUE TO DIRECT SPREAD TO THE LARYNX FROM
CONTAMINATED SPUTUM.
• FREQUENT IN SPUTUM POSITIVE PATIENTS & MOST COMMONLY INVOLVES
POSTERIOR GLOTTIS DUE TO POOLING OF INFECTED SPUTUM WHEN PATIENT IS
IN RECUMBENT POSITION.THIS RESULTS IN LOCALISED EDEMA, GRANULOMA OR
ULCERATIONS
• CAN ALSO SPREAD BY LYMPHOHEMATOGENOUS ROUTE. RECENT EVIDENCE
SUGGESTS THAT LARYNGEAL TB WITH EDEMATOUS, POLYPOID PANLARYNGITIS
OCCURING BY THIS ROUTE IS INCREASING

7. EPIDEMOLOGY
• AT PRESENT , INCIDENCE OF LARYNGEAL INVOLVEMENT IN PATIENTS OF
PULMONARY TB RANGES FROM 1.5-50% IN COUNTRIES OF HIGH TB
ENDEMICITY, ALMOST ALL PATIENTS OF LARYNGEAL TB HAVE RADIOLOGICAL
EVIDENCE OF PULMONARY TB & MANY ARE SPUTUM SMEAR POSITIVE
• IN LOW ENDEMIC COUNTRIES, PATIENTS WITH LARYNGEAL TB SELDOM HAVE
PULMONARY TB.
• HOWEVER, PATIENTS WITH A HEAVY BACILLARY LOAD & STRONGLY POSITIVE
SPUTUM SPECIMEN MAY NOT HAVE LARYNGEAL INVOLVEMENT.

8. PATHOLOGY
• TUBERCLE BACILLI INDUCE LOW GRADE INFLAMMATION WITH FORMATION OF
TYPICAL TB GRANULATION TISSUE WHICH LATER UNDERGOES COAGULATION
NECROSIS AND CASEATION.
• LARYNGEAL LESIONS REVEAL EDEMA,HYPEREMIA,GRANULOMAS OR
ULCERATION.
• VOCAL CORD THICKENING & PALSY CAN OCCUR.

9. • EPIGLOTTIS MAY SHOW IRREGULAR MARGINS & NIBBLED APPEARANCE. M.TB
MAY BE FOUND IN SUBEPITHELIAL TISSUE.
• THE PROCESS OF DESTRUCTION & REPAIR PROCEED SIMULTANEOUSLY.
• SUBMUCOSA OF EPIGLOTTIS & ARYEPIGLOTTIC FOLDS ARE LIKELY TO UNDERGO
FIBROUS INFILTRATION RESULTING IN PSEUDO EDEMA, ALSO KNOWN AS
TURBAN EPIGLOTTIS.

10. CLINICAL FEATURES
• SYMPTOMS
• UNEXPLAINED HOARSENESS OF VOICE
• ODYNOPHAGIA/DYSPHAGIA
• REFERRED OTALGIA

11. • SIGNS
• ANY LARYNGEAL STRUCTURE CAN BE INVOLVED BY TB .MC SITE INCLUDE TRUE
VOCAL CORD, EPIGLOTTIS, FALSE VOCAL CORD, ARYEPIGLOTTIC FOLDS, ARYTENOIDS,
INTERARYTENOID AREA & SUBGLOTTIS
• EDEMA, HYPEREMIA, NODULARITY, ULCERATION, EXOPHYTIC MASS, VOCAL CORD
THICKENING & OBLITERATION OF ANATOMICAL LANDMARKS CAN BE SEEN.
• VOCAL CORD PARALYSIS, SUBGLOTTIC EDEMA/GRANULATION TISSUE CAN CAUSE
STRIDOR.

12. • LARYNGEAL TB AND CARCINOMA CAN COEXIST. C/F MAY OVERLAP & LESIONS
MAY LOOK SIMILAR.
• INCIDENCE IS REPORTED TO BE 1.4%
• ATT SHOULD BE GIVEN FOR ATLEAST 2-3WEEKS BEFORE INITIATING TREATMENT
OF LARYNGEAL CARCINOMA
• WHEN TB DEVELOPS AFTER ANTINEOPLASTIC THERAPY, THE INFECTION IS MORE
SEVERE WITH A HIGH MORTALITY.

