A Case of Primary Tuberculosis of Tonsil: A Rare
Entity- Case Report
Sushna Maharjan1*, Ramesh Parajuli 2 and Puja Neopane3
1Department of Pathology, Chitwan Medical College Teaching Hospital, Nepal
2Department of Department of Otorhinolaryngology, Chitwan Medical College Teaching Hospital, Nepal
3Department of Oral Medicine and Pathology, School of Dentistry, Health Sciences University of Hokkaido, Japan
Submission:February 10, 2017; Published: February 22, 2017
*Corresponding author: Sushna Maharjan, Department of Pathology, Chitwan Medical College Teaching Hospital (CMC-TH), P.O. Box 42, Bharatpur, Chitwan, Nepal, Email:[email protected]
How to cite this article: Sushna M, Ramesh P, Puja N. A Case of Primary Tuberculosis of Tonsil: A Rare Entity- Case Report. Glob J Oto 2017; 4(1): 555629. DOI: 10.19080/GJO.2017.04.555629
Key Clinical MessageTuberculosis of tonsil should be in differential diagnosis if a patient presents with sore throat, cervical lymphadenopathy and unilateral
tonsillar enlargement. Histopathological examination should be sent for confirmation and rule out malignancy. Chest X-ray and HIV-screening is
always recommended since there is increased incidence of extrapulmonary tuberculosis in AIDS patients.
Primary tuberculosis of tonsils is rare. We reported a case of primary tonsillar tuberculosis in a 55-year-old female who presented with
sore throat and enlargement of right tonsil. Histopathology revealed tuberculoisis. Complete resolution was found after antitubercular therapy.
Tonsillar tuberculosis should be considered if patient is not responding to antibiotics.
Keywords:Antitubercular therapy; Primary tuberculosis of tonsil; Sore throat
Tuberculosis (TB) is one of the most serious and life
threatening infectious diseases in the world . Upper
respiratory tract involvement is encountered in approximately
2% of patients with active pulmonary TB . It affects all
organs and tissues but tonsil is one of the uncommon sites for
tuberculosis. Primary TB of tonsils is even rarer and thus it
usually occurs as secondary involvement to pulmonary infection
. The advent of antitubercular drugs has overall diminished
the incidence of TB and the occurrence of TB of tonsils is further
reduced after widespread use of pasteurized milk . It is
surprising for not infecting tonsils although tonsils are placed
at the site of frequent contact with infected sputum by tubercle
bacilli and it is postulated that cleaning and antiseptic effects of
saliva protect tonsils . The presence of saprophytes and thick
protecting epithelial layer covering the tonsils might be further
resisting them to tubercle bacilli [6,7]. A few research articles
and case reports of extrapulmonary TB are available from Nepal.
Thus, the rare involvement of tonsils with tuberculous infection
encouraged us to report a case of primary foci of tonsillar TB.
A 55-year-old female presented with history of sore throat,
difficulty and pain in swallowing of solid food for 2 months in Department of Otorhinolaryngology in our hospital. There was
no history of cough, fever, hoarseness of voice, vomiting and
regurgitation of food. On examination of oropharyngeal cavity,
there was congestion and slight enlargement of right tonsil.
Left tonsil was normal. She had past history of recurrent sore
throat. Clinical diagnosis of chronic tonsillitis was made. She
was given Ciprofloxacin (500 mg) twice daily and Paracetamol
(500mg) twice daily for five days. The patient re-visited with the
same complaints after 5 days since symptoms did not subside.
On examination, enlargement of right tonsil about 9x9 mm in
dimension with an ulcer and slough was found.
Rest of the oral cavity was normal. Right cervical
lymphadenopathy was also noted. Systemic examination
revealed no abnormality. Chest X-ray and sputum for acid fast
bacilli were suggested to rule out primary foci in lungs. Chest
X-ray was normal (Figure 1) and sputum for acid fast bacilli
was also negative. Routine investigations of blood, urine and
biochemical tests were normal except for ESR-55mm at 1hour.
The patient was HIV seronegative. Mantoux test was positive
with indurations of 20× 18 mm. The differential diagnosis of TB
and malignancy was made. Hence, histopathological examination
was recommended. Punch biopsy was taken from the ulcerative
lesion on right tonsil and sent to Department of Histopathology. The histopathological examination of the tonsillar biopsy
revealed epithelioid cell granulomas, caseous necrosis,
Langhans’ giant cells and lymphocytes (Figures 2 & 3). Ziehl
Neelsen stain was negative for acid-fast bacilli. Antitubercular
therapy was started. Patient was kept under regular follow up.
The symptoms of sore throat, difficulty and pain in swallowing
were absent, and there was a complete resolution of lesion on
right tonsil on his recent follow up.
The burden of extrapulmonary TB represents approximately
25 % of overall tubercular morbidity . TB of the oral cavity is
uncommon and tonsillar involvement is even rare . The cause
of TB of tonsils is either infection with Mycobacterium bovis due
to ingestion of unpasteurized cow’s milk as primary form, or it
may be as secondary form associated with contact of infected
sputum expectorated from TB of lungs. The secondary form is
common in the present day as pasteurization of milk almost
eliminate the primary TB of tonsils . The route of spread
of bacilli may be hematogenous or inhalation of tubercle bacilli
which harbour in the Waldeyer’s ring. Although TB of tonsil is
not frequent, tonsillar granulomata are commonly observed
in patients with poor host reaction due to alcoholism, HIV
infection, and so on . Poor dental hygiene, dental extraction,
periodontitis, and leukoplakia are some of the predisposing
factors for primary oral TB [12,13].
Patients usually present clinically with enlargement of tonsils,
painful ulceration, white patches, cervical lymphadenopathy,
productive cough, sore throat, dysphagia, odynophagia, with or
without constitutional symptoms and signs of TB [14-16]. The
most common presentation is sore throat . Few features
are typically suggestive of tonsillar TB, such as asymmetric
enlargement of tonsil, tonsillar enlargement without exudate,
obliteration of crypts, painful deglutition, and the presence of
enlarged mobile jugulo-digastric lymph nodes . However,
its presentation usually simulates tonsillar malignancies which
are more common in elderly patient. Thus, it is very difficult to
differentiate them only on clinical ground, and histopathological
examination is mandatory to remove the confusion. Hence,
diagnosis of tonsillar TB is based on histopathological findings
and the identification of tubercle bacilli [16-18].
Jana et al.  reported a unique case of tonsillar TB in a
young adult male, prior to involvement of lungs. There was a late
appearance of cough and infiltration in chest X-ray. This case is
quite unique as it suggested primary involvement of tonsils with
secondary spread of hilar lymph node and lungs which is very
rare. The clinician should keep in mind about the possibility of
TB especially in older patients and in developing countries like
India , and Nepal  where the incidence of TB still remains
high. Antitubercular therapy is the choice of treatment but
requirement of tonsillectomy depends on condition of tonsil and
duration of illness. Miller et al.  had provided guideline that
tonsillectomy is performed in recent infection under coverage of
antitubercular therapy, and avoidance of removal of tonsil in old
calcified and fibrotic tonsil.
It is difficult to differentiate tonsillar tuberculosis from
a malignant tumor as both conditions may have similar
presentations and common abnormal tonsillar findings. Thus,
histopathological examination is mandatory. Tonsillar TB should be suspected if the patient is not responding to antibiotics,
especially in our country where TB is still a prevalent disease.