TUBERCULOSIS IN ENT DR TEJASWI M 1st year ENT PG INTRODUCTION  It is a chronic granulomatous systemic disease Mycobacterium tuberculosis Atypical mycobacteria Mode of infection Air borne  Hematogenous  Primary disease  Secondary to Pulmonary TB/ Miliary TB  MANIFESTATIONS Cervical lymphadenopathy  Aural TB  Nasal TB  TB - Oral cavity  Pharyngeal TB  Laryngeal TB  TB-Salivary glands  CERVICAL LYMPHADENOPATHY Most common extra pulmonary manifestation  It occurs in 80% to 90% of cases in the absence of pulmonary tuberculosis  Commonly involves the posterior and supraclavicular lymph nodes.  CLINICAL FEATURES Isolated, discretely affected node  A collection of matted nodes.  Fluctuant mass  Draining sinus  Very few patients present with classic constitutional symptoms of fever, chills, night sweats, anorexia, weight loss, and hemoptysis.  PATHOGENESIS MANAGEMENT INVESTIGATIONS  Chest X Ray  USG of nodes - multiple matted nodes .  Excision biopsy - confirmation TREATMENT  ATT Surgical intervention When a node remains enlarged after antimicrobial therapy. Incision and drainage of fluctuant disease should be avoided because this commonly results in a draining sinus.  It can be repaired at the end of therapy by excising the fistula along with a cuff of affected tissue enmass.  ATYPICAL MYCOBACTERIAL INFECTION CLINICAL FEATURES  Generally seen in children between the ages of 1 and 5 years and in immuno compromised – HIV patients.  Presents as isolated disease involving submandibular and submental cervical lymph nodes MANAGEMENT INVESTIGATIONS  Chest radiographs are almost always negative for signs of pulmonary tuberculosis.  Biopsy- confirmation  Should be suspected if the patient has documented acid-fast bacilli on smear and does not respond to multi drug therapy. TREATMENT  Excision of the involved lymph node before capsular rupture  Wide resection of involved tissue – if capsule ruptures AURAL TUBERCULOSIS It is a very rare disease entity.  Usually a primary disease  Mechanism of aural infection 1. Nasopharyngeal spread through Eustachian tube into middle ear 2. Hematogenous spread  CLINICAL FEATURES SYMPTOMS Chronic serous/seromucinous/blood stained painless otorrhea (despite adequate conventional antibiotic therapy).  Otalgia  Conductive hearing loss.  Cough, fever & night sweats +/ SIGNS Otoscopic findings  Polyps in external auditory canal  Tympanic membrane perforation  Multiple perforations considered hallmark of the disease Eroded handle of malleus  Middle ear mucosa appears pale  Abundant pale granulations in middle ear and mastoid  Preauricular adenopathy with postauricular fistula - pathognomonic for tuberculosis otitis media.  COMPLICATIONS  Profound sensorineural hearing loss if infection gains entry into internal ear  Facial nerve paralysis  Intracranial infections  petrous apicitis  extradural abscess  meningitis  labyrinthitis MANAGEMENT INVESTIGATIONS  Aural swab  Chest radiographs  Mantoux test  CT scan temporal bone destruction of the ossicular chain sclerosis of the mastoid opacification of the middle ear and mastoid air cells. TREATMENT  Multidrug therapy with ATT.  Surgical intervention  facial paralysis  subperiosteal abscess  fistulization  labyrinthitis  intracranial complications  progressive disease unresponsive to medical therapy. NASAL TUBERCULOSIS  It can present as 3 entities: 1.Nodular form(LUPUS VULGARIS) 2.Ulcerative form 3.Sinus Granuloma Nasal infection may be consequent to  Direct inoculation  Haematogenous dissemination  LUPUS VULGARIS Most common  It is a post primary form of tuberculosis  Arises in induviduals with moderate type of immunity  Infection arises from direct inoculation into dermis  CLINICAL FEATURES  It begins in vestibule  Extends to adjoining skin and mucosa  Presents as solitary, soft ,tiny, reddish brown gelatinous plaque known as apple jelly nodules. Blanching manouvers make them more prominent.  