13. TB OF SALIVARY GLAND
• TB SIALITIS IS USUALLY SECONDARY TO TB OF ORAL CAVITY OR PULMONARY TB.
PRIMARY TB OF SALIVARY GLANDS IS RARE.
• PAROTID GLAND IS MOST COMMONLY INVOLVED.
• C/F MAY BE ACUTE OR CHRONIC
• ACUTE FEATURES RESEMBLE ACUTE NON TB SIALITIS & DIFFERENTIATION MAY BE
DIFFICULT
• OCCASIONALLY TB MAY BE FOUND FOLLOWING SURGERYPERFORMED FOR A
SALIVARY GLAND TUMOR.
• CHEST XRAY & FNAC ARE USEFUL IN CONFIRMING DIAGNOSIS

14. TB OF PHARYNX
• AT PRESENT, TONSILS & PHARYNX ARE UNCOMMONLYINVOLVED BY TB.
• PRESENTING FEATURES INCLUDE A)ULCER ON THE TONSIL OROROPHARYNGEAL WALL
B)GRANULOMA OF THE NASOPHARYNXCNECK ABSCESS.
• CO EXISTENCE OF TB & CANCER OF PHARYNC COULD BE
 A)MERE COINCIDENCE
 B)METASTATIC CARCINOMADEVELOPING IN A RECENT/OLD TB LESION
 C)TB INFECTIONENGRAFTED ON CANCER IN FULL EVOLUTION
 D)CHRONICPROGRESSIVE TB IN WHICH CANCER DEVELOPS LYMPHORETICULAR MALIGNANCY MAY
BE ASSOCIATED WITHTB ABSCESS & SINUS OF THE NECK.
• RARELY, TB & CANCER MAY INVOLVE 2 DIFFERENT ORGANS.

15. TB OF EAR
• PRIMARY INFECTION OF EAR IS RARE.
• TB OF EXTERNAL EAR IS UNCOMMON. HOWEVER LUPUS VULGARIS OF
EXTERNAL EAR HAS BEEN REPORTED.
• MIDDLE EAR CAN GET INFECTED WITH M.TB BY THE BACILLI INVADING THE
EUSTACHIAN TUBE WHILE THE INFANT IS BEINGFED OR BY HEMATOGENOUS
SPREAD TO MASTOID PROCESS.
• SYMPTOMS INCLUDE PAINLESS OTORRHEA & HEARING LOSS HOWEVER PTS
WITH TB MASTOIDITIS MAY HAVE OTALGIA

16. • SIGNS
 PALE GRANULATION TISSUE IN MIDDLE EAR WITH DILATED VESSELS IN
ANTERIOR PART OF TYMPANIC MEMBRANE
MULTIPLE PERFORATION IN TYMPANIC MEMBRANE MAY OCCUR DUE TO
CASEATION NECROSIS WHICH LATER COALESCE TO FORM A LARGE
PERFORATION WHICH MAY INVOLVE ANNULUS AS WELL.
PARS FLACCIDA IS USUALLY NOT INVOLVED BY TB.

17. FACIAL NERVE PALSY MAY OCCUR WITH OR WITHOUT SEQUESTRUM.
PERSISTENT NON HEALING GRANULATIONS IN A POST-MASTOIDECTOMY
PATIENTS MAY BE DUE TO TB.
PREAURICULAR LYMPHADENOPATHY WITH POSTAURICULARFISTULA IS
PATHOGNOMONIC OF TB OTITIS MEDIA.

18. TB OF NASOPHARYNX
• TB OF NASOPHARYNX IS UNCOMMON.
• MOST COMMON COMPLAINT IS NASAL OBSTRUCTION & RHINORRHEA
• YOUNG FEMALES IN THE AGE RANGE OF 20 TO 40 YRS ARE MOSTCOMMONLY
INVOLVED.
• MOST COMMON CLINICAL MANIFESTATION INCLUDE
CERVICALLYMPHEDENOPATHY(53%) F/B
HEARINGLOSS(12%),TINNITUS,OTALGIA,NASAL OBSTRUCTION AND PND(6%EACH).
• ADENOID HYPERTROPHY MAY BE SEEN.

