PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 34 no. 2 July – december 2019
PhiliPPine Journal of otolaryngology-head and neck Surgery 76 PhiliPPine Journal of otolaryngology-head and neck Surgery
ORIGINAL ARTICLES
ABSTRACT
Objective: This study aimed to determine the prevalence of nasopharyngeal tuberculosis
among patients who were initially assessed to have a nasopharyngeal mass and subsequently
underwent biopsy in a Philippine Tertiary General Hospital from Year 2013 to 2015.
Methods:
Design: Case Series
Setting: Tertiary National University Hospital
Participants: All patients with nasopharyngeal mass identified from January 2013
to December 2015 from a hospital wide census who underwent biopsy were investigated using
chart and histopathology review. The prevalence of tuberculosis, malignancies and other findings
were determined.
Results: Among 285 nasopharyngeal biopsies done between 2013 and 2015, 33 (11.6%) were
histologically compatible with nasopharyngeal tuberculosis, 177 (62.1%) were different types of
nasopharyngeal carcinoma, 59 (20.7%) were chronic inflammation, 4 (1.4%) were lymphoma, 5
(1.8%) were normal, and 7 (2.5 %) had diagnoses other than those above..
Conclusion: This study suggests a relatively high prevalence rate (11.6%) of nasopharyngeal
tuberculosis in patients who have a nasopharyngeal mass. This indicates that nasopharyngeal
tuberculosis should always be a differential when confronted with a mass in the nasopharynx
especially in tuberculosis endemic areas.
Keywords: nasopharyngeal tuberculosis; prevalence; censuses; tertiary care centers; Philippines;
carcinoma; nasopharynx; biopsy; tuberculosis; lymphoma
While the majority of tuberculosis infection is found in the lungs, tuberculosis can manifest
in the head and neck region including cervical lymph nodes, parotid, the larynx, middle ear and
tonsils.1-4 Nasopharyngeal tuberculosis (NPTB) is rarer and to the best of our knowledge, has been
characterized in only a few case reports and series worldwide. There has only been one published
case report in the Philippines.5
Nasopharyngeal Tuberculosis
in a Philippine Tertiary General Hospital
Mark Anthony T. Gomez, MD, MPM-HSD1
Romeo L. Villarta, Jr., MD, MPH1,2
Ruzanne M. Caro, MD3
Criston Van C. Manasan, MD4
Jose M. Carnate, Jr., MD5
1Department of Otorhinolaryngology
Philippine General Hospital
University of the Philippines Manila
2Department of Epidemiology and Biostatistics
College of Public Health
University of the Philippines Manila
3Department of Otorhinolaryngology
College of Medicine – Philippine General Hospital
University of the Philippines Manila
4Department of Laboratories
Philippine General Hospital
University of the Philippines Manila
5Department of Pathology
College of Medicine
University of the Philippines Manila
Correspondence: Dr. Jose M. Carnate, Jr.
Department of Pathology
Philippine General Hospital
Taft Avenue, Ermita, Manila 1000
Philippines
Phone: (632) 8554 8400 local 3200
Email: jmcjpath@yahoo.com
The authors declared that this represents original material
that is not being considered for publication or has not been
published or accepted for publication elsewhere in full or in
part, in print or electronic media; that the manuscript has been
read and approved by all the authors, that the requirements
for authorship have been met by each authors, and that each
author believes that the manuscript represents honest work.
Disclosures: The authors signed disclosures that there are no
financial or other (including personal) relationships, intellectual
passion, political or religious beliefs, and institutional
affiliations that might lead to a conflict of interest.
Presented at the Philippine Society of Otolaryngology Head
and Neck Surgery Annual Convention Free Paper Forum,
December 2, 2017, The Manila Hotel.
Philipp J Otolaryngol Head Neck Surg 2019; 34 (2): 7-10 c Philippine Society of Otolaryngology – Head and Neck Surgery, Inc.
