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Tuberculoid granulomatous lesion of the pharynx—Review of the literature
Auris Nasus Larynx 25 (1998) 187 – 191
Tuberculoid granulomatous lesion of the pharynx—Review of the literature Hari Shankar Sharma a,*, Daya Nath Kurl b, Meor Zamari Meor Kamal c a
Department of Otorhinolaryngology, School of Medical Sciences, Uni6ersiti Sains Malaysia, 16150 Kota Bharu, Kelantan, Malaysia b Department of Microbiology and Parasitology, School of Medical Sciences, Uni6ersiti Sains Malaysia, 16150 Kota Bharu, Kelantan, Malaysia c Department of Pathology, School of Medical Sciences, Uni6ersiti Sains Malaysia, 16150 Kota Bharu, Kelantan, Malaysia Received 7 May 1997; received in revised form 18 August 1997; accepted 19 September 1997
Abstract Pharyngeal involvement in tuberculosis is rare and is usually secondary to pulmonary tuberculosis. We report a very rare case of chronic granulomatous pharyngitis, which later turned out to be due to primary tuberculosis of the pharynx. The clinical presentation, diagnosis, treatment and complications of this rare clinical entity are presented. © 1998 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Tuberculosis pharynx; Nasopharynx; Nasopharyngeal stenosis
1. Introduction Non-pulmonary tuberculosis is rarely encountered in modern practice but may be seen in patients with poor host reaction due to HIV infection, alcoholism, etc. [1,2]. The upper respiratory tract is resistant to tuberculosis mainly due to the presence of saliva which, apart from its cleansing action [3] has an inhibitory effect on tubercle bacilli [4]. Other factors contributing to this im-
* Corresponding author. Fax: + 60 9 7653370; e-mail: [email protected]
munity against tuberculosis in this region include the presence of saprophytes, the antagonism of the striated musculature to bacterial invasion and thickness of the protective epithelial covering [3,5]. Tuberculosis of the pharynx is rare and is probably always secondary to pulmonary or laryngeal form of tuberculosis [6–8]. It can be present in three forms: acute miliary tuberculosis, chronic tuberculous ulceration and lupus vulgaris [9]. In the present report, we describe a case of chronic granulomatous pharyngitis which on histology showed non-caseating tuberculoid granulomatous lesion. Clinical features, treatment and sequel of this rare condition is discussed.
0385-8146/98/$19.00 © 1998 Elsevier Science Ireland Ltd. All rights reserved. PII S0385-8146(97)10027-X
188
H.S. Sharma et al. / Auris Nasus Larynx 25 (1998) 187–191
Fig. 1. Histopathological section from the pharyngeal biopsy showing the presence of non-caseating granulomas with multinucleated giant cells of the Langhan type ( × 400).
2. Case report A 38-year-old Malay man presented to the ENT out-patient clinic with complaints of pain, hypersensitivity of the throat and excessive postnasal drip for the last 6 months. He was a chronic smoker. He had neither past history of tuberculosis nor contact with any known patient of tuberculosis. Apart from pallor, the findings of systemic examination were normal. Examination of the oral cavity revealed a pale, thickened, hypertrophied posterior pharyngeal wall with a fine, granular surface which was coated with sticky mucoid secretions. Active post-nasal drip was present. Nasopharyngeal examination showed similar lesion in the posterior nasopharyngeal wall with consequent narrowing. This pharyngeal lesion was very friable and bled on palpation with a probe. Laryngeal examination was normal. Examination of the neck showed bilateral enlargement of the jugulodigastric lymph nodes (0.5× 0.5 cm) which were firm and mobile. The rest of the ENT examination was normal. A clinical diagnosis of chronic granular pharyngitis was made. Haematological findings were: Hb. 10.2/dl; WBC 7.4 × 109 L, with normal differential count;
and ESR 67 mm after 1 h. The culture of the throat showed growth of Lancefield group C streptococcus which was sensitive to erythromycin and penicillin. The patient was given conservative treatment consisting of erthromycin, phenol gargles, Mandl’s throat paint, vitamins and analgesics. After a month, there was some improvement in his oropharyngeal symptoms although the examination of his oral cavity showed no changes. A punch biopsy taken from the lesion in the posterior pharyngeal wall showed non-caseating granulomas rimmed by fibroblasts composed of epitheloid cells with multinucleated giant cells of Langhan’s type. The stroma showed diffuse chronic inflammatory cells, composed of lymphocytes and plasma cells suggestive of tuberculous granuloma (Fig. 1). Ziehl-Nielsen stain did not show any acid-fast bacilli. Gomorri methanamine silver stain did not reveal any fungus. VDRL and ELISA screening test for HIV were negative. The chest X-ray was normal. A swab and tissue samples taken from the posterior pharyngeal wall were negative for Mycobacterium tuberculosis when grown on Lowenstein-Jensen medium for 8 weeks. The tuberculin test was also
