Clinical Study of Extrapulmonary Head and Neck Tuberculosis: A Single-Institute 10-year Experience

Laryngeal tuberculosis in the early 21st century. Literature review of clinical, diagnostic and therapeutic data, according to SWiM guidelines

OBJECTIVES

Review of the scientific medical literature dedicated to clinical data, diagnosis and treatment for laryngeal tuberculosis published since the turn of the 21st century.

MATERIAL AND METHODS

Search of the Medline, Cochrane and Embase databases for the period 2000-2022. Selection of cohorts and case reports documenting clinical data, diagnosis and treatment for laryngeal tuberculosis.

RESULTS

In total, 119 articles were analyzed. Immunodepression, HIV infection, history of lung tuberculosis, general symptoms suggesting tuberculosis, smoking and associated laryngeal cancer were noted in 18%, 3%, 20% and 41% of cases, respectively. No pathognomonic symptoms or signs emerged. Voice impairment, of various types and severity, isolated and/or associated with other signs, was the most frequent laryngeal symptom, in 86% of cases. All laryngeal sites were involved, with numerous and various associations. Impaired laryngeal motion and tracheotomy were noted in 6% and 1% of cases, respectively. Time to diagnosis varied from less than 1month to 36months, for a median 3months, in case reports. Laryngeal tuberculosis was diagnosed bacteriologically with certainty in 28% of cases while diagnosis was based on indirect criteria and/or involvement of another site in the other 72%, with lung involvement in 54%. Treatment duration ranged from 6 to 24months (median, 6months), using 3 to 5 (median: 4) antitubercular antibiotics, with 4 used in 80% of cohorts and 77% of case reports. Overall rates of cure, death, treatment resistance, adverse events, and laryngeal sequelae were 99%, 0.5%, 0.5%, 6% and 5%, respectively.

CONCLUSION

The clinical presentation and diagnostic difficulty in laryngeal tuberculosis did not change since the end of the 20th century. Quadritherapy is highly effective, with a low resistance rate and few adverse effects or laryngeal sequelae.

Extrapulmonary Tuberculosis: An Otorhinolaryngologist's Perspective

Objective

The study aimed to determine the clinical manifestations and epidemiology of extrapulmonary tuberculosis (EPTB) of the head and neck in the otorhinolaryngeal regions. There is an increase in the incidence of EPTB in recent years because of increase in immunocompromised states and development of resistant bacteria. The clinical symptoms and signs of EPTB of the otorhinolaryngeal regions overlap with that of malignancies and other diseases in otorhinolaryngology thereby requiring correct early diagnosis so as to avoid unnecessary surgeries and procedures with initiation of appropriate anti tuberculous treatment under RNTCP.

Study design

Our prospective study was done on 45 patients who attended the ENT OPD at a tertiary care centre in Southern India over a period of 18 months with diagnosed EPTB of the otorhinolaryngeal regions.

Results

The study included 29 (64.4%) patients who presented with cervical lymphadenopathy, 11 (24.4%) patients with tuberculous laryngitis, 3 (6.6%) patients with tuberculous otitis media and 1 each with nasal and oral cavity tuberculosis. In our study 6 (13.3%) patients had co-existing pulmonary tuberculosis, 8 (18%) had diabetes, 5 (11%) had past history of tuberculosis and 7 (16%) had contact with patient with tuberculosis.

Conclusion

A high index of suspicion of EPTB must be kept among patients where (i) the clinical symptoms are out of proportion to the signs, (ii) common treatment fails or (iii) there is persistence or recurrence of symptoms despite therapy. The challenge is in confirming diagnosis which requires histopathological examination (HPE) of the tissue specimen. The timely diagnosis and initiation of anti tuberculous treatment (ATT) as per RNTCP helps in complete recovery thereby reducing morbidity.

Aural tuberculosis at the start of the 21st century. Literature review according to SWiM guidelines. Part 1: Clinical and diagnostic data

OBJECTIVES

Review of the scientific literature dedicated to clinical data and diagnosis modalities for aural tuberculosis published since the start of the 21st century.

MATERIAL AND METHODS

Search of the Medline, Cochrane and Embase databases for the period 2000-2020. Selection of articles in English, French and Spanish devoted to clinical cases and series documenting clinical data and diagnosis for aural tuberculosis of articles by two authors. Analysis performed according to SWiM guidelines. Extraction of data on pre-established files documenting clinical and diagnostic data.

