Tuberculosis of the nasopharynx: clinicopathological features

The clinicopathological features of 10 adult patients with nasopharyngeal tuberculosis (TB) are presented. 9 patients had no evidence of chest or systemic disease. 7 patients presented with cervical lymphadenopathy, and only 4 had nasal symptoms. Examination of the nasopharynx showed no abnormality in 2 patients, lymphoid hyperplasia in 4 patients, and a tumour-like mass in 4 patients. These findings suggest that nasopharyngeal TB may occur more frequently as part of an isolated upper respiratory tract infection than as secondary to pulmonary infection. The nasopharynx may be a portal of entry for tubercle bacilli in patients who develop cervical lymphadenitis. Involvement of the nasopharynx by TB may be underdiagnosed because it does not produce obvious symptoms or physical signs in all cases.     

Pharyngeal tuberculosis

PURPOSE: To increase awareness of tuberculosis (TB) as an important differential diagnosis of lesions in the pharynx and discuss its presentation. PATIENTS AND METHODS: The study included nine patients (2 males and 7 females); each with a diagnosis of primary pharyngeal tuberculosis (PTB). Of these, 3 had nasopharyngeal TB, 5 had tonsillar TB, and 1 had hypopharyngeal TB. The diagnostic criteria were either positive culture, positive smear, or histopathologic features of caseating granuloma consistent with TB in the biopsy specimen and a response to treatment. RESULTS: All patients had primary infection. The main presenting symptom in all nasopharyngeal TB was neck mass, whereas tonsillar TB patients presented with sore throats or discomfort. Dysphagia was the presenting symptom in hypopharyngeal TB. Six patients (3 with nasopharyngeal TB and 3 with tonsillar TB) had cervical adenopathy. The smear for acid-fast bacillus was positive in 4 patients (44.4%); culture was positive in 2 patients (22.2%). Histopathologic features of caseating granuloma, consistent with TB, were positive in all patients who received antituberculous medications. CONCLUSION: Otolaryngologists should consider pharyngeal TB as one of the differential diagnosis of lesions of the pharynx especially in those countries where TB is endemic.     

Tuberculosis of the nasopharynx: a rare entity revisited

OBJECTIVES: Tuberculosis of the nasopharynx is uncommon. A large series of 17 cases is reported, and the clinical and pathological features are discussed. STUDY DESIGN: A retrospective review. METHODS: Seventeen archived cases of biopsy-proven nasopharyngeal tuberculosis were reviewed for patient age and sex, presenting complaint and duration, systemic symptoms, cervical lymphadenopathy, and chest x-ray findings. These findings were compared with a compilation of 40 cases reported in the English literature. RESULTS: There was a female predominance (13 women and 4 men), with age range of 20 to 74 years (mean age, 38 y). The most common presentation was enlargement of the cervical lymph nodes (53%), followed by hearing loss (12%), tinnitus, otalgia, nasal obstruction, and postnasal drip (6% each). The duration of the presenting symptoms ranged from 1 week to 1 year (mean duration, 16 wk). Ten patients (59%) had cervical lymphadenopathy, two (12%) had systemic symptoms (fever, weight loss, night sweats), and one patient (6%) had miliary pulmonary tuberculosis. Direct endoscopic examination showed nasopharyngeal mucosal irregularity or mass in the majority of patients (12 patients [70%]). These features were similar to those reported in the literature. CONCLUSIONS: Nasopharyngeal tuberculosis is uncommon, usually occurring without pulmonary or systemic involvement. Cervical lymphadenopathy occurs in more than half of the patients and is the most common presenting complaint; this, together with the nasopharyngeal findings of mass or mucosal irregularity, makes differentiation from carcinoma on clinical examination difficult, necessitating histological evaluation.     

Routine nasopharyngeal biopsy in adult secretory otitis media.