H.S. Sharma et al. / Auris Nasus Larynx 25 (1998) 187–191
negative. Smears of three consecutive sputum samples did not reveal any tubercle bacilli. Based on the histopathological findings and high endemicity of tuberculosis in this region, the patient was given antituberculous treatment for 1 year. The treatment included streptomycin, isoniazid and pyrazinamide. A month later the streptomycin was replaced by rifampicin as the patient complained of tinnitus. The follow up examination after 2 months of antituberculous treatment showed an improvement in his symptoms and the oropharyngeal surface appeared smoother and less fragile. Neck examination showed no lymphadenopathy. However, the patient noticed a change in his voice and loss of taste sensation except for coffee. Examination after 6 months of antituberculous treatment showed marked improvement in the oropharyngeal symptoms. The posterior pharyngeal wall was smooth and pale in appearance with thinning and scarring, but was not hypersensitive or fragile on palpation. The oropharynx showed synechiae formation involving both posterior pillars of the tonsils and base of the uvula along with the posterior pharyngeal wall. Nasopharyngeal examination using flexible nasopharyngoscope showed a pin-hole opening at the junction of nasopharynx and oropharynx, suggestive of pharyngeal stenosis. CT scan of the pharynx (Fig. 2) confirmed the nasopharyngeal stenosis. After the completion of antituberculous treatment the patient did not have any oropharyngeal pain or hypersensitivity. He still had complaints of altered taste sensation and speech which were due to the stenosis of the pharynx. The patient was referred to the plastic surgeon for the correction of the pharyngeal stenosis.
3. Discussion Pharyngeal tuberculosis is rare and usually secondary to pulmonary tuberculosis. In a study conducted at our hospital on 320 new cases of active pulmonary tuberculosis, 96 (30%) cases had extrapulmonary involvement. These extra pulmonary sites were (in order of frequency): cervical lymph nodes, lower thoracic and lumbar spine,
189
gastrointestinal system, genitourinary system, central nervous system and rarely eye involvement as uveitis and retinitis [10]. Rohwedder [11] found only 16 cases of tuberculous involvement of upper respiratory tract in a series of 843 cases admitted for pulmonary tuberculosis. Bath et al. [12] reported a patient with isolated nasopharyngeal tuberculosis, who presented with unilateral otalgia and otorrhoea. Haacke and Stafford [13] reported a case of tuberculoid granuloma of the pharynx. There are three possible methods of acquiring tuberculous infection: inhalation, ingestion and inoculation. Inhalation is all-important, since ingestion is now rare due to use of pasteurized milk and inoculation in skin is also rare [14]. The tuberculosis acquired in our case appears to be by inhalation and oropharynx was involved as primary complex with spread to regional jugulodigastric lymphnodes. The differential diagnosis in chronic granulomatous like lesions of the pharynx includes tuberculosis, syphilis, fungal infection, leprosy, lymphoma, midline granuloma, Wegner’s granuloma [15], nasopharyngeal carcinoma and periarteritis nodosa [12]. The diagnosis is usually confirmed by biopsy. Bath et al. [12] emphasised the difficulty in reaching a diagnosis of tuberculosis in such unusual sites and has suggested that a diagnosis of tuberculosis should always be considered where the histological appearance suggests granulomatous disease; even in non-caseating granulomas. Our case showed histologically the presence of non-caseating granuloma with multinucleated giant cells of Langhan’s type. The tissue sample from the lesion sent for the bacteriological culture for tuberculosis was negative in our case. Waldman et al. [16] also observed similar findings where tissue taken from a tuberculous lesion rarely showed the growth of Mycobacterium tuberculosis. Haacke and Stafford [13] recommended a trial of antituberculous treatment in difficult cases especially those where acid-fast bacilli could not be isolated. We had similar experience in managing this case who responded well to antituberculous treatment. Coulder [15] suggested a strong possibility of Wegner’s granuloma in cases who failed to respond to antituberculous
190
H.S. Sharma et al. / Auris Nasus Larynx 25 (1998) 187–191
Fig. 2. Axial CT slices at the level of lower nasopharynx (6 mm interval). From above downwards: (a) Passavant’s ring (arrows) noted with normal central airways. There is fluid within both the maxillary antra; (b) There is narrowing of the airway (arrow) due to asymmetrical thickening of the pharyngeal walls; (c) The airway is reduced to a pinhole (arrow). Note the oral cavity anterior to the soft palate (double arrow). Below this level (oropharynx) the airway merges with the oral cavity and appears normal.