RESULTS

In total, 173 articles: 163 case reports (228 patients) and 10 cohorts (177 patients) from 49 countries were analyzed. Female/male sex ratio was 1.05, with ages ranging from less than 1 month to 87 years. Tuberculosis involved another site in 35.1% of cases. Aural involvement was bilateral in 19.7% of cases. Clinical presentation corresponded to otitis media (prior antibiotic treatment and auricular surgery in 41.4% and 10.1% of cases, respectively) without any pathognomonic symptoms or signs. Associated severe locoregional complications were seen in 32% of cases, with 23.2% and 13% incidence of peripheral facial palsy and severe intracranial complications, respectively. Time to diagnosis ranged from less than 1 month to 384 months, and was longer than 12 months in 26.5% of case reports, without significant correlation (P=0.29) with severe revelatory locoregional complications. Incidence of Mycobacterium tuberculosis detection ranged from 33.4% of documented cases in auricular secretions to 64.6% in polyps, granulomas, and/or biopsies. In the case reports, diagnosis with certainty was done in 58.3% of cases, while it was based on involvement of another site and on indirect criteria or positive clinical progression after treatment in the other 10.1% and 31.6%, respectively.

CONCLUSION

Aural tuberculous must always be considered in case of unfavorable progression of otitis. Definitive diagnosis is based on multiple auricular sample sites, polymerase chain reaction, and γ interferon blood assay.

Tuberculosis in the Head and Neck: Changing Trends and Age-Related Patterns

OBJECTIVE

To evaluate changing trends in patient collectives, age-related patterns of manifestation, and diagnostic pathways of patients with extrapulmonary head and neck tuberculosis (TB), and to provide strategies to fasten diagnosis in these patients.

STUDY DESIGN

Case control study.

METHODS

A 10-year retrospective analysis of 35 patients diagnosed with extrapulmonary TB in the head and neck at a tertiary university institution from 2009 to 2019, with special focus on the influence of the patient's age on consideration of TB and clinical patterns.

RESULTS

The vast majority of patients younger than 40 years had their origin in countries with high TB burden (P = .0003), and TB was considered very early as a differential diagnosis (P = .0068), while most patients older than 40 years were domestic citizens initially suspected for a malignancy, who more often had an underlying immunosuppressive condition (0.0472). Most frequent manifestations in both groups were the lymph nodes, larynx, and oropharynx. Surprisingly, no differences in the rates of open TB or history of TB infection in the family anamnesis were found.

CONCLUSION

The two groups of patients found most often are younger patients migrating from regions with high TB burden and elderly domestic patients suffering from immunosuppressive conditions, with the latter often being misdiagnosed as malignancies. TB remains an important but difficult differential diagnosis, due to the initially unspecific symptoms and the great variety in the presentation of manifestations in the head and neck.

LEVEL OF EVIDENCE

4 "case-control study" Laryngoscope, 2021.

Cervical Tuberculosis Combined With Papillary Thyroid Carcinoma With Lateral Neck Metastasis

Extrapulmonary tuberculosis in the head and neck region accounts for 10% of all tuberculosis cases. Cervical lymph nodes are the most common sites of head and neck tuberculosis and often mimics neck metastasis leading to overstaging and overtreatment. Fine needle aspiration has proven effective in diagnosing cervical tuberculosis. If a diagnosis of tuberculosis is confirmed, then the first-line treatment is oral antituberculosis medication.

The rare multidrug cervical tubercular lymphadenitis in an infant from Iran: A case report and literature review

Cervical-TB lymphadenitis is the most frequent extrapulmonary manifestation of tuberculosis infection. There are limited documents (only five documents) on multidrug-resistant cervical tubercular lymphadenitis, but there is no evidence for MDR-cervical tuberculosis lymphadenitis in infants, which may occur in TB endemic regions.

An eight-year epidemiologic study of head and neck tuberculosis in Texas, USA

BACKGROUND

Head and neck tuberculosis (HNTB) especially cervical lymphadenopathy are the most common extrapulmonary indications of TB, but remain a diagnostic challenge. In this study, we describe and analyze the epidemiologic characteristics of HNTB on a population-level.