This study was to determine whether routine examination under anaesthesia and nasopharyngeal biopsy in adults presenting with deafness due to secretory otitis media (SOM) is necessary for detection of nasopharyngeal malignancy. Two patient groups were studied. The first comprised 72 adults with SOM. Of these patients, 3 had nasopharyngeal tumours, 2 of whom also had cervical lymphadenopathy. The prevalence of malignancy in patients with SOM but no other suspicious signs was 1/72 (1.4%). The second group comprised 66 patients receiving treatment for nasopharyngeal neoplasms. In this group, 8 patients had SOM at presentation, 7 of whom had other features suspicious of malignancy. SOM as the sole presenting feature of nasopharyngeal malignancy was 1/66 (1.5%). EUA and biopsy of the nasopharynx is a cost effective investigation which continues to be indicated in adults presenting with deafness due to SOM.     

Routine nasopharyngeal biopsy in adult secretory otitis media

This study was to determine whether routine examination under anaesthesia and nasopharyngeal biopsy in adults presenting with deafness due to secretory otitis media (SOM) is necessary for detection of nasopharyngeal malignancy. Two patient groups were studied. The first comprised 72 adults with SOM. Of these patients, 3 had nasopharyngeal tumours, 2 of whom also had cervical lymphadenopathy. The prevalence of malignancy in patients with SOM but no other suspicious signs was 1/72 (1.4%). The second group comprised 66 patients receiving treatment for nasopharyngeal neoplasms. In this group, 8 patients had SOM at presentation, 7 of whom had other features suspicious of malignancy. SOM as the sole presenting feature of nasopharyngeal malignancy was 1/66 (1.5%). EUA and biopsy of the nasopharynx is a cost effective investigation which continues to be indicated in adults presenting with deafness due to SOM.     

Lymphoepithelioma of the nasopharynx

There is uncertainty as to whether the clinical behavior of nasopharyngeal lymphoepithelioma differs from that of squamous cell carcinoma of the nasopharynx. To determine if significant differences existed, we have studied 39 patients with nasopharyngeal lymphoepithelioma and compared their data with 50 nasopharyngeal squamous cell carcinoma patients. In contrast to squamous cell carcinoma, lymphoepithelioma occurred at a younger age, presented as smaller primary tumors, and manifested more extensive cervical lymph node involvement. When analyzed by T stage, N stage, or overall stage groups, the 5-year actuarial survivals were better in the lymphoepithelioma patients. Late tumor recurrences (beyond 4 years) were seen in the lymphoepithelioma patients, whereas all of the recurrences in the squamous cell carcinoma group occurred within 4 years. Tumor recurrences were more common in the cervical lymph nodes in the lymphoepithelioma group and in the primary site of the squamous cell carcinoma group.     

Endoscopic management of skull base osteoradionecrosis

OBJECTIVE: Osteoradionecrosis is one of the most serious complications in radiotherapy of nasopharyngeal carcinoma. We describe a new endoscopic approach to resolve resultant skull base osteoradionecrosis. The objective of this study is to evaluate the efficacy of endoscopic management of skull base osteoradionecrosis. STUDY DESIGN: A prospective study of the outcome of endoscopic management for patients with skull base osteoradionecrosis. METHODS: Between 1994 and 1998 six patients who had irradiation previously for nasopharyngeal carcinoma had skull base osteoradionecrosis. A sinoscopic approach was applied for diagnosis and sequestrectomy. This diagnosis was based on the criterion of exposed necrotic bone after removing all crust in the nasopharynx and further confirmed on pathological examination after sequestrectomy. Effective cure was defined as intact mucosal coverage without any ulcer or exposed necrotic bone observed in the nasopharynx and the absence of antecedent accompanying symptoms after management. RESULTS: Six patients (10%) were symptom free. Five (83.3%) patients had effective cure. There was no surgical morbidity or mortality. CONCLUSION: Endoscopic sequestrectomy is a justified approach to skull base osteoradionecrosis.     