H.S. Sharma et al. / Auris Nasus Larynx 25 (1998) 187–191
treatment as there is marked histological overlap between the pharyngeal lesion due to tuberculosis and Wegner’s granuloma. Our case had symptoms of chronic sore throat and oedematous, granular, pale and fragile pharyngeal mucosa which bled after minimal trauma. Diagnosis was made by histology and the patient responded well to antituberculous treatment. As a sequel of the disease he developed pharyngeal stenosis. Thus, cases of chronic sore throat with features as described above, should alert the clinician to a possibility of tuberculosis, especially in countries where the incidence of tuberculosis is high. Prognosis in these cases should be guarded since pharyngeal stenosis can develop during the course of treatment as a sequelae.
Acknowledgements We wish to thank the Dean, School of Medical Sciences, Universiti Sains Malaysia for permission to publish this paper.
References [1] Sunderam G, McDonald RJ, Maniatis T, Oleske J, Kapila R, Reichman LB. Tuberculosis as a manifestation of the acquired immunodeficiency syndrome (AIDS). J Am Med Assoc 1986;256:362–6.
.
191
[2] Chaisson RE, Schecter GF, Theuer CP, Rutherford GW, Echenberg DF, Hopewell PC. Tuberculosis in patients with acquired immunodeficiency syndrome. Am Rev Respir Dis 1987;136:570 – 4. [3] Brennan TF, Vrabec DP. Tuberculosis of the oral mucosa. Ann Otolaryngol 1970;79:601 – 5. [4] Verma A, Mann SBS, Randotra B. Primary tuberculosis of the tongue. Ear Nose Throat J 1989;68:719 – 20. [5] Rauch DM, Freidman E. Systemic tuberculosis initially seen as an oral ulceration: Report of case. J Oral Surg 1978;36:387 – 9. [6] Ballanger JJ. Diseases of the Nose, Throat and Ear, 12th ed. Philadelphia, PA: Lea and Febiger, 1977:291 pp. [7] Goh KL, Chang CM. Pharyngeal tuberculosis. Trop Geogr Med 1990;42:75 – 7. [8] Shah A, Pande A, Vora IM, Ogale SB. Primary lupus vulgaris of the pharynx. J Postgrad Med 1990;36:106 – 8. [9] Ballantyne J, Groves J. Scott-Brown’s Diseases of the Ear, Nose and Throat, 4th ed., vol. 4. London: Butterrworth, 1979:88 – 89. [10] Ismail Y. Extrapulmonary tuberculosis: A review of 97 cases in Hospital Universiti Sains Malaysia. Diagnosa 1993;7:5 – 8. [11] Rohwedder J. Upper respiratory tract tuberculosis. Sixteen cases in a general hospital. Ann Intern Med 1974;80:708 – 13. [12] Bath AP, Flynn PO, Gibbin KP. Nasopharyngeal tuberculosis. J Laryngol Otol 1992;106:1079– 80. [13] Haacke N V, Stafford N. Tuberculoid granuloma of the pharynx. J Laryngol Otol 1984;98:325 – 6. [14] Walter FB, Israel MS. General Pathology, 5th ed. Edinburgh: Chuchill Livingstone, 1979:239. [15] Couldery D. Tuberculosis of the upper respiratory tract misdiagnosed as Wegner’s granulomatosis— an important distinction. J Laryngol Otol 1990;104:255 – 8. [16] Waldman SR, Levine HL, Sebek BA, Parker W, Tucker HM. Nasal tuberculosis: a forgotten entity. Laryngoscope 1981;91:11 – 6.
