Ipsilateral Oropharyngeal and Cervical Lymph Node Tuberculosis Simulating Oropharyngeal Malignancy with Regional Lymph Node Metastasis: A Case Report

Case Report Iranian Journal of Otorhinolaryngology, Vol.37(5), Serial No.142, Sep-2025 Ipsilateral Oropharyngeal and Cervical Lymph Node Tuberculosis Simulating Oropharyngeal Malignancy with Regional Lymph Node Metastasis: A Case Report V Sha Kri Eh Dam1, Nusaibah Azman2 * Abstract Introduction: Tuberculosis (TB) is an important contagious disease and a major public health problem globally. It may manifest as pulmonary TB or primary or secondary extrapulmonary TB. Primary oropharyngeal TB is very rare and may mimic presentation of oropharyngeal malignancy especially in the negative initial TB workup. Case Report: We would like to highlight a case of an elderly man presented with ipsilateral oropharyngeal mass and cervical lymph node (LN) enlargement, mimicking oropharyngeal malignancy with regional LN metastasis. Conclusion: History of TB contact, poor oral hygiene, and poor immunity should alert the possibility of oropharyngeal TB. Involvement of ipsilateral oropharyngeal structure and cervical LN may simulate presentation of oropharyngeal malignancy with regional LN metastasis. Tissue biopsy for histopathological examination and appropriate staining is considered gold standard for diagnosis of TB and excluding malignancy. It is an important communicable disease, thus notification and referral to infectious disease team should be done without delay. Keyword: Tuberculosis, Oropharynx, Neoplasm Received date: 30 Jan 2025 Accepted date: 29 Apr 2025 *Please cite this article; Eh Dam V SK, Azman N. Ipsilateral Oropharyngeal and Cervical Lymph node Tuberculosis Simulating Oropharyngeal Malignancy with Regional Lymph Node Metastasis: A Case Report. Iran J Otorhinolaryngol. 2025:37(5):287-290. Doi: 10.22038/ijorl.2025.85739.3877 1Department of Otorhinolaryngology-Head & Neck Surgery, Hospital Lahad Datu, Peti Surat 60065, 91110 Lahad Datu, Sabah, Malaysia. 2 Department of Pathology, Hospital Queen Elizabeth 1, Karung Berkunci No. 2029, 88586 Kota Kinabalu, Sabah, Malaysia. *Correspondence author: Department of Otorhinolaryngology-Head & Neck Surgery, Hospital Lahad Datu, Peti Surat 60065, 91110 Lahad Datu, Sabah, Malaysia. E-mail: Copyright©2025 Mashhad University of Medical Sciences. This work is licensed under a Creative Commons Attribution-Noncommercial 4.0 International License https://creativecommons.org/licenses/by-nc/4.0/deed.en 287 Eh Dam V SK, et al Introduction Tuberculosis (TB) infection is a major public health problem worldwide, especially in developing countries. In 2023, 8.2 million people were diagnosed with TB globally, and of these, 84% were pulmonary TB (PTB), and 16% were extrapulmonary TB (EPTB) (1). Lymph nodes (LN), especially those at the cervical region and pleura, are the most common sites for EPTB (2,3). By contrast, oral cavity and oropharyngeal involvements are rare and account for only 0.05%–5% of total TB cases (4,5). Tongue is the most common site for the oral cavity subsite (6), while tonsils are the most frequent site for the oropharyngeal subsite (3,5). The involvement of the ipsilateral oropharyngeal structure and cervical LN may simulate the presentation of oropharyngeal malignancy with regional LN metastasis. Although rare, concomitant TB and malignancy may occur and need to be confirmed or ruled out by histopathological examination (HPE) of the specimen. A systemic review of oral cavity TB showed that 3% of patients had concomitant carcinoma in the same lesion site (6). smooth surface without ulceration or a fungating mass. The patient was partially edentulous and oral hygiene was poor. Flexible indirect laryngoscope showed unilateral right tonsil enlargement and a smooth surface mass at the right base of the tongue (Figure 3). Tongue mobility was normal, and other head and neck examinations were unremarkable. Fig 1. Normal chest x-ray without feature of tuberculosis Case Report A 66-year-old male with underlying diabetic mellitus presented with right neck swelling for a duration of one month. The swelling was painless but progressively increased in size. It was associated with loss of appetite and weight, on and off fever and night sweats. There were no local obstructive symptoms, such as dysphagia or shortness of breath, and no changes in voice. The patient denied having a chronic cough or being in contact with TB patients. He was an active and chronic smoker but did not consume alcohol or engage in highrisk behaviour. There was no family history of malignancy. Screening for TB, including sputum for acid-fast bacilli, tuberculin skin test and chest X-ray (Figure 1), was performed at primary care before he was referred to us and was not suggestive of TB. On examination, there were multiple lymph nodes palpable on the right side of the neck at levels II, III and V (Figure 2). They were firm in consistency and mobile, with some of them being matted and non-tender. There was no palpable lymph node on the contralateral side. Oral examination revealed unilateral right tonsil enlargement, which appeared to have a Fig 2. Multiple lymph nodes enlargement at the right side of the neck, at the level II, III and V. Fig 3. Flexible indirect laryngoscope shows unilateral right tonsil enlargement (black arrow) and a smooth surface mass at the right base of tongue (yellow arrow). Blue arrowhead – epiglottis; Red star – uvula; A – anterior; P – posterior; R – right; L- left. Subsequently, the patient underwent direct laryngoscopy under general anaesthesia for a 288 Iranian Journal of Otorhinolaryngology, Vol.37(5), Serial No.142, Sep-2025 Oropharyngeal Tuberculosis more detailed examination and biopsy. Direct laryngoscopy revealed that the mass at the right base of the tongue was continuous with the right tonsil (Figure 4). Fig 4. Direct laryngoscopy shows the mass at the right base of tongue (yellow arrow) is continuous with the right tonsil (black arrow). Blue arrowhead – epiglottis; Green star – anterior tongue; A – anterior; P – posterior; R – right; L- left. The mass had a smooth surface, was firm in consistency and was confined to the right oropharynx. The contralateral side, larynx, hypopharynx and anterior 2/3 of the tongue were not involved. A right tonsillectomy and biopsy of the right base of the tongue mass were performed. A computed tomography scan was not performed prior to the diagnostic tonsillectomy and biopsy because of limited resources and difficulty in obtaining an early CT scan at our centre. However, we planned to do so later if the HPE confirmed malignancy for staging purposes.The HPE of the right tonsil showed lymphoid tissue lined by stratified squamous epithelium with multiple foci of granulomatous formation, few foci of central suppurative material and necrosis, and more than 30 bacilli were seen using Ziehl–Neelsen stain (Figure 5). The HPE of the right base of the tongue mass showed reactive lymphoid tissue lined by squamous epithelium without granuloma. No atypical lymphocytes or malignancy was seen (...truncated)