Marble impaction in the nasopharynx following oral ingestion

Foreign body ingestion is an important emergency occurring in childhood. In this article, we report the case of a 5-year-old girl with marble impaction in the nasopharynx, which had not been discovered by routine X-rays of the chest and abdomen at the time of ingestion. The patient presented 4 months after the event with typical symptoms of adenoid hypertrophy and sinusitis, and the diagnosis was established on the basis of a plain film of the nasopharynx. This rare situation is potentially dangerous, since the foreign body may descend and cause sudden airway obstruction. Therefore, in all cases with vanishing foreign bodies in the aerodigestive system, nasopharyngeal impaction and its fatal consequences should be kept in mind and endoscopic examination of the region should be considered.     

Breast carcinoma metastatic to the nasopharynx

A case report of a patient with adenocarcinoma of the breast with metastasis to the nasopharynx is described. The patient presented initially with pulmonary metastasis followed later by metastasis to the left jugulo-digastric lymph nodes. A prominent but asymptomatic nasopharyngeal mass was concomitantly discovered on head and neck examination. Three months later, symptoms of panhypopituitarism developed. Invasion of the base of the skull and pituitary were documented. Patients with adenocarcinoma of the breast and high cervical node metastasis should have a thorough otolaryngologic and head and neck evaluation. Metastatic carcinoma to the nasopharynx is an extremely rare occurrence. Only two cases of bronchogenic carcinoma of the lung and two cases of hypernephroma metastatic to the nasopharynx have been reported in the literature (Bernstein et al., 1966). We present what we believe to be the first case of metastatic adenocarcinoma of the breast to the nasopharynx.     

Outcome of acute otitis media and its relation to clinical features and nasopharyngeal colonization at the time of diagnosis

Children (n = 115; age range 1-9 years) with a diagnosis of acute otitis media (AOM) were eligible for this study and were enrolled within 24 h of the onset of symptoms/signs. A nasopharyngeal culture was obtained at the initial visit. Children were treated with a single oral antibiotic for 7 days. Changes in symptoms/signs and tympanic membrane features assessed by a scoring system were monitored for 1 month and related to the nasopharyngeal pathogen recovered on Day 1. More than 80% of children had no symptoms/signs by Day 3, and 60% of cases had normal tympanic membranes by Day 29. Children without any symptoms/signs on Day 3 had significantly lower symptom/sign scores on Day 1 (p = 0.005). Seventy-nine percent of cases carried middle ear pathogens in the nasopharynx at diagnosis: Streptococcus pneumoniae (48%); Haemophilus influenzae (24%); and Moraxella catarrhalis (16%). Children with S. pneumoniae showed significantly higher tympanic membrane scores than children with no pathogen at Days 8, 15 and 29 (p < 0.01 for each comparison). Multivariate regression analysis revealed that lower tympanic membrane score on Day 1, the absence of S. pneumoniae in the nasopharynx and treatment with amoxillin were independent factors for rapid normalization of the tympanic membrane. These data suggest that the clinical course of AOM may be predicted, in part, at the time of diagnosis by means of careful evaluation of symptoms/signs and the tympanic membrane as well as knowledge of pathogens harbored in the nasopharynx.     

Outcome of Acute Otitis Media and its Relation to Clinical Features and Nasopharyngeal Colonization at the Time of Diagnosis