Tuberculoid granulomatous lesion of the pharynx—Review of the literature Hari Shankar Sharma a,*, Daya Nath Kurl b, Meor Zamari Meor Kamal c a
Department of Otorhinolaryngology, School of Medical Sciences, Uni6ersiti Sains Malaysia, 16150 Kota Bharu, Kelantan, Malaysia b Department of Microbiology and Parasitology, School of Medical Sciences, Uni6ersiti Sains Malaysia, 16150 Kota Bharu, Kelantan, Malaysia c Department of Pathology, School of Medical Sciences, Uni6ersiti Sains Malaysia, 16150 Kota Bharu, Kelantan, Malaysia Received 7 May 1997; received in revised form 18 August 1997; accepted 19 September 1997
Abstract Pharyngeal involvement in tuberculosis is rare and is usually secondary to pulmonary tuberculosis. We report a very rare case of chronic granulomatous pharyngitis, which later turned out to be due to primary tuberculosis of the pharynx. The clinical presentation, diagnosis, treatment and complications of this rare clinical entity are presented. © 1998 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Tuberculosis pharynx; Nasopharynx; Nasopharyngeal stenosis
1. Introduction Non-pulmonary tuberculosis is rarely encountered in modern practice but may be seen in patients with poor host reaction due to HIV infection, alcoholism, etc. [1,2]. The upper respiratory tract is resistant to tuberculosis mainly due to the presence of saliva which, apart from its cleansing action [3] has an inhibitory effect on tubercle bacilli [4]. Other factors contributing to this im-
* Corresponding author. Fax: + 60 9 7653370; e-mail: [email protected]
munity against tuberculosis in this region include the presence of saprophytes, the antagonism of the striated musculature to bacterial invasion and thickness of the protective epithelial covering [3,5]. Tuberculosis of the pharynx is rare and is probably always secondary to pulmonary or laryngeal form of tuberculosis [6–8]. It can be present in three forms: acute miliary tuberculosis, chronic tuberculous ulceration and lupus vulgaris [9]. In the present report, we describe a case of chronic granulomatous pharyngitis which on histology showed non-caseating tuberculoid granulomatous lesion. Clinical features, treatment and sequel of this rare condition is discussed.
0385-8146/98/$19.00 © 1998 Elsevier Science Ireland Ltd. All rights reserved. PII S0385-8146(97)10027-X
188
H.S. Sharma et al. / Auris Nasus Larynx 25 (1998) 187–191
Fig. 1. Histopathological section from the pharyngeal biopsy showing the presence of non-caseating granulomas with multinucleated giant cells of the Langhan type ( × 400).
2. Case report A 38-year-old Malay man presented to the ENT out-patient clinic with complaints of pain, hypersensitivity of the throat and excessive postnasal drip for the last 6 months. He was a chronic smoker. He had neither past history of tuberculosis nor contact with any known patient of tuberculosis. Apart from pallor, the findings of systemic examination were normal. Examination of the oral cavity revealed a pale, thickened, hypertrophied posterior pharyngeal wall with a fine, granular surface which was coated with sticky mucoid secretions. Active post-nasal drip was present. Nasopharyngeal examination showed similar lesion in the posterior nasopharyngeal wall with consequent narrowing. This pharyngeal lesion was very friable and bled on palpation with a probe. Laryngeal examination was normal. Examination of the neck showed bilateral enlargement of the jugulodigastric lymph nodes (0.5× 0.5 cm) which were firm and mobile. The rest of the ENT examination was normal. A clinical diagnosis of chronic granular pharyngitis was made. Haematological findings were: Hb. 10.2/dl; WBC 7.4 × 109 L, with normal differential count;
and ESR 67 mm after 1 h. The culture of the throat showed growth of Lancefield group C streptococcus which was sensitive to erythromycin and penicillin. The patient was given conservative treatment consisting of erthromycin, phenol gargles, Mandl’s throat paint, vitamins and analgesics. After a month, there was some improvement in his oropharyngeal symptoms although the examination of his oral cavity showed no changes. A punch biopsy taken from the lesion in the posterior pharyngeal wall showed non-caseating granulomas rimmed by fibroblasts composed of epitheloid cells with multinucleated giant cells of Langhan’s type. The stroma showed diffuse chronic inflammatory cells, composed of lymphocytes and plasma cells suggestive of tuberculous granuloma (Fig. 1). Ziehl-Nielsen stain did not show any acid-fast bacilli. Gomorri methanamine silver stain did not reveal any fungus. VDRL and ELISA screening test for HIV were negative. The chest X-ray was normal. A swab and tissue samples taken from the posterior pharyngeal wall were negative for Mycobacterium tuberculosis when grown on Lowenstein-Jensen medium for 8 weeks. The tuberculin test was also
