Tuberculosis in ENT
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Direct answer
Tuberculosis involves the head and neck more often than any other extrapulmonary territory, and cervical lymphadenitis — scrofula — leads the list: painless matted posterior-triangle nodes progressing to cold abscess and, untreated, a collar-stud sinus. Laryngeal tuberculosis presents with hoarseness from a granular or ulcerated larynx that can mimic carcinoma, classically posterior; tuberculous otitis media is painless otorrhoea with multiple perforations, pale granulations and early facial palsy. Fine-needle aspiration or biopsy with cartridge-based nucleic acid amplification testing (CBNAAT/TrueNat under India's National TB Elimination Programme) delivers diagnosis and rifampicin sensitivity within hours; treatment is antitubercular therapy, with surgery reserved for drainage and diagnostic tissue.
What you must remember
- Cervical lymphadenitis: painless firm nodes matting into groups (level V favoured), progressing through caseation to a fluctuant cold abscess, then a collar-stud abscess and discharging sinus — the physical sign most written in Indian practicals.
- Laryngeal TB: hoarseness with posterior glottis and arytenoid granular or ulcerative change in cavitary lung disease; modern lesions may involve the anterior glottis and mimic carcinoma, so biopsy is mandatory.
- Tuberculous otitis media: painless chronic otorrhoea with multiple perforations, pale, pale granulations early facial nerve palsy (compared with ordinary CSOM), and hearing loss out of proportion; culture-confirmation on aural discharge or biopsy tissue completes the diagnosis.
- Other sites: pharyngeal ulcers, retropharyngeal cold abscess, lupus vulgaris of facial skin, tuberculosis of the temporal bone, and tuberculous meningitis with cranial nerve palsies.
- Diagnostic ladder as practised in India: fine-needle aspiration cytology or biopsy showing caseating granulomas, then CBNAAT (GeneXpert) or TrueNat on the same sample for Mycobacterium tuberculosis and rifampicin resistance within hours — liquid culture remaining the reference standard; sputum and chest imaging accompany, as pulmonary disease changes the public-health pathway.
- Treatment per NTEP: daily therapy under direct observation — two months of isoniazid, rifampicin, pyrazinamide and ethambutol, then four months of continuation therapy per current NTEP guidance; corticosteroids for laryngeal oedema; drug-resistant disease follows NTEP regimens after sensitivity testing.
- Surgical role: aspiration of cold abscess through healthy skin, excision biopsy where diagnosis is in doubt, and closure of healed sinuses — excision never replaces chemotherapy.
- The Indian weight of the topic: India carries the world's largest TB burden, so every chronic neck node, non-healing oral ulcer and atypical chronic otitis media is investigated with TB on the differential — the clinical reflex the exam expects you to articulate.
From node to diagnosis in a district hospital
A 26-year-old woman has a three-month painless right neck lump: matted level V nodes, non-tender, with evening fevers and weight loss. Fine-needle aspiration returns caseating granulomas, and CBNAAT on the aspirate detects Mycobacterium tuberculosis with rifampicin sensitivity the same day.
She is registered under NTEP and started on daily therapy; the nodes shrink over two months without drainage. Had she presented later with a fluctuant swelling: aspiration through healthy skin, or excision biopsy if diagnosis were in doubt — but chemotherapy remains the definitive treatment. Now substitute a 55-year-old smoker with hoarseness and an ulcerated cord lesion that looks like carcinoma: biopsy granulomas with CBNAAT positivity confirm laryngeal tuberculosis, and therapy restores the voice. In India, tissue answers before assumption, and every specimen travels with a TB test.
Where examiners dig
The first question is the cold abscess: what is it, and how is it drained? A caseating, non-inflamed abscess of tuberculous origin, drained by aspiration through healthy skin away from the adherent site precisely to avoid a chronic sinus — the technical detail that separates a pass answer from a good one. The second is the collar-stud abscess: the tuberculous abscess erodes between two layers of deep cervical fascia and presents as a dumbbell configuration, a standard short-note diagram. Third, tuberculous versus ordinary chronic suppurative otitis media: painless, pale, multiple perforations, disproportionate hearing loss and early facial palsy favour tuberculosis. And examiners expect national programme vocabulary — CBNAAT, TrueNat, daily therapy under NTEP — not a generic "ATT for 6 months".
Frequently asked questions
What is scrofula and how does it evolve?
Tuberculous cervical lymphadenitis — painless matted nodes progressing to caseation, cold abscess, collar-stud configuration and, untreated, a discharging sinus over the neck.
How does tuberculous otitis media differ from ordinary CSOM?
It is typically painless with pale granulations and multiple perforations, hearing loss out of proportion, and a notable tendency to early facial nerve palsy.
Which rapid test confirms tuberculous lymphadenitis in India?
Cartridge-based nucleic acid amplification testing (CBNAAT, GeneXpert) or TrueNat on aspirate or biopsy tissue, detecting Mycobacterium tuberculosis and rifampicin resistance within hours under NTEP.
How is laryngeal tuberculosis treated?
With antitubercular therapy under NTEP — two months of four drugs followed by a continuation phase; corticosteroids may be added for laryngeal oedema.
Why is a cold abscess aspirated through healthy skin?
To avoid traversing the adherent, thinned skin over the abscess, which would seed the tract and create a persistent tuberculous sinus — aspiration at a distance, or excision, protects the skin.