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Oral Surgery

Authors: Dr. Monika Parmar, Dr. Manish Sahore, Dr. Abhishek Soni

ABSTRACT

Tuberculosis is a recognised occupational risk for dentists, as their close proximity to the nasal and oral cavities of the patient. It is a prevalent systemic bacterial infectious disease usually caused by mycobacterium tuberculosis.Cervical tubercular lymphadenitis is acommon cause of extra-pulmonary tuberculosis.The common sites of involvement are Submandibular lymphnodes.Tuberculous lesion in the oral and maxillofacial region generally develops secondary to pulmonary disease.Here, in this case report we present a case of a 23 year old female patient with painless swelling in the lower right submandibular region.She was diagnosed with right submandibular lymphadenitis without pulmonary involvement based on fine needle aspiration cytology biopsy and MRI.

INTRODUCTION

Tuberculosis is a chronic granulomatous infection principally caused by Mycobacterium tuberculosis and less frequently by ingestion ofMycobacterium bovis infected unpasteurized cow’s milk or by other atypical mycobacteria.1There are nearly 9 million new cases and 2 million deaths from tuberculosis worldwide every year.2The regions with the highest incidence rates are the Indian subcontinent,southeast Asia, and Africa.3

The incidence of mycobacterial lymphadenitis has increased in with the increase in the incidence of mycobacterial infection worldwide.Tuberculosischiefly affects the pulmonary system besides involving extra-pulmonary locations, comprising head and neck region. Extra pulmonary tuberculosisis rare occurring in 0.05-5% ofpatients with tuberculosis.1 Extrapulmonary tuberculosis may present in concurrence with a focus in the lungs or may present primarily without pulmonary involvement. The latter situation may provide a difficulty in diagnosis due to the absence of systemic signs and symptoms of the disease.\Chest radiographs are required to rule out pulmonary tuberculosis, even in those without systemic signs and symptoms of the disease.5

Only emergency dental cases should be undertaken for treatment in controlled environments for those with active tuberculosis.6The constant risk of contacting the disease should encourage dental clinicians to follow basic precautions of using face masks,protective eye gear, and gloves. Also, high standards of operatory disinfection and instrument sterilization should be maintained.7

Dentists are involved in the effort to control tuberculosis through identification and referral of patients who may require chemoprophylaxis or treatment and by developing and implementing an appropriate infection control program. Submandibular swellings are common phenomena that require a precise diagnosis. The differential diagnosis involves mainly the pathologic conditions involving the regional lymph nodes and the submandibular salivary glands. Both of these can have either an inflammatory or neoplastic basis.8Here, we report the case of a 23 year old female patient diagnosed with submandibular tuberculous lymphadenitis without pulmonary involvement, which resolved completely after anti-tuberculosis therapy.

CASE REPORT

A 23-year-old female patientreported to Oral and Maxillofacial Surgery department in Hiimachal Pradesh government dental college and hospital,Shimla, with the chief complaint of a painless swelling in the lower right side of the jaw since 3 months. The swelling was small in size and has gradually increased to the present size. There was noassociated history of any abscess or pus discharge secondary to decayed tooth. Previously the patient consulted local dentist at panchkula, fine needle aspiration biopsy done revealing pleomorphic adenoma.Initially it was suspected for pleomorphic adenoma. patient was advised for repeating FNAC and MRI at our centre.

General examination concluded that the patient was moderately built and minor signs such as weight loss, fever, and cough were absent. Past medical and family history was not significant. Extra-oral examination presented a distinct localised enlargement with precise borders of nearly 4 cm × 3 cm in the right submandibular region. The superimposing skin was the same as the surrounding skin. On palpation a mass was felt in the right submandibular region which was enlarged,firm in consistency,non- tender, non-fluctuant, non-compressible, mobile, and showed signs of matting. On intraoral examination,there was grossly decayed lower right first, second and third molar tooth.

Differential diagnosis of right submandibular tuberculous lymphadenitis,pleomorphic adenoma, submandibularsialadenitis,submandibular gland calcification was considered. A clinical diagnosis of right submandibular tuberculous lymphadenitis was considered. The routine blood investigations were done for the patient along with peripheral smear, blood culture, however, there was no variation identified except that increased erythrocyte sedimentation rate.Her chest X-ray gave a normal impression.A panoramic radiograph was carried out and it did not reveal odontogenic origin in relation to the swelling.

Patient was advised for ultrasound of the neck that revealed multiple hypo-echoic nodular lesions of varying sizes in the right submandibular region giving the impression as submandibular sialadenitis with no obvious collection. A MRI scan was also instructed for her, report of which presented with all the cervical lymph nodes involvement extending till mediastinal lymph nodes. Ultrasound-guided fineneedle aspiration biopsy (FNAB) revealed a cellular aspirate showing plenty of small and large lymphocytes. Necrotic debris was seen in focal areas, and few epitheloid cells or giant cells seenThe ultrasound-guided FNAB report was compatible with that of tuberculous lymphadenitis.Regarding the clinical presentation of the case and the investigation reports a final diagnosis of right submandibulartuberculous lymphadenitis was arrived at.

The patient was referred to the tuberculosis hospital for further treatment. Treatment consisted of anti-tuberculosis drugs for a period of 6 months. No complicationsoccurred, and no further surgery was required.

DISCUSISION

In the present case the patient had a swelling of about 4× 3 cm in the right submandibular region. Intraoral examination revealed no obvious odontogenic involvement, which could be the cause of the swelling. A panoramic radiograph of the affected area was taken to check for any underlying source of odontogenic involvement with respect to the swelling; it did not revealed any odontogenic origin in relation to the swelling and thus it was determined that the swelling was non-odontogenic in origin.

Non-odontogenic nature of the swelling was taken into consideration for a differential diagnosis of rightsubmandibular sialadenitis, submandibular gland calcification,pleomorphic adenoma and submandibular tuberculouslympadinitis. A chest radiograph of the patient was taken and no abnormality was observed in the chest radiograph. If a tubercular lesion is suspected, a chest X-ray is indicated to investigate the possibility of pulmonary involvement.9To evaluate the swelling further, an ultrasound scan of the patient was takenWith the results of all the above investigations pointing towards a diagnosis of tuberculosis lymphadenitis, an ultrasoundguidedFNAB was carried out for the histopathological examination,and MRI was advised.

Primary tuberculosis of the oro-facial region is more commonly found in children and adolescents than in adults.10In the present case, the clinical presentation of the case, and the investigation reports were taken into consideration for afinal diagnosis of right submandibular primary tuberculouslymphadenitis.

SUMMARY

tuberculosis affecting primarily cervical lymph nodes is uncommon. In absence of systemic signs and symptoms, as in our case, it can be difficult to diagnose tuberculosis. Awareness by the clinician of such a presentation would make diagnosis of tuberculosis easier. Diagnosis of the disease in the initial stages would be beneficial not only to the patient to allow them to receive early treatment,but also in preventing the spread of the disease to others Thus, oral clinicians can contribute to the diagnosis of tuberculosis with awareness of the presentation of the disease and extra care in their regular practice.

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