H.S. Sharma et al. / Auris Nasus Larynx 25 (1998) 187–191
negative. Smears of three consecutive sputum samples did not reveal any tubercle bacilli. Based on the histopathological findings and high endemicity of tuberculosis in this region, the patient was given antituberculous treatment for 1 year. The treatment included streptomycin, isoniazid and pyrazinamide. A month later the streptomycin was replaced by rifampicin as the patient complained of tinnitus. The follow up examination after 2 months of antituberculous treatment showed an improvement in his symptoms and the oropharyngeal surface appeared smoother and less fragile. Neck examination showed no lymphadenopathy. However, the patient noticed a change in his voice and loss of taste sensation except for coffee. Examination after 6 months of antituberculous treatment showed marked improvement in the oropharyngeal symptoms. The posterior pharyngeal wall was smooth and pale in appearance with thinning and scarring, but was not hypersensitive or fragile on palpation. The oropharynx showed synechiae formation involving both posterior pillars of the tonsils and base of the uvula along with the posterior pharyngeal wall. Nasopharyngeal examination using flexible nasopharyngoscope showed a pin-hole opening at the junction of nasopharynx and oropharynx, suggestive of pharyngeal stenosis. CT scan of the pharynx (Fig. 2) confirmed the nasopharyngeal stenosis. After the completion of antituberculous treatment the patient did not have any oropharyngeal pain or hypersensitivity. He still had complaints of altered taste sensation and speech which were due to the stenosis of the pharynx. The patient was referred to the plastic surgeon for the correction of the pharyngeal stenosis.
3. Discussion Pharyngeal tuberculosis is rare and usually secondary to pulmonary tuberculosis. In a study conducted at our hospital on 320 new cases of active pulmonary tuberculosis, 96 (30%) cases had extrapulmonary involvement. These extra pulmonary sites were (in order of frequency): cervical lymph nodes, lower thoracic and lumbar spine,
189
gastrointestinal system, genitourinary system, central nervous system and rarely eye involvement as uveitis and retinitis [10]. Rohwedder [11] found only 16 cases of tuberculous involvement of upper respiratory tract in a series of 843 cases admitted for pulmonary tuberculosis. Bath et al. [12] reported a patient with isolated nasopharyngeal tuberculosis, who presented with unilateral otalgia and otorrhoea. Haacke and Stafford [13] reported a case of tuberculoid granuloma of the pharynx. There are three possible methods of acquiring tuberculous infection: inhalation, ingestion and inoculation. Inhalation is all-important, since ingestion is now rare due to use of pasteurized milk and inoculation in skin is also rare [14]. The tuberculosis acquired in our case appears to be by inhalation and oropharynx was involved as primary complex with spread to regional jugulodigastric lymphnodes. The differential diagnosis in chronic granulomatous like lesions of the pharynx includes tuberculosis, syphilis, fungal infection, leprosy, lymphoma, midline granuloma, Wegner’s granuloma [15], nasopharyngeal carcinoma and periarteritis nodosa [12]. The diagnosis is usually confirmed by biopsy. Bath et al. [12] emphasised the difficulty in reaching a diagnosis of tuberculosis in such unusual sites and has suggested that a diagnosis of tuberculosis should always be considered where the histological appearance suggests granulomatous disease; even in non-caseating granulomas. Our case showed histologically the presence of non-caseating granuloma with multinucleated giant cells of Langhan’s type. The tissue sample from the lesion sent for the bacteriological culture for tuberculosis was negative in our case. Waldman et al. [16] also observed similar findings where tissue taken from a tuberculous lesion rarely showed the growth of Mycobacterium tuberculosis. Haacke and Stafford [13] recommended a trial of antituberculous treatment in difficult cases especially those where acid-fast bacilli could not be isolated. We had similar experience in managing this case who responded well to antituberculous treatment. Coulder [15] suggested a strong possibility of Wegner’s granuloma in cases who failed to respond to antituberculous
190
H.S. Sharma et al. / Auris Nasus Larynx 25 (1998) 187–191
Fig. 2. Axial CT slices at the level of lower nasopharynx (6 mm interval). From above downwards: (a) Passavant’s ring (arrows) noted with normal central airways. There is fluid within both the maxillary antra; (b) There is narrowing of the airway (arrow) due to asymmetrical thickening of the pharyngeal walls; (c) The airway is reduced to a pinhole (arrow). Note the oral cavity anterior to the soft palate (double arrow). Below this level (oropharynx) the airway merges with the oral cavity and appears normal.