Creative Commons (CC BY-NC-ND 4.0)
Attribution - NonCommercial - NoDerivatives 4.0 International
PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 34 no. 2 July – december 2019
PhiliPPine Journal of otolaryngology-head and neck Surgery 98 PhiliPPine Journal of otolaryngology-head and neck Surgery
ORIGINAL ARTICLES
years old. The mean age of patients with nasopharyngeal carcinoma
was 47.84 years old while the mean age of patients with nasopharyngeal
tuberculosis was younger at 29.15 years old. The mean age of patients
with chronic inflammation and lymphoma were 38.82 and 40.5 years old,
respectively. The youngest patients with NPCA, chronic inflammation,
NPTB and lymphoma were 15, 15, 14 and 17 years old, respectively. The
oldest patients with NPCA, chronic inflammation, NPTB and lymphoma
were 78, 70, 60 and 66 years old, respectively.
The patients had variable distributions among different age groups.
The distribution of disease according to age group is shown in Table 1.
In terms of sex, the ratio of nasopharyngeal carcinoma and chronic
inflammation were almost the same at 3:1. On the other hand, the sex
ratio for nasopharyngeal tuberculosis and lymphoma were the same
and equal at 1:1. The distribution of patients is shown in Table 2.
Of the 33 patients with NPTB, only seven complete patient charts
were retrieved. Most of the records of other patients had been transferred
to their local Tuberculosis Treatment Center or were missing. Among
the seven patients whose complete charts were reviewed, two had a
previous history of pulmonary tuberculosis and had been treated with
anti-tuberculosis chemotherapy and one had a history of unrecalled
chronic lung illness which could also be pulmonary tuberculosis. All
the seven patients had presence of cervical lymphadenopathy which
prompted the initial medical consult. There was no mention of history
of Human Immunodeficiency Virus infection, multidrug resistant
tuberculosis infection or diabetes mellitus in the charts of the seven
NPTB patients.
Table 1. Distribution of Disease according to Age Group
Age
Group
(years)
Nasopharyngeal
Carcinoma (%)
N=177
Nasopharyngeal
Tuberculosis (%)
N=33
Chronic
Inflammation (%)
N=59
Lymphoma
(%) N=4
14-20
21-55
56-70+
5 (2.8%)
127 (71.8%)
45 (25.4%)
10 (30.3%)
20 (60.6%)
3 (9%)
9 (15.3%)
38 (64.4%)
12 (20.3%)
1 (25%)
2 (50%)
1 (25%)
Based on available literature, NPTB usually presents with nasopha-
ryngeal mass associated with cervical lymphadenopathy as well as na-
sal, ocular and otologic symptoms.6-10 These findings overlap with the
clinical presentation of nasopharyngeal malignancies, posing impor-
tant diagnostic and therapeutic issues.6,11-15
The study aimed to determine the prevalence of nasopharyngeal
tuberculosis among patients who underwent nasopharyngeal biopsy
in the Philippine National University Hospital from January 2013 to
December 2015.
METHODS
With Institutional Ethical and Technical Review Board approval
(UPMREB ORL - 2016-387-01), this descriptive case series sought to
review records of patients of any age who were previously assessed
to have a nasopharyngeal mass on endoscopy and who eventually
underwent nasopharyngeal mass biopsy at the Philippine General
Hospital from January 1, 2013 to December 31, 2015.
Patients who underwent nasopharyngeal mass biopsies were
initially identified from the Department of Otorhinolaryngology census
and logbooks of the in-patient and out-patient operating rooms.
Records were retrieved by the first author and basic demographic
(age and sex) and histopathologic data were collated and recorded
using Microsoft Office Professional Plus 2010 for Windows (Microsoft
Corporation, Redmond, WA USA).
Excluded were patients whose biopsies were deferred due to other
health reasons, who underwent intranasal (instead of nasopharyngeal)
mass biopsies and those with incomplete entries. Patients who had
previous recurrences of the condition and appeared twice in the
registry were considered as one patient.
The final histopathological diagnoses were retrieved from the
database of histopathology results at the Department of Laboratories.
Full hospital chart reviews were attempted on all patients with NPTB.
Descriptive statistics were used to define demographics and
summarize and describe the data. The prevalences of each of the
diagnosis were computed based on the data. The different prevalences
were then described.
