Indian Journal of Medical Microbiology, Vol. 29, No. 1, January-March, 2011, pp. 63-65
Tuberculosis of nose and palate with vanishing uvula
B Baruah1, A Goyal1, NB Shunyu1, ZA Lynrah1, V Raphael2
1 Department of ENT, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Mawdiangdiang, Shillong - 793 018, Meghalaya, India
Correspondence Address: A Goyal, Department of ENT, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Mawdiangdiang, Shillong - 793 018, Meghalaya, India, email@example.com
Date of Submission: 17-May-2010
Code Number: mb11015
AbstractDuring the past two decades, tuberculosis - both pulmonary and extrapulmonary - has re-emerged as a major health problem worldwide. Nasal tuberculosis - either primary or secondary to pulmonary tuberculosis or facial lupus - is rare, but it should be considered in the differential diagnosis of nasal granulomas. We describe a case of tuberculosis in an adult male who presented with palatal perforation with vanishing uvula and arch deformity of the palate. The diagnosis was based on histopathology and patient's successful response to antituberculous drug treatment.
Keywords: Palate, tuberculosis, uvula
Tuberculosis, a disease caused by acid- and alcohol-fast bacilli of the family Mycobacteriaceae (Mycobacterium tuberculosis, M. bovis, M. microti and M. africanum), is one of the earliest diseases known to affect humans. 
Tuberculous involvement of the palate is rare. It is usually secondary either to pulmonary tuberculosis or to lupus vulgaris of the facial skin.  Nasal tuberculosis was first described in 1761 by the Italian anatomy professor Giovanni Morgagni while reporting the autopsy findings of a young man with pulmonary tuberculosis who had ulcerations of the nose, soft palate and nasopharynx. 
Primary tuberculosis of the nose is also rare. The first case of primary tuberculosis of the upper respiratory tract and nose was presented to the Pathological Society of London by Clarke in 1852.  Later in the 18th century, reviews published by Herzog described 20 cases of primary nasal tuberculosis among 80 cases of nasal tuberculosis overall.  In a review of the 20th century medical literature published in 1997, Butt found only 35 cases of nasal tuberculosis. 
In this article, we report a case of nasal and palatal tuberculosis with palatal perforation, and we review the literature relevant to the incidence, investigation and treatment of this condition.
A 62-year-old male presented to the Department of Otorhinolaryngology at our institute with a history of bilateral nasal obstruction and occasional epistaxis along with nasal regurgitation of food since 1 year. He also gave a history of a frequent evening rise in temperature for the last 1 year. Clinical examination revealed crusting of nose with arch deformity of the soft palate with vanishing uvula with patchy mucosal congestion of the anterior pillar on the left side [Figure - 1].
Office endoscopy of the nose revealed the presence of ulceration with crusting and slight bleeding on nasal septal mucosa on both sides with about 1 × 1 cm perforation on the cartilagenous nasal septum. The mucosa on the floor of the nose on the posterior part was also showing patchy mucosal congestion with ulceration.
Investigations showed an erythrocyte sedimentation rate (ESR) of 81 mm/h in the first hour by Westergren′s method, human immunodeficiency virus (HIV) enzyme-linked immunosorbent assay (ELISA) non-reactive and the Mantoux test elicited a strongly positive reaction (20 mm after 72 h). Other routine investigations were within normal limits. Three sputum smears were negative for acid-fast bacilli, as were subsequent cultures. His chest X-ray showed collapse and consolidation of the left lung [Figure - 2].
His paranasal sinus X-ray (Water′s view) did not reveal any significant abnormality.
Biopsy was done for ulcerated lesions from the nose and upper surface of the soft palate under topical anaesthesia; minimal bleeding was noted. A diagnosis of granulomatous disease of the nose and palate was tendered.
Biopsy analysis was suggestive of tuberculosis [Figure - 3]. Special staining for fungus and leprid bacilli was negative. A few acid-fast bacilli were noted on Ziehl-Neelsen staining.
The patient refused to undergo repeat biopsy for mycobacterial culture.
In accordance with the existing guidelines, the patient was administered antitubercular medication. Treatment resulted in a rapid resolution of nasal blockade, crusting and bleeding and a regression of the nasal and palatal mucosal lesions.
