|Year : 2005 | Volume
| Issue : 4 | Page : 127-129
Primary pharyngeal tuberculosis
KB Gupta, S.P.S Yadav, Sarita, M Manchanda
Department of Tuberculosis and Chest Disease & Otorhinolaryngology, PT. B.D. Sharma Post Graduate Institute of Medical Sciences, Rohtak (Haryana), India
K B Gupta
16/6J Medical Enclave PT. B.D. Sharma PGIMS, Rohtak - 124 001 (Haryana)
| Abstract|| |
Pharynx is not a common site for clinical manifestation of tuberculosis. Primary tuberculosis of pharyngeal wall is uncommon. Usually its symptoms mimic malignancy causing delay in diagnosis. We report a case of primary pharyngeal tuberculosis in a 60 years old male.
Keywords: Extrapulmonary tuberculosis, Pharyngeal tuberculosis
|How to cite this article:|
Gupta K B, Yadav S, Sarita, Manchanda M. Primary pharyngeal tuberculosis. Lung India 2005;22:127-9
| Introduction|| |
Incidence of extrapulmonary tuberculosis is on the rise. Extrapulmonary tuberculosis can involve any part of the body except nail, hair and teeth. Of these, the common sites are lymph node, pleura, genitourinary tract, bone and joint, CNS, abdomen etc. Tuberculosis of oral cavity is uncommon. Out of this, primary pulmonary tuberculosis of pharynx is a very rare occurrence. Pharyngeal tuberculosis is usually secondary to pulmonary tuberculosis. However, it is also the site of primary infection which occurs in childhood and results in an asymptomatic primary focus of pharynx with cervical lymphadenopathy.
At the time of presentation, it usually mimics malignancy presenting mostly with odynophagia or dysphagia and ulceroproliferative lesions; thus causing problems in diagnosis.
| Case Report|| |
A 60 year old male presented with odynophagia and dysphagia of one month duration. There was no loss of appetite, cough and fever. There was no past history of tuberculosis or contact. Patient was a chronic smoker and non-alcoholic.
On general physical examination, the patient was well built, moderately nourished and mildly anaemic. There was no clubbing and lymphadenopathy. Laboratory findings revealed Hb-10.0g%, TLC10000/cmm, DLC-72,26, 2, 0, ESR - 50mm in Ist hour and platelets adequate. Skiagram of chest was normal [Figure 1]. Ultrasonography of abdomen and thorax was normal. Tuberculin test showed induration of 22mm. Examination of nose on anterior rhinoscopy showed no abnormality.
On indirect laryngoscopy, larynx was normal. Pharynx showed a large 3x4 cm ulcerative and granular lesion on posterior pharyngeal wall which was red in colour and showed signs of bleeding on touch [Figure 2]. On the basis of clinical finding, a provisional diagnosis of carcinoma of posterior pharyngeal wall was made. A biopsy was taken from posterior pharyngeal wall which on histopathological examination showed epithelioid cell granuloma with Langhan's and foreign body type giant cells indicating tubercular inflammation [Figure 3]. Patient was put on short course chemotherapy regimen (2HRZE/4HR).
After 2 months of treatment, patient showed marked improvement in pharyngeal wall lesion [Figure 4]. He is continuing antitubercular treatment with regular follow up.
| Discussion|| |
Primary pharyngeal tuberculosis is extremely rare even in endemic area. , Usually, it is more commonly seen in association with pulmonary tuberculosis  and presents as ulcer on tonsil or oropharyngeal wall, granuloma of nasopharynx and neck abscess / neck mass.  Primary disease has been reported in small numbers, in the area of nasopharynx and palatine tonsil but reported as extremely rare manifestation in area of posterior oropharyngeal wall.  HajioffD et al reported a case of primary tuberculosis of posterior oropharyngeal wall, presented as sore throat, fever and malaise. Our case involving post pharyngeal wall presented as dysphagia and odynophagia which is very unusual in presentation. 
Tuberculosis of oral cavity is unusual because of protective mechanism in the upper respiratory tract. Saliva, containing saprophytes with phagocytic property and epithelium of oral cavity, inhibit growth and multiplication of tuberculosis bacilli. Any breach in the mucosa due to chronic irritation or inflammation can predispose to tuberculosis.  Poor dental hygiene, leukoplakia and dental extraction are other predisposing factors. Even if there is no breach in mucosa, mycobacterium tuberculosis cross mucosal barriers by endocytosis within mucosal lymphoepithelial sites. These entry sites commonly include oropharyngeal and nasopharyngeal tonsils and Peyer's patches. Bacilli discharged at basolateral surfaces of engulfing epithelial M cells are taken up by professional antigen presenting cells along with Tlymphocytes of parafollicular area. Dendritic cells and macrophages in these sites allow mycobacterial replication, due to permissive immunological environment in lymphoepithelial tissues. Abrogation of local delayed type hypersensitivity reactions generally ensures continuing integrity and function of these tissues. Phagocytes containing intracellular mycobacteria disseminate infection to other parts of the body and also probably migrate back onto mucosal surface to shed bacilli. 
Tuberculous lesions of the oral cavity have become so infrequent that it is virtually a forgotten clinical entity. Prevalence of tuberculous lesions in nose, mouth and pharynx even at the peak period in 1930 were reported only in an average of 0.66%.  Though the symptoms are generally very mild and often not more than a sense of discomfort in the throat, the danger lies in disease extending to larynx and eventually leading to pulmonary tuberculosis. This can cause problems in diagnosis. Usually, on first or primary presentation, they appears like neoplasm.  But in ulceroproliferative lesions of oropharynx or oral cavity not responding to antibiotic therapy, diagnosis of tuberculosis should be suspected and confirmed subsequently by tissue biopsy. 
| References|| |
|1.||Shah A, Pande A, Vora IM, Ugale SB. Primary lupus vulgaris of the pharynx (a case report). 1990; 36(2): 106-8. |
|2.||Aktan B, Selimoglu E, Veukeu H, Sutbeyaz Y. Primary nasopharyngeal TB in a patient with complaint of smoking. J Laryngol Otol 2002; 116(4): 301-3. |
|3.||Hajioff D, Snow MH, Thakur H, Wilson JA. Primary TB of posterior oropharyngeal wall. J Laryngol Otol 1999; 113(11): 1029-30. |
|4.||Al Serhani AM, Al-Mazrou K. Pharyngeal TB. Am J Otolaryngol 2001; 22(4): 236-40. |
|5.||Madhuris, Chandermohan, Sharma ML TK. Posterior oropharyngeal wall tuberculosis. Indian J Otolaryngol Head Neck Surg 2002; 54(2): 152-3. |
|6.||Lugton I. Lymphoid mucosa associated lymphoid tissues as sites for uptake, carriage and excretion of tubercle bacilli and other pathogenic mycobacteria. Immunol Cell Biol 1999; 77(4): 364-72. |
|7.||Falek A, Larkowski A, Konieezna A, Orrzanska A. Primary TB of nasopharynx. Otolaryngol Pol 1996; 50(2): 194-9. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]