19. • SYSTEMIC SYMPTOMS LIKE FEVER,NIGHT SWEATS,WT LOSS MAY BE SEEN.
• DIRECT ENDOSCOPIC EXAMINATION SHOWS NASOPHARYNGEAL MUCOSAL
IRREGULARITY OR MASS IN THE NASOPHARYNX

20. TB OF PARA NASAL SINUSES
• ITS NEARLY ALWAYS SECONDARY TO PULMONARY OREXTRAPULMONARY TB.
• THOUGH ANY SINUS MAY BE INVOLVED, MAXILLARY &ETHMOID SINUS ARE
MOST COMMONLY INVOLVED
• INFECTION REACHES SINUS EITHER BY HEMATOGENOUS ROUTE OR BY DIRECT
EXTENSION FROM TB OF SKULL BASE.

21. • CAN OCCUR IN 2 FORMS‣
 IN THE FIRST FORM(SINONASAL TB), INFECTION IS LIMITED TO SUBMUCOSA
ONLY. MUCOSA MAY BE THICKENED OR FILLED WITH A POLYP WHICH HAS A
PALE & BOGGY APPEARANCE WITH MINIMAL PURULENT DISCHARGE. THIS FORM
IS MORE COMMON.
• IN THE SECOND TYPE, BONY INVOLVEMENT(OSTEOMYELITIS) IS SEEN WITH A
SEQUESTRUM & FISTULA FORMATION.

22.  IT IS MORE DIFFICULT TO TREAT SINONASAL TB CAN SPREAD TO BRAIN OR
ORBIT RESULTING IN BRAIN ABSCESS, EPIPHORA & DETERIORATION OF VISION.
 TB OF SPHENOID SINUS MAY PRESENT WITH BLINDNESS &FEATURES OF
CAVERNOUS SINUS THROMBOSIS WITH GRADUAL ONSET & SIOW
PROGRESSION
 RARELY TB OF MAXILLARY SINUS MAY BE ASSOCIATED WITH CARCINOMA.

23. NASAL TB
• TB OF NASAL CAVITY USUALLY MANIFESTS AS NASAL OBSTRUCTION &
CATARRH.
• PHYSICAL EXAMINATION MAY REVEAL PALLOR OF NASAL MUCOSA WITH
MINUTE APPLE JELLY NODULES THAT DO NOT BLANCH WITH NASAL
DECONGESTANTS.
• THESE NODULES MAY COALESCE TO FORM A GRANULAR LESION WITH
SUBSEQUENT PERFORATION OF SEPTAL CARTILAGE.

24. • OTHER SITES WHICH CAN BE INVOLVED ARE INFERIOR TURBINATE, SEPTAL
MUCOSA & VESTIBULAR SKIN.
• NASOLACRIMAL DUCT INVOLVEMENT IS RARE.
• TB OF NOSE CAN CAUSE COMPLICATIONS LIKE SEPTAL PERFORATION, ATROPHIC
RHINITIS & SCARRING OF NASAL VESTIBULE.

25. DIFFERENTIAL DIAGNOSIS
• TB OF ORAL CAVITY: PRIMARY SYPHILIS, FUNGAL INFECTION, CHRONIC
TRAUMATIC ULCERS, SQUAMOUS CELL CARCINOMA
• TB OF LARYNX: SQUAMOUS CELL CARCINOMA, OTHER GRANULOMATOUS
DISEASES SUCH AS FUNGAL INFECTIONS, SYPHILIS, LEPROSY, WEGENER'S
GRANULOMATOSIS & SARCOIDOSIS.
• TB OF NOSE & PARANASAL SINUSES: OTHERGRANULOMATOUS DISEASES(HERE
LESIONS ARE PAINLESS).