RESULTS
Among the 285 nasopharyngeal biopsies we identified between
2013 and 2015, 33 (11.6%) were histologically compatible with
nasopharyngeal tuberculosis (NPTB), 177 (62.1%) were different types
of nasopharyngeal carcinoma (NPCA), 59 (20.7%) were interpreted as
chronic inflammation, four (1.4%) were lymphoma, five (1.8%) were
normal, and seven (2.5 %) were diagnosis other than those mentioned.
The mean age of all patients with nasopharyngeal mass was 43.47
Table 2. Distribution of Disease according to Sex
Diagnosis
Male (%) Female (%)
Sex
NPCA (N=177)
NPTB (N=33)
Chronic Inflammation (N=59)
Lymphoma N=4
132 (74.6%)
17 (51.5%)
45 (76.3%)
2 (50%)
45 (25.4%)
16 (48.5)
14 (23.7%)
2 (50%)
PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 34 no. 2 July – december 2019
PhiliPPine Journal of otolaryngology-head and neck Surgery 98 PhiliPPine Journal of otolaryngology-head and neck Surgery
ORIGINAL ARTICLES‰
DISCUSSION
Nasopharyngeal Tuberculosis (NPTB) has been described prior to
the advent of the anti-tuberculosis antibiotics in 1936 by Graff who
identified a high presence (82%) of nasopharyngeal tuberculosis by
histology in 118 pulmonary tuberculosis cases.16 After the emergence
of anti-tuberculosis medications, there was a dramatic decrease in
cases of nasopharyngeal tuberculosis. A 1976 survey of 843 cases
of pulmonary tuberculosis by Rohwedder found 16 patients with
tuberculosis of the upper respiratory tract and only one of these had
nasopharyngeal tuberculosis.17 The recent worldwide upsurge in the
incidence of nasopharyngeal tuberculosis in the literature could be
due to increased awareness of disease, improvement of knowledge
regarding the entity, improved diagnostic techniques and of course,
increase in incidence of the disease itself.6
Most of the literature on the topic is only in the form of case reports
and series that were gathered over many years and are not enough to
give a clear picture of the prevalence of the illness. As of this writing,
we could find no other studies detailing its prevalence. Based on
our study, the prevalence of NPTB can reach as high as 1.1 for every
10 nasopharyngeal biopsies. This prevalence of nasopharyngeal
tuberculosis is second only to nasopharyngeal carcinoma and even
higher than lymphoma.
There are several important implications of the results of our study.
First, clinicians usually have two main differential diagnoses when faced
with a nasopharyngeal mass –nasopharyngeal carcinoma or lymphoma.
The results of our study would add nasopharyngeal tuberculosis to the
differentials especially in areas where tuberculosis is endemic. These
three diagnoses each entail totally different managements and accurate
diagnosis is necessary to provide proper treatment. The additional
differential should guide other medical specialists. Pathologists must
thoroughly analyse histopathologic slides especially those with chronic
inflammatory patterns because hidden in the sea of inflammatory cells
might be islands of tuberculosis or granulomatous lesions that may be
overlooked. Pathologists should also be careful in making diagnosis
because concomitant TB infection of the nasopharynges of patients
with nasopharyngeal carcinoma may be present.18 Radiologists should
consider the possibility of nasopharyngeal tuberculosis in interpreting
CT Scans of patients with a nasopharyngeal mass. The possibility of
nasopharyngeal tuberculosis should also be mentioned in patient
education, and patient anxiety may be decreased by the knowledge
that not all nasopharyngeal masses are cancer.
There are also important implications related to the safety of
clinicians. Although it is the usual practice for otorhinolaryngologists
to wear standard personal protective equipment in performing
nasopharyngeal biopsies, the high prevalence of tuberculosis in
patients with nasopharyngeal mass will require additional precautions
such as wearing N95 masks instead of regular masks and ultraviolet
disinfection after surgery. As patients with nasopharyngeal tuberculosis
may have other co-morbidities such as HIV infection, these additional
precautionary measures mentioned are well-justified.