Children ( n = 115; age range 1-9 years) with a diagnosis of acute otitis media (AOM) were eligible for this study and were enrolled within 24 h of the onset of symptoms signs. A nasopharyngeal culture was obtained at the initial visit. Children were treated with a single oral antibiotic for 7 days. Changes in symptoms signs and tympanic membrane features assessed by a scoring system were monitored for 1 month and related to the nasopharyngeal pathogen recovered on Day 1. More than 80% of children had no symptoms signs by Day 3, and 60% of cases had normal tympanic membranes by Day 29. Children without any symptoms signs on Day 3 had significantly lower symptom sign scores on Day 1 ( p = 0.005). Seventy-nine percent of cases carried middle ear pathogens in the nasopharynx at diagnosis: Streptococcus pneumoniae (48%); Haemophilus influenzae (24%); and Moraxella catarrhalis (16%). Children with S. pneumoniae showed significantly higher tympanic membrane scores than children with no pathogen at Days 8, 15 and 29 ( p < 0.01 for each comparison). Multivariate regression analysis revealed that lower tympanic membrane score on Day 1, the absence of S. pneumoniae in the nasopharynx and treatment with amoxillin were independent factors for rapid normalization of the tympanic membrane. These data suggest that the clinical course of AOM may be predicted, in part, at the time of diagnosis by means of careful evaluation of symptoms signs and the tympanic membrane as well as knowledge of pathogens harbored in the nasopharynx.     

Primary radiation therapy for juvenile nasopharyngeal angiofibroma

Evidence is presented of the effectiveness and relative lack of serious toxicity of external beam megavoltage radiation therapy (RT) as primary treatment for juvenile nasopharyngenl angiofibroma. The importance of careful radiological evaluation of tumor extent prior to irradiation is stressed, and only moderate dose RT is required. Fifty-five patients have been treated by RT and followed for from 3 to 26 years. Forty-four of 55 patients (80%) had permanent tumor control following a single course of 3000 cGy to 3500 cGy over 3 weeks. Surgical resection or a second course of RT controlled the tumor in all 11 patients in whom regrowth occurred. Angiofibromas involute slowly after RT so that 50% of patients still had visible masses in the nasopharynx 12 months after treatment, but only 10% had any visible abnormality 36 months after RT. Retreatment was necessary only if symptoms recurred, and continued follow-up showed that most asymptomatic nasopharyngeal masses resolved completely. Acute and late toxicity rates were low. Two patients developed tumors in the head or neck following RT. There was no significant clinical impairment of growth or endocrine function. A single course of external beam megavoltage radiation to 3000 cGy in 3 weeks is an effective first treatment for patients with juvenile nasopharyngeal angiofibroma.     

Tuberculosis in ear, nose, and throat practice: its presentation and diagnosis

PURPOSE: The aim of this study was to increase awareness of the different presentations of head and neck tuberculosis (TB) and to discuss its diagnostic difficulties. MATERIALS AND METHOD: A retrospective analysis of patients who presented to us, at a secondary referral hospital, primarily with TB of head and neck was done from January 1999 to July 2003. RESULTS: A total of 117 patients presented with primary head and neck TB during the study period. Most of these (95%) had cervical lymphadenopathy, 2 patients had laryngeal TB, and there was 1 patient each of TB of cervical spine, oropharynx, ear, and retropharyngeal abscess. Forty-one were males, and 76 were females. Thirty percent of cases had associated lung or other organ TB. Nine percent gave history of previous or subsequent TB. CONCLUSIONS: 1) Diagnosing TB requires a high index of suspicion. 2) Tuberculosis of the cervical lymph nodes is the commonest presentation followed by laryngeal TB. 3) Fine needle aspiration cytology (FNAC) is a reliable and easy way to diagnose TB. However, newer diagnostic tests will increase the yield of positive cases and should be used whenever required. 4) In the larynx, the vocal cords were the commonest site affected and laryngeal TB need not be associated with lung TB or positive sputum always. 5) Patients who have TB of head and neck must be investigated to exclude pulmonary or systemic TB. 6) In cases of previous or subsequent TB infection, culture and drug sensitivity is indicated to reduce the problem of multiple drug resistance.     