26. DIAGNOSIS
• DIAGNOSIS OF LARYNGEAL TB INVOLVES DEMONSTRATION OF M.TB IN
SPUTUM, LARYNGEAL SWAB BY SMEAR, CULTURE METHODS & HPE OF BIOPSY
MATERIAL.
• COEXISTENT PULMONARY TB SHOULD BE LOOKED FOR.
• TB OF THE EAR SHOULD BE ASCERTAINED BY TISSUE BIOPSY.
• TB OTITIS MEDIA IS DIAGNOSED BY SMEAR & CULTURE OF EAR DISCHARGE/HPE
OF AFFECTED TISSUE

27. • TB OF NOSE/PNS/NASOPHARYNX IS DIAGNOSED BY SMEAR & CULTURE
EXAMINATION OF NASAL DISCHARGE, NASOPHARYNGEAL SECRETIONS
COLLECTED BY NASAL ENDOSCOPY ALONG WITH HPE OF AFFECTED TISSUE.
• TB OF TONGUE, ORAL CAVITY, SALIVARY GLANDS IS DIAGNOSED BY HPE &
MICROBIOLOGY OF BIOPSY MATERIAL
• PCR SEEMS TO BE USEFUL IN THE DIAGNOSIS OF ENT TB BUT LARGE SCALE
STUDIES ARE NEEDED TO CONFIRM ITS ROLE.

28. IMAGING IN ENT TB
• RADIOLOGICAL FINDINGS ARE NONSPECIFIC IN CT/MRI.
• DIFFUSE THICKENING OF EPIGLOTTIS OR VOCAL CORDS IS SEEN.
• DEEP SUBMUCOSAL INFILTRATION OF PRE-EPIGLOTTIC & PARA LARYNGEAL FAT
SPACES IS NOT SEEN EVEN WHEN THERE WAS EXTENSIVE INVOLVEMENT OF
LARYNGEAL SPACE IN TB OF EAR, SEQUESTRUM MAY BE SEEN.

29. • CT OF TEMPORAL BONE MAY SHOW DESTRUCTION OF OSSEOUS CHAIN,
SCLEROSIS OF MASTOID CORTEX, OPACIFICATION OF MIDDLE EAR & MASTOID
AIR CELLS.
• MRI MAY SHOW THICKENED 7TH & 8TH CRANIAL NERVE

30. • SURGICAL BIOPSY WAS GOLD STD FOR DIAGNOSING TB BUT CAUSED CHRONIC
DRAINING FISTULAS(14%).
• CHILDREN USUALLY PRESENTED WITH OTORRHEA
• LOT OF CONFOUNDING FACTORS & ILLNESSES DELAYED DIAGNOSIS.

31. TREATMENT
• ATT (FOR 6 MONTHS)IS THE MAINSTAY OF TREATMENT.
• IF RESPONSE IS INADEQUATE OR SLOW, TREATMENT IS PROLONGED.
• AS LARYNX HEALS, FIBROSIS OF LARYNGEAL TISSUE OCCUR RESULTING IN
SEQUELAE:CRICOARYTENOID JOINT FIXATION, POSTERIOR GLOTTIC STENOSIS &
ANTERIOR GLOTTIC WEB, SUBGLOTTIC STENOSIS, VOCAL CORD SCARRING.
• OCCASIONALLY SECOND LINE DRUGS MAY BE REQUIRED FOR ATYPICAL
MYCOBACTERIA/DRUG RESISTANT TB

32. ROLE OF SURGERY
• DIAGNOSTIC INDICATIONS
BIOPSY OF MUCOSAL LESIONS
LYMPH NODE BIOPSY WHERE FNAC IS INCONCLUSIVE

33. • THERAPEUTIC INDICATIONS
EXCISION OF A SINUS/FISTULA WITH TB INFECTION WHICH FAILS TO HEAL WITH
ADEQUATE ATT.
DRAINAGE OF NECK ABSCESS
 PRESENCE OF SEQUESTRUM IN MASTOID REGION
REPEATED DRAINAGE/EXTERNAL DRAINAGE OF RETROPHARYNGEAL ABSCESS
REVISION OF COSMETICALLY BAD SCARS LEFT AFTER TB INFECTION HAS
HEALED.

34. REPEATED ASPIRATION IS PREFERRED OVER OPEN DRAINAGE FOR COLD
ABSCESSES.
 HOWEVER IF REQUIRED, EXTERNAL DRAINAGE IS PREFERRED OVER PERORAL
DRAINAGE TO AVOID SINUS FORMATION & PREVENT THE ABSCESS FROM
DRAINING INTO OROPHARYNX.
DEBRIDEMENT OF DISEASED BONE/GRAFTING MAY BE REQUIRED.
SUPERIOR LARYNGEAL NERVE BLOCK HAS BEEN ADVOCATED FOR
ODYNOPHAGIA

35. •
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