Evaluation of Tubercular Cervical Lymphadenopathy: Diagnostic and Therapeutic Utility

Introduction: Lymphadenitis is the most common extrapulmonary manifestation of tuberculosis. It remains both diagnostic and therapeutic challenge as not only mimics other diseases but also inconsistent physical and laboratory findings. Diagnosis is difficult often requiring biopsy. Aim: Aim of the study was to evaluate the role of surgical dissection of tuberculous cervicle lymphadenopathy for diagnosis as well as therapeutic purpose. Methods: This observational study was conducted during the time period of 01 july 2015 to 30 june 2017 in ENT & Pulmonology department, combined military hospital Dhaka on 100 patients who have undergone surgical neck dissection. Result: In our study total 100 patients were biopsied. Among them 56 patient was diagnosed as tubercular lymphadenitis after lymphnode excision biopsy. Among them 47 tubercular lymphadenitis patient responded to ATT (CAT-1), only 2 patient developed cold abscess which required further surgery. Six patient showed relapse during follow-up and 9 patient did not respond to CAT-1 treatment (treatment failure). Surgical intervention along with CAT-2 treatment showed cure in all of them. 2 surgical interventions were done in total 17 patients, 2 TB abscess during ATT (CAT-1 HRZE), 9 treatment failure patients and 6 relapse patients along with ATT (CAT-2 SHRZE) and all these patients had no relapse or treatment failure during further follow up. Keyward: Tubercular lymphadenopathy, Anti tubercular drug, surgical treatment 1. Classified ENT Specialist & Head-Neck Surgeon, Dept. of ENT and Head-Neck Surgery, Combined Military Hospital, Dhaka. 2. Classified Medicine specialist, Dept. of Medicine, Combined Military Hospital, Dhaka. 3. Classified ENT Specialist& Head-Neck surgeon, Dept. of ENT and Head-Neck surgery, Combined Military Hospital, Dhaka 4. Graded ENT Specialist & Head-Neck surgeon, Dept. of ENT and Head Neck Surgery, Combined military hospital, Dhaka 5. Classified Specialist in pathology, Dept. of Pathology, Armed Forces Institute of Pathology, Dhaka Address of correspondence: Col (Dr.) AKM Asaduzzaman, Classified ENT Specialist & Head-Neck surgeon, Dept. of ENT and Head Neck surgery, Combined Military Hospital, Dhaka. Cell: 01769014786, E-mail: asad 100780@gmail.com Introduction: Tuberculosis (TB) is a granulomatous inflammatory disease caused by mycobacterium tuberculosis. Lymphadenitis is the most common extrapulmonary manifestation of tuberculosis.Tuberculous lymphadenopathy commonly involves lymphnodes of the head and neck region (posterior and anteriorcervical chains, supraclavicular fossae, submandibular) inwhich cervical lymphadenopathy is most common. It is important for otolaryngologists to be aware of TB in head and neck region and its various manifestations. Tuberculous lymph-adenopathy is not a lifethreatening problem, but does require treatment by physicians and surgeons. The majority of patients tend to be young, healthy, working adults without constitutional symptoms. However, lymphadenopathy can progress to abscess and fistula formation, which can be disabling and socially unacceptable. ATT under dots is the main treatment while surgery is required for enlarged lymph nodes or tuberculous lymph node which does not regress with medication. Surgical techniques include aspiration, incision and drainage, curettage, complete surgical excision of the affected lymph nodes and overlying skin and selective nodal or functional neck dissection when required. The diagnosis of TB is mainly based on a positive mycobacterial smear and/or culture, Gene X-Pert positive or the histopathological presence of a chronic or caseating granuloma. Histopathology and Gene X-pert is the most confirmatory test. In this study an attempt was made to evaluate the role of surgical dissection in tubercular cervical lymphadenopathy for diagnostic and therapeutic purposes. Methods: This observational study was conducted at Combined Military Hospital, Dhaka during the period of Jan 2015 to December 2016. The patient those reported to ENT outpatient department and those referred from Pulmonology and various other department are included in the study. The patient didn’t had the confirmatory FNAC report underwent excision biopsy. In biopsy, materials is divided into three parts ( 1/3 in normal saline for c/ s, 1/3 in normal saline for Gene X-pert, 1/3 in formalin for histopathology. Diagnostic findings were recorded in predesigned “diagnostic notes” register. Charts of the patients both male and female in the age range from 12 to 74 years were reviewed and operation notes analyzed. Total number of cases were 100. Approval of the Institutional Ethical committee was obtained for publishing the study. All patients gave informed written consent prior to study. Inclusion criteria for tubercular lymphadenitis is clinical sign symptoms + caseation granuloma OR granuloma + Gene X-pert positive.Asymptomatic TB (without constitutional symptoms of TB) but biopsy showed caseation granuloma or granuloma + Gene X-pert positive also included in the study. Patients do not response to anti tubercular therapy(CAT-1 HRZE) undergone surgical intervention( excision, neck dissection etc) along with anti tubercular medication (CAT-2 SHRZE) for tubercular cervical lymphadenopathy . Required data regarding diagnostic findings and method of surgery were retrieved. Data thus obtained were analyzed using SPSS version 16 for testing the significance of data, Pearson chi square was used as test of significance. A p-value of <0.05 was considered statistically significant. Results: Out of total 100 patients operated, 28 were male and 72 were female. 128 Bangladesh J Otorhinolaryngol Vol. 23, No. 2, October 2017