Usually painless  Nodules may coalesce and breakdown to form characteristic ulcers.  It follows a chronic course and can lead to scarring, contractures and tissues destruction  Diagnosis is by histopathology and microbiological culture.  Treatment is anti tubercular therapy.  ULCERATIVE FORM  It involves cartilagenous part of nasal septum or inferior turbinate.  Unilateral or bilateral  Presents with nasal obstruction, crusting , discharge and epistaxis.  Progress to septal perforation. INVESTIGATIONS  Biopsy of edge/ nodules around non healing ulcer. TREATMENT  ATT  Surgical : silastic buttons skin grafting SINUS GRANULOMA  Involves paranasal sinuses  Presents with diffuse soft tissue swelling and multiple discharging sinuses  CT and MRI show soft tissue mass.  Diagnosis - external or endoscopic biopsy.  Treatment is anti tubercular therapy. TB-ORAL CAVITY  Mycobacterial infections of the oral cavity result from pulmonary disease.  Infection of the oral cavity requires mucosal injury and is associated with poor dental hygiene. CLINICAL FEATURES Chronic ulceration on tip of tongue.  Irregular ulcers  Painless  Regional adenopathy  These lesions also occur on the gums, tongue, palate and floor of mouth.  MANAGEMENT Histopathologic examination may be required to distinguish these lesions from those of carcinoma  Treatment – Antitubercular therapy  PHARYNGEAL TUBERCULOSIS  The nasopharynx and oropharynx are the two main sites of pharyngeal involvement.  Most of them are primary infection. CLINICAL FEATURES  The most common complaint is nasal obstruction with rhinorrhea.  Examination of the nasopharynx shows adenoid hypertrophy.  Ulceromembranous lesions in oropharynx  Both forms present with cervical adenopathy TREATMENT  ATT LARYNGEAL TUBERCULOSIS  Primary TB in larynx is a very rare entity.  It usually presents secondary to pulmonary TB. CLINICAL FEATURES Hoarseness – most common  Odynophagia  Dysphagia  Cough  Otalgia  Dysphonia  PATHOLOGY  Classically involves posterior commissure of glottis.  Disease progresses to involve entire laryngeal framework - the vocal folds, vocal cords, epiglottis, aryepiglottic folds, arytenoids, and the subglottis.  Epiglottis – turban shaped epiglottis  Vocal cords –mouse nibbled appearance  Lesions : ulcero fungative lesions ulcerative lesions nonspecific inflammation polypoid masses. MANAGEMENT INVESTIGATIONS  Histo pathologic Examination  Sputum microscopy - positive in 20%  Chest radiograph - consistent with pulmonary tuberculosis. TREATMENT  ATT.  Rarely require tracheostomy to secure the airway TB-SALIVARY GLANDS Salivary gland mycobacterial infections are very rare  Result from an infected intraparotid lymph node.  These nodes are infected either through lymphatic channels draining the tonsil or nasopharyngeal area  retrograde migration of disease through Stenson’s duct  Patients are usually asymptomatic.  Lymphadenitis which mimics sialadenitis  Diagnosis by fine-needle aspiration cytology.  Treatment : ATT  Surgical intervention should be avoided in these patients.  ADVERSE EFFECTS OF ATT Ototoxicity occurs with aminoglycosides.  Major target is sensory neuroepithelium of inner ear.  Cochlea :outer hair cells > inner hair cells  Vestibule : type 1cells > type 2 cells Symptoms : tinnitus and hearing loss  High frequency sensorineural hearing loss- it progresses to low frequencies   Monitored by using oto acoustic emissions or pure tone audiometry.  Permanent hearing loss is treated with hearing aid or cochlear implant. KEYPOINTS Cervical lymphadenopathy – MC  Clinical suspicion arises when symptoms not responding to regular antibiotic therapy  Diagnosis by histopathology  ATT  Surgery reserved for cases which progress to complications and as part of diagnostic confirmation.  THANK YOU