MATERIALS AND METHODS

We retrospectively assessed 547 HNTB cases reported to the Centers for Disease Control and Prevention's TB Genotyping Information Management System in Texas from 2009 to 2016 and compare and contrast differences between diagnosed exclusively HNTB and HNTB with concurrent pulmonary tuberculosis (PTB).

RESULTS

The majority of patients with HNTB were diagnosed with cervical lymphadenopathy (96.9%), age 25-44 (47.3%) and female (52.7%). Co-infection with human immunodeficiency virus, being homeless, excessive alcohol use within the past 12 months and drug use were more frequently seen for HNTB with concurrent pulmonary involvement compared to reported patients with exclusively HNTB. The highest prevalence of Mycobacterium tuberculosis lineage in exclusively HNTB was Euro-American L4 (52.3%), followed by Indo-Oceanic L1 (21.5%) and East-Asian L2 (13.1%). One multidrug resistant TB case was identified. Seven deaths were reported during treatment.

CONCLUSION

Our findings provide a better understanding of the epidemiology of HNTB and characteristics associated with the disease at the population-level, which is important in managing HNTB patients.

Empirical treatment with non-anti-tuberculosis antibiotics decreased microbiological detection in cervical tuberculous lymphadenitis

Diagnosis of cervical tuberculous lymphadenitis (CTL), the most commonly occurring form of extrapulmonary tuberculosis, remains as a challenge in clinic. Detection of the presence of Mycobacterium tuberculosis (Mtb) in fine needle aspiration cytology (FNAC) samples is one golden criterion to confirm the CTL diagnosis. Due to the non-specific clinical presentation, CTL might be confused with other lymph node enlargement diseases; therefore empirical treatment with non-anti-TB antibiotics is often initially administered. However, it is still unclear whether this diagnostic antibiotic treatment affects the positivity of Mtb detection in FNAC. The demographics and clinical characteristics of 732 lymph node enlargement patients who had underwent FNAC were retrospectively analyzed and 605 (82.65%) of them were diagnosed as CTL. A total of 279 CTL cases (279/605, 46.11%) with completion of three Mtb tests (AFB, NAAT, and Mtb culture) in FNAC samples were selected for analyzing the effect of empirical antibiotic treatment on the positivity of Mtb tests. Compared to CTL patients without antibiotic treatment prior to FNAC, patients received empirical non anti-TB treatment had significantly lower positivity for acid fast bacilli staining (adjusted OR 0.11, 95% CI 0.06-0.21), nucleic acid amplification test (NAAT) (adjusted OR 0.38, 95% CI 0.21-0.71), and Mtb culture (adjusted OR 0.11, 95% CI 0.06-0.19). In conclusion, this study demonstrated that empirical non anti-TB antibiotic treatment reduced the opportunity to confirm CTL by microbiological analysis. Patients with cervical lymph node enlargement should undergo FNAC for Mtb tests prior to initiation of empirical non anti-TB treatment.

Clinical study of tuberculosis in the head and neck region-11 years' experience and a review of the literature

Tuberculosis (TB) is an infectious disease and major health concern. Head and neck tuberculosis (HNTB) is relatively rare, but can arise in many regions, including the lymph nodes, larynx, oral cavity and pharynx. We retrospectively reviewed the clinical records of 60 patients diagnosed with HNTB in our department between March 2005 and January 2016. A review and summary of previous HNTB articles published in PubMed since 1885 was also performed. The subjects consisted of 17 males and 43 females, and the average age of patients was 45 ± 14.67 years. The major clinical presentation was a lump or swelling, followed by an oral ulcer and skin fistula. The most common site of tuberculosis was in the cervical lymph node. Three patients also suffered from a malignant tumor in the head and neck region. A total of 980 papers involving 5881 patients were included in our literature review. The included subjects ranged in age from 15 months to 100 years with a male-to-female ratio of 1.5:1. The larynx (38.92%), cervical lymph nodes (38.28%) and oral cavity (9.92%) were the three most common development sites. 465 patients were positive according to a HIV test, and 40 patients had comorbidities with different types of tumors. Head and neck tuberculosis should always be considered during a differential diagnosis for lesions in the head and neck region. Early diagnosis and treatment can greatly enhance the therapeutic effect and patients’ quality of life.