Nasopharyngeal amyloidosis

PURPOSE: To discuss the presentation of localized amyloidosis affecting the nasopharynx and discuss the management options. Amyloidosis in the head and neck is a rare and benign condition that usually takes the form of localized amyloidosis. Because systemic amyloidosis markedly shortens life expectancy owing to its involvement with vital organs, rectal biopsy or fat aspiration of the anterior abdominal wall must be carried out to exclude systemic involvement. Localized amyloidosis in the head and neck can involve the orbit, sinuses, nasopharynx, oral cavity, salivary glands, and larynx. METHODS: We present the case of a patient with conductive hearing loss and serous otitis media with effusion secondary to nasopharyngeal amyloidosis, as well as present a review of the literature. RESULTS: Only a few cases of nasopharyngeal amyloidosis have thus far been reported. Patients with this disease can also present with recurrent epistaxis, postnasal drip, nasal obstruction, and eustachian tube dysfunction. Localized amyloidosis of the nasopharynx, which is slow growing, has proved difficult to treat because it can persist or recur despite surgical treatment. Furthermore, bleeding may be a major complication in treating patients with nasopharyngeal amyloidosis by transpalatal excision because the amyloid deposits cause vascular wall fragility. Finally, there is no evidence that surgical treatment of nasopharyngeal amyloidosis can prolong survival or that localized amyloidosis can progress to systemic amyloidosis. For these reasons, we elected to treat our patient with a tympanostomy tube and observation. CONCLUSION: In the absence of systemic disease, localized amyloidosis of the nasopharynx may be treated conservatively.     

Significance of the involvement of parapharyngeal space cervical nodes and cranial nerves in nasopharyngeal carcinoma

Two hundred cases of nasopharyngeal carcinoma (NPC) admitted to this department from Feb. 1985 to May. 1988 were analysed according to the CT scanning and clinical findings of the primary lesions prior to radiotherapy. The results showed that involvement of parapharyngeal space was very common in NPC, about 80% (160/200 cases); particularly unilateral or bilateral retro-styloid spaces, about 69.5% (139/200 cases). It was proposed that patients with NPC had a high incidence of ipsilateral cervical node metastasis. Contralateral cervical node metastasis was rare. The development of cervical node metastasis in NPC has to modes: one is direct infiltration of the retro-styloid space by the lesion; the other is along the nasopharyngeal lymphatic rete. The data also showed that patients with NPC who presented symptoms of IX-XII cranial nerve paralyses always had ipsilateral or bilateral retro-styloid space infiltrations.     

Primary nasopharyngeal tuberculosis in a patient with the complaint of snoring

Isolated nasopharyngeal tuberculosis is a rare condition, even in endemic tuberculosis areas. The most common presentation of nasopharyngeal tuberculosis is with a cervical lymphadenopathy followed by nasal discharge or obstruction. Here we present a 58-year-old patient with nasopharyngeal tuberculosis whose only complaint was snoring. Her oropharyngeal and anterior rhinoscopic examination was normal. On endoscopic examination, mucosal oedema and hyperaemia of the nasopharynx was observed. There was no cervical lymphadenopathy. The tuberculin skin test was positive and histopathological examination of the biopsy taken from posterior nasopharyngeal wall supported the diagnosis of tuberculosis. After anti-tuberculosis therapy, the snoring stopped and the nasopharyngeal examination was normal.     

Routine nasopharyngeal biopsy in adults presenting with isolated serous otitis media: is it justified?

