Tuberculosis is a chronic infectious disease caused by infection with Mycobacterium tuberculosis. It can affect multiple organs throughout the body, but pulmonary tuberculosis is the most common form. Tuberculosis of the ear, nose, throat, and head and neck region is typically secondary to pulmonary or gastrointestinal tuberculosis, with primary cases being rare.
Tuberculosis in this region most commonly affects the larynx, followed by the pharynx, the ear, and, less frequently, the nose. A detailed description is provided below.
Laryngeal Tuberculosis
Primary laryngeal tuberculosis is rare and usually occurs secondary to severe pulmonary tuberculosis or tuberculosis of other organs. The disease spreads through direct contact, the bloodstream, or the lymphatic system. Contact infection in the larynx often results from sputum containing M. tuberculosis adhering directly to the laryngeal mucosa or mucosal folds, with damaged mucosa being more susceptible to infection.
Pathology
Three primary pathological processes—exudation, degeneration, and proliferation—are observed. These processes are classified into three major types:
- Infiltrative Type: Characterized by localized mucosal congestion and edema, with lymphocyte infiltration in the submucosa forming nodules.
- Ulcerative Type: Central caseous necrosis occurs in tuberculous nodules, forming tuberculous ulcers. Secondary infections are common, and the ulcers exhibit irregular edges and surrounding submucosal infiltration. The ulceration may extend to the perichondrium, causing perichondritis.
- Proliferative Type: Late-stage infiltration leads to fibroblastic proliferation. When the disease improves, healing may occur with scar formation, while some lesions may develop into tuberculomas.
Clinical Presentation
Early symptoms are non-specific and may include burning or dryness in the throat. Hoarseness becomes the primary symptom, starting mildly and progressing to complete loss of voice in the late stages. Pain in the larynx, which worsens during swallowing, is common. In cases where the perichondrium is involved, the pain can be intense. Extensive laryngeal lesions may result in respiratory difficulty due to granulation tissue proliferation and soft tissue swelling. Systemic manifestations of pulmonary tuberculosis, such as coughing, sputum production, fever, weight loss, and anemia, are often present. Laryngoscopy may reveal pale laryngeal mucosa, congested lesions typically in the interarytenoid region or on one vocal cord, and ulcerations with irregular, undermined edges and granulation tissue at the base. Edema and thickening of the epiglottis or aryepiglottic fold may be observed. In advanced cases, involvement of the cricoarytenoid joint can limit or fix vocal cord movement. Extensive lesions may result in cicatricial stenosis of the larynx.
Treatment
Systemic anti-tuberculosis therapy is emphasized in combination with supportive care and voice rest. In severe cases of respiratory distress, tracheotomy may be necessary.
Pharyngeal Tuberculosis
Nasopharyngeal tuberculosis often presents as mucosal ulceration or granuloma formation, with symptoms such as nasal obstruction, rhinorrhea, and hearing loss. Pathological examination confirms the diagnosis. Oropharyngeal and hypopharyngeal tuberculosis can manifest in two forms: acute miliary type or chronic ulcerative type.
Acute Miliary Type
Secondary to active pulmonary tuberculosis or miliary tuberculosis, this type features systemic toxic symptoms, severe pharyngeal pain that radiates to the ears, and worsens during swallowing. Examination reveals pale pharyngeal mucosa with scattered millet-seed-sized nodules on the soft palate, palatal arches, or posterior pharyngeal wall. These nodules may rapidly progress into shallow ulcers with irregular edges and foul exudates covering their surfaces.
Chronic Ulcerative Type
This type most commonly affects the palatal arches or posterior pharyngeal wall. It is characterized by pale, edematous mucosa and localized ulcers that progress slowly over time. Deep ulceration may cause perforation of the soft palate, defects in the palatal arches or uvula, and complications such as cicatricial stenosis or deformities after healing. Nasopharyngeal tuberculosis may lead to nasopharyngeal occlusion. Tuberculosis involving the palatine tonsils or adenoids is often asymptomatic and identified only upon histopathological examination after surgical removal.
Treatment focuses on anti-tuberculosis therapy. Severe pain may be temporarily alleviated through spraying the pharynx with 0.5%–1% dicaine solution. Ulcers may be treated topically with 30% trichloroacetic acid or 20% silver nitrate. Cicatricial stenosis or occlusion may require surgical intervention.
Otic Tuberculosis
Tuberculous otitis media is more common than external ear tuberculosis. Most cases develop secondary to pulmonary tuberculosis or from nasopharyngeal or cervical lymphatic tuberculosis. The onset is insidious, with painless otorrhea that is relatively thin and watery. Hearing impairment occurs early, initially presenting as conductive hearing loss and progressing to mixed hearing loss or total deafness if the inner ear is involved. Characteristic findings include large, solitary perforations in the tense part of the tympanic membrane, often extending to the annulus. In the absence of secondary pyogenic infection, the tympanic mucosa typically appears pale, with granulation tissue growth. Facial nerve paralysis and vertigo may result from destruction of the bony labyrinth or facial nerve canal. Lateral mastoid bone wall destruction may lead to post-auricular fistulae.
Temporal bone CT scans typically demonstrate destruction of the tympanic cavity and mastoid with soft tissue filling the area, often revealing sequestra. Intracranial involvement may lead to complications such as tuberculous meningitis.
Treatment primarily involves systemic anti-tuberculosis medications. Surgery, including mastoidectomy, may be considered for sequestra, fistula formation, poor drainage, or facial paralysis, provided the patient’s general health permits.、
Nasal Tuberculosis
Nasal tuberculosis is rare and predominantly secondary. It is generally classified into ulcerative and granulomatous types. Local symptoms are often mild, and lesions are commonly found in the anterior portion of the nasal septum, the skin of the nasal vestibule, the floor of the nasal cavity, and the anterior portion of the inferior turbinate. Ulcerative lesions are more common and typically present as shallow superficial ulcers with scabs. Beneath the scabs, the tissue appears pale, soft, and granular, and bleeding occurs upon contact. Deep lesion progression can lead to cartilage destruction, causing nasal deformities such as alar abnormalities and nasal septum perforation.
Systemic anti-tuberculosis therapy is the primary treatment method. Local treatments include using 0.5% streptomycin solution as nasal drops or cauterizing ulcer surfaces with 30% trichloroacetic acid solution.
Cervical Lymph Node Tuberculosis
Cervical lymph node tuberculosis is typically secondary. Local manifestation is classified into nodular, infiltrative, abscess, and ulcerative-sinus types. Mild cases may not show systemic discomfort, while severe cases may present with symptoms such as low-grade fever, fatigue, and night sweats. Fine-needle aspiration biopsy of the affected lymph nodes generally confirms the diagnosis. For cases where the diagnosis remains uncertain, tissue biopsy is used. Differential diagnosis includes distinguishing this condition from chronic lymphadenitis, metastatic carcinoma, malignant lymphoma, and other cervical masses.
Systemic anti-tuberculosis therapy is the mainstay of treatment. For nodular or infiltrative types that do not shrink with systemic therapy, surgical removal of the affected lymph nodes may be performed. Abscess-type cervical lymph node tuberculosis may require incision and drainage, and for cases with sinus formation, complete removal of the sinus tract is recommended.