Diagnosis of NPTB in previous reports were done initially by nasal
endoscopy, biopsy and culture of tuberculous bacilli from secretions and
nasopharyngeal tissue. Histopathology of the biopsied nasopharyngeal
may also be helpful since results of TB culture may cause delays in
diagnosis up to 6 weeks.6 Additional radiologic examinations may also
be helpful such as CT scan and MRI.6 A study in China reported that a
presence of necrosis and striped pattern in nasopharyngeal lesions and
lack of invasion of regional structures as seen in CT and MRI of 36 NPTB
patients may suggest the diagnosis of NPTB instead of malignancy.19
In terms of management, previous reports differed in the duration of
anti-tuberculosis treatment. Some had the minimal six-month course
of triple combination therapy that included isoniazid, rifampicin and
ethambutol. Others were treated with nine months of quadruple
therapy (adding an initial short course of pyrazinamide). There is
even a study in China which used an oral anti tuberculosis regimen of
3HRZS(E)/9HR(E) for one year combined with nasal spray combination
medication of isoniazid, rifampicin and streptomycin injection solution
for 3 months.20 However, to the best of our knowledge, there have been
no published recommendations on the proper diagnosis, treatment and
monitoring of response to treatment specifically for nasopharyngeal
tuberculosis. While this may reflect the global rarity of the disease,
further studies must be performed in tuberculosis endemic countries
like the Philippines to evaluate the means of diagnosis and treatment
response of nasopharyngeal tuberculosis so that management can be
optimised to prevent development of multiple drug resistance.
There were at least two patients in our study with a past history of
previously treated pulmonary tuberculosis. Although it is not known
whether the nasopharyngeal tuberculosis appeared before or after
pulmonary tuberculosis treatment, this finding could mean that the
nasopharyngeal tuberculosis in these patients may not have been
affected by the initial treatment given or may have developed despite
treatment. Although there have been no studies that state the clear
association between disseminated tuberculosis and development
of multi-drug resistant tuberculosis, having multiple sites in a
patient might trigger the development of resistance especially if the
other sites are not known or undiagnosed. For example, a known
pulmonary tuberculosis patient with a hidden or undiagnosed
nasopharyngeal component will only be given six months of initial
pulmonary tuberculosis treatment. Because an extrapulmonary site
is involved, nasopharyngeal tuberculosis might need a longer anti-
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PhiliPPine Journal of otolaryngology-head and neck Surgery 1110 PhiliPPine Journal of otolaryngology-head and neck Surgery
ORIGINAL ARTICLES
tuberculosis treatment regimen or additional medications on top of
the usual medications for pulmonary tuberculosis. The treatment for
such a hypothetical patient may only be enough for the pulmonary
involvement but insufficient for the nasopharyngeal disease which
may lead to development of drug resistance. Moreover, should nasal
endoscopy be recommended to search for nasopharyngeal masses
in patients with pulmonary tuberculosis prior to treatment? Further
studies are needed in this regard.
There are several limitations of our study. The purely observational
and descriptive study design makes it only a preliminary study to
generate epidemiological knowledge and local information among
Filipinos. The study only involved a database review and it is possible
that not all data were available. The study only sought to establish a local
picture of nasopharyngeal tuberculosis using the limited data gathered
within a tertiary general hospital. Even if it is the National University
Hospital, many other regions of the country were not represented by
the study population and our findings may not be generalizable to
them.
In conclusion, this study suggests a relatively high prevalence
rate of nasopharyngeal tuberculosis (11.6%) in patients who have
a nasopharyngeal mass. Although nasopharyngeal carcinoma
(62.1%) remains to be the most common diagnosis, nasopharyngeal
tuberculosis should always be a differential aside from lymphoma
(1.8%) when confronted with a mass in the nasopharynx in areas with
high tuberculosis endemicity.
ACKNOWLEDGEMENTS
We would like to thank Dr. Cristina C. Arcinue - Gomez for assistance with data collection and
initial editing of the manuscript. We would also like to express our gratitude to Dr. Jose Florencio F.
Lapeña Jr. for helping us rewrite the manuscript. Lastly, we are also immensely grateful to the nurses
of the TB-DOTS office and personnel of the Records Section at the Philippine General Hospital for their
time and effort in helping us retrieve the patient records within their respective offices.
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