H.S. Sharma et al. / Auris Nasus Larynx 25 (1998) 187–191
treatment as there is marked histological overlap between the pharyngeal lesion due to tuberculosis and Wegner’s granuloma. Our case had symptoms of chronic sore throat and oedematous, granular, pale and fragile pharyngeal mucosa which bled after minimal trauma. Diagnosis was made by histology and the patient responded well to antituberculous treatment. As a sequel of the disease he developed pharyngeal stenosis. Thus, cases of chronic sore throat with features as described above, should alert the clinician to a possibility of tuberculosis, especially in countries where the incidence of tuberculosis is high. Prognosis in these cases should be guarded since pharyngeal stenosis can develop during the course of treatment as a sequelae.
Acknowledgements We wish to thank the Dean, School of Medical Sciences, Universiti Sains Malaysia for permission to publish this paper.
References [1] Sunderam G, McDonald RJ, Maniatis T, Oleske J, Kapila R, Reichman LB. Tuberculosis as a manifestation of the acquired immunodeficiency syndrome (AIDS). J Am Med Assoc 1986;256:362–6.
.
191
[2] Chaisson RE, Schecter GF, Theuer CP, Rutherford GW, Echenberg DF, Hopewell PC. Tuberculosis in patients with acquired immunodeficiency syndrome. Am Rev Respir Dis 1987;136:570 – 4. [3] Brennan TF, Vrabec DP. Tuberculosis of the oral mucosa. Ann Otolaryngol 1970;79:601 – 5. [4] Verma A, Mann SBS, Randotra B. Primary tuberculosis of the tongue. Ear Nose Throat J 1989;68:719 – 20. [5] Rauch DM, Freidman E. Systemic tuberculosis initially seen as an oral ulceration: Report of case. J Oral Surg 1978;36:387 – 9. [6] Ballanger JJ. Diseases of the Nose, Throat and Ear, 12th ed. Philadelphia, PA: Lea and Febiger, 1977:291 pp. [7] Goh KL, Chang CM. Pharyngeal tuberculosis. Trop Geogr Med 1990;42:75 – 7. [8] Shah A, Pande A, Vora IM, Ogale SB. Primary lupus vulgaris of the pharynx. J Postgrad Med 1990;36:106 – 8. [9] Ballantyne J, Groves J. Scott-Brown’s Diseases of the Ear, Nose and Throat, 4th ed., vol. 4. London: Butterrworth, 1979:88 – 89. [10] Ismail Y. Extrapulmonary tuberculosis: A review of 97 cases in Hospital Universiti Sains Malaysia. Diagnosa 1993;7:5 – 8. [11] Rohwedder J. Upper respiratory tract tuberculosis. Sixteen cases in a general hospital. Ann Intern Med 1974;80:708 – 13. [12] Bath AP, Flynn PO, Gibbin KP. Nasopharyngeal tuberculosis. J Laryngol Otol 1992;106:1079– 80. [13] Haacke N V, Stafford N. Tuberculoid granuloma of the pharynx. J Laryngol Otol 1984;98:325 – 6. [14] Walter FB, Israel MS. General Pathology, 5th ed. Edinburgh: Chuchill Livingstone, 1979:239. [15] Couldery D. Tuberculosis of the upper respiratory tract misdiagnosed as Wegner’s granulomatosis— an important distinction. J Laryngol Otol 1990;104:255 – 8. [16] Waldman SR, Levine HL, Sebek BA, Parker W, Tucker HM. Nasal tuberculosis: a forgotten entity. Laryngoscope 1981;91:11 – 6.