Introduction:
Tuberculosis (TB) is a granulomatous inflammatory disease caused by mycobacterium tuberculosis. Lymphadenitis is the most common extrapulmonary manifestation of tuberculosis.Tuberculous lymphadenopathy commonly involves lymphnodes of the head and neck region (posterior and anteriorcervical chains, supraclavicular fossae, submandibular) inwhich cervical lymphadenopathy is most common. 1-3 It is important for otolaryngologists to be aware of TB in head and neck region and its various manifestations. Tuberculous lymph-adenopathy is not a lifethreatening problem, but does require treatment by physicians and surgeons. The majority of patients tend to be young, healthy, working adults without constitutional symptoms. However, lymphadenopathy can progress to abscess and fistula formation, which can be disabling and socially unacceptable. 4 ATT under dots is the main treatment while surgery is required for enlarged lymph nodes or tuberculous lymph node which does not regress with medication. 5 Surgical techniques include aspiration, incision and drainage, curettage, complete surgical excision of the affected lymph nodes and overlying skin and selective nodal or functional neck dissection when required. 6 The diagnosis of TB is mainly based on a positive mycobacterial smear and/or culture, Gene X-Pert positive or the histopathological presence of a chronic or caseating granuloma. 7 Histopathology and Gene X-pert is the most confirmatory test. 8 In this study an attempt was made to evaluate the role of surgical dissection in tubercular cervical lymphadenopathy for diagnostic and therapeutic purposes.

Methods:
This observational study was conducted at Combined Military Hospital, Dhaka during the period of Jan 2015 to December 2016. The patient those reported to ENT outpatient department and those referred from Pulmonology and various other department are included in the study. The patient didn't had the confirmatory FNAC report underwent excision biopsy. In biopsy, materials is divided into three parts ( 1/3 rd in normal saline for c/ s, 1/3 rd in normal saline for Gene X-pert, 1/3 rd in formalin for histopathology.
Diagnostic findings were recorded in predesigned "diagnostic notes" register. Charts of the patients both male and female in the age range from 12 to 74 years were reviewed and operation notes analyzed. Total number of cases were 100. Approval of the Institutional Ethical committee was obtained for publishing the study. All patients gave informed written consent prior to study.
Inclusion criteria for tubercular lymphadenitis is clinical sign symptoms + caseation granuloma OR granuloma + Gene X-pert positive.Asymptomatic TB (without constitutional symptoms of TB) but biopsy showed caseation granuloma or granuloma + Gene X-pert positive also included in the study.
Patients do not response to anti tubercular therapy(CAT-1 HRZE) undergone surgical intervention( excision, neck dissection etc) along with anti tubercular medication (CAT-2 SHRZE) for tubercular cervical lymphadenopathy . Required data regarding diagnostic findings and method of surgery were retrieved. Data thus obtained were analyzed using SPSS version 16 for testing the significance of data, Pearson chi square was used as test of significance. A p-value of <0.05 was considered statistically significant.

Results:
Out of total 100 patients operated, 28 were male and 72 were female.
Incidence of tubercular lymphadenitis was more in case of female. The ratio of male and female is 2.57:1 .The age range of the patients was 12-74 years.
Tubercular lymphadenitis was diagnosed in 56 patient. 3 sarcoidosis, 2 kikuchi disease,2 toxoplasmosis, 3 foreign body granuloma , 8 lymphoma, 16 metastatic carcinoma, 6 non specific lymphadenitis and 4 patient was undiagnosed.  Surgical interventions were done in total 17 patients, 2 TB abscess during ATT (CAT-1 HRZE), 9 treatment failure patients and 6 relapse patients along with ATT (CAT-2 SHRZE) and all these patients had no relapse or treatment failure during further follow up.    Having caseation necrosis but no change in size 1 Having caseation necrosis but increase in size

Discussion:
The most common manifestation of mycobacterial infection encountered in otolaryngological practice is cervical lymphadenopathy (Munck and Mandpc, 2003). 9 A higher proportion of the patients are females (Polakova, 1993;Dvorski, 1989). 10 TCL is not a life-threatening problem, but does require treatment by physicians and surgeons. The majority of patients tend to be young, healthy, working adults without constitutional symptoms. However, lymphadenopathy can progress to abscess formation and fistula formation, which can be disabling and socially unacceptable. Physical and laboratory findings may be inconsistent or unreliable. They can mimic other pathologic processes which may be treated with either surgery or medication 11 ATT under DOTS is the main treatment while surgery is required for enlarged lymph nodes or TCL which does not regress with medication 12 .
In our study out of total 56 patients patients were completely cured by ATT(CAT-1 HRZE) alone and only 02 required surgical interventions, 6 patients who were cured by ATT(CAT-1 HRZE)had relapse and required 2 nd surgical interventions. Surgical interventions were done in total 17 patients{(2 TB abscess patients during ATT(CAT-1 HRZE),9 treatment failure patients and 6 relapse patients} and all these patients were completely cured without relapse or treatment failure after surgical intervention and (CAT-2 SHRZE) during follow up. were treated with drug therapy alone had problems: 2progressed to abscess formation and 4 had residual enlargement of their lymph nodes that required surgery. Of the47 cases with multiple cervical lymph nodes e"3 cm in diameter, 13 were treated with medication alone; 9 (69%) did well and 4 developed an abscess and had residual lymphadenopathy.
Similar to other studies, our study has also reported that combination of surgical intervention with anti tubercular chemotherapy showed better outcome compared to chemotherapy alone.

Conclusion:
Surgical intervention has strong role to confirm diagnosis in undiagnosed patient. Antitubercular treatment is main treatment for tubercular lymphadenitis but in those patients who developed complications and those got relapse or failure to antitubercular treatment require surgical interventions. Early surgical intervention in these patients reduce complications such as abscess, sinus, fistula formation, or spread of disease to other parts of body. Timely surgical intervention also reduce the morbidity and increase the quality of life of patients.