Nasopharyngeal malignancy accounts for less than 2 per cent of all head and neck cancers. Serous otitis media (SOM) causing deafness is a recognized indicator of nasopharyngeal obstruction and the possibility of a nasopharyngeal malignancy must be considered in all adults. Examination under anaesthesia (EUA) and biopsy of the nasopharynx is routinely undertaken in many centres to rule out nasopharyngeal malignancy in adults with SOM. The purpose of this 10-year retrospective study was to evaluate the case records of all adult cases of SOM, including their presentation, clinical findings, management and nasopharyngeal biopsy results. Eighty-five patients were included in the study. Fifty-nine presented with unilateral SOM and 26 with bilateral SOM. The primary presenting complaint in all cases was hearing loss. A nasopharyngeal mass was documented in 55 patients (69 per cent). Four nasopharyngeal masses were noted to have irregular or exophytic mucosa on flexible nasendoscopy. All patients underwent a EUA of the ears and a nasopharyngeal biopsy. The four patients with suspicious-looking masses were all found to have malignancies (two squamous cell carcinomas, one B-cell non-Hodgkin lymphoma and one adenocarcinoma). Three of these patients presented with unilateral SOM and one with bilateral SOM. All other patients with masses were found to have benign lymphoid hyperplasia. In total, 4.7 per cent of the adults with conductive hearing loss secondary to SOM were found to have a malignancy on nasopharyngeal biopsy. We would advocate a high index of suspicion of a nasopharyngeal tumour in adults presenting with SOM. If a mass is found in the nasopharynx then it should be biopsied. If no mass is found then it is not necessary to biopsy; however, close follow up, with repeat fibre-optic nasendoscopy, is advised.     

以颈淋巴结肿大为首发表现的鼻咽粘膜下型癌4例报告

目的：加深对以颈上深淋巴结肿大为首发表现的鼻咽粘膜下型癌的认识。方法：报告４例本病患者的临床资料。结果：４例直至发现颈部淋巴结肿大３￣６个月后,才得以确诊为鼻咽粘膜下型癌;均行放疗加化疗,３例在１年内死亡,１例尚生存。结论：对颈上深部淋巴结肿大,首先应考虑为鼻咽粘膜下型癌的转移癌。即使细胞学、ＶＣＡ－ＩｇＡ、ＣＴ、ＭＲＩ、鼻咽部等检查均为阴性,有的甚至已确诊为淋巴结核瘤,但仍不能排除鼻咽粘膜下型癌     

Tuberculous parotitis: case report and literature review

OBJECTIVES: Our aim was to better understand the rarely encountered tuberculous (TB) parotitis. METHODS: A case of TB parotitis is reported, and the literature is reviewed. RESULTS: Forty-nine patients (27 men, 22 women; mean age, 38.3 +/- 16.4 years) were enrolled. The median duration of symptoms before these patients sought medical help was 6 months. Except for 1 patient with bilateral TB parotitis, all had unilateral involvement; complications included draining sinuses in 4 patients (8%) and facial palsy in 2 patients (4%). Twenty-one of 36 patients (58%) had a painless parotid mass, 12 of 19 (63%) had cervical lymphadenitis, 8 of 11 (73%) had fever, and 11 of 44 (25%) had pulmonary tuberculosis (4 active and 7 inactive cases). Neoplasm was the most common presumptive diagnosis. The diagnosis of TB parotitis in most cases was made on the basis of cytologic analysis of the fine-needle aspirate or histopathologic analysis of the excised tissue. Forty-six patients with TB parotitis who had a traceable outcome survived after 6 to 10 months of antituberculosis chemotherapy. CONCLUSIONS: Physicians should have a high index of suspicion for TB parotitis in patients with a chronic parotid lump, even if the chest radiographs appear normal. Fine-needle aspiration should be performed first for diagnosis, and TB parotitis should be medically treated.     

Nasopharyngeal hamartoma: importance of routine complete nasal examination

The authors report clinical experience in managing an 82-year-old female presenting with long-standing bilateral nasal obstruction resulting from a nasopharyngeal mass. The patient had undergone a number of treatments including surgery. The previous examinations, investigations and treatment had all been performed within the previous 10 years and although examination had been documented there was no evidence on review of the notes that the nasopharynx had been inspected either by nasendoscopy or indirectly. The mass was removed via a combined nasal and oral approach. Histopathological examination of the specimen was consistent with mesenchymal hamartoma. In addition to describing a rare presentation the authors believe this case highlights the importance of complete examination in all patients with nasal symptoms.