Antituberculous chemotherapy and public health measures led to a dramatic decline in the incidence of tuberculosis by the middle of the 20th century. However, since 1986, a steady and progressive increase in the number of cases has been reported worldwide.  Acquired immunodeficiency syndrome (AIDS), which progressively destroys the cell-mediated immunity required to combat tuberculosis, is one of the primary factors responsible for the resurgence of tuberculosis. Other implicated factors are inadequate public health systems and crowded and substandard living conditions. Poverty and inadequate access to health care place elderly homeless populations and those in drug treatment centres and correctional facilities at greatest risk. ,
The incidence of extrapulmonary tuberculosis has also increased. Extrapulmonary tuberculosis represents a diagnostic challenge to specialists in the involved anatomic area. This disease is rarely infectious, and patients typically have bacterial counts much lower than do those who have cavitary pulmonary disease.  Patients with extrapulmonary tuberculosis account for only 15% of patients with tuberculosis, but 70% of patients with AIDS and tuberculosis.  It should be noted that tuberculosis is often difficult to diagnose in patients with AIDS because their radiographic findings are often atypical; they lack granuloma formation and their purified-protein-derivative skin tests are negative. ,
Nasal tuberculosis can be caused by either a pulmonary disease or a retrograde involvement of the nose by lupus vulgaris of the facial skin. In only a few cases, it represents a primary infection. Primary disease is caused by inhalation of infected particles or traumatic digital inoculation. The lower frequency of nasal tuberculosis might be explained by the protection afforded by ciliary movement, the bactericidal action of nasal secretions and the filtering provided by the nasal vibrissae. It has also been postulated that the nasal mucosa is inherently resistant to mycobacterial growth. 
A case of tuberculosis affecting the skin and nasal septum and 10 years later involving the hard palate causing perforation is reported.  The presenting symptoms (in their order of frequency) are nasal obstruction, nasal discharge, nasal discomfort, epistaxis, crusting, eye watering, postnasal discharge, recurrent nasal polyps and ulceration. Lesions may be ulcerative, infiltrative or proliferative, and most cases are unilateral.  There are many diseases which can lead to palatal perforation. The differential diagnosis includes the following: 
Wegener′s granulomatosis, sarcoidosis
Lethal midline granuloma
Even after extensive literature search, we could not find any case of nasal/palatal tuberculosis with vanishing uvula.
The diagnosis is difficult to establish because the symptoms and signs of the various causative conditions are similar and nonspecific. , A definitive diagnosis is made by identifying or isolating tuberculous bacilli from the tissue removed during biopsy or surgery. Nasal secretions and swab specimens have a very low yield and should not be used to rule out this condition. On histology, both caseating and noncaseating granulomas have been described. Biopsies of noncaseating granulomas are histologically confusing, and these cases are often misdiagnosed as Wegener′s granuloma. The numbers of Langerhans giant cells and epithelioid cells are believed to be greater in tuberculosis than in other granulomas.  Cultures of involved tissues are more often positive than are smears. The roles of polymerase chain reaction assays, DNA probes and high-performance liquid chromatography are limited by their cost, lack of availability and lack of sensitivity. These modalities are currently recommended for species identification and to detect primary resistance to drugs. ,
Secondary nasal and palatal tuberculosis may present as either lupus verrucosus (hypertrophic lesions) or lupus necrogenica (ulcerative lesions). These are usually seen in patients with strong immune responses and considered to be due to hypersensitivity to acid-fast bacilli which further causes tissue destruction. These lesions heal with dense scarring with organ deformity which is seen in our case as an arched palate with vanishing uvula. 
Some patients with nasal tuberculosis subsequently develop pulmonary tuberculosis and/or extrapulmonary tuberculosis in adjacent sites such as the larynx, though it is rare and constitutes only 2-6% of extrapulmonary cases. , Therefore, the physician should look for these concomitant manifestations during both the initial work-up and subsequent follow-up.
The treatment of palatal tuberculosis should follow the general guidelines established for the treatment of extrapulmonary tuberculosis.
The case of nasal tuberculosis described in this report was noteworthy because the patient was apparently healthy and his immune status had not been demonstrably compromised.
Given current trends in the incidence of tuberculosis, it would be prudent for otolaryngologists to remain cognizant of tuberculosis as a potential entity when encountering an unusual lesion in the head and neck. 
Copyright 2011 - Indian Journal of Medical Microbiology