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National Journal of Maxillofacial Surgery
 
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Table of Contents
CASE REPORT
Year : 2012  |  Volume : 3  |  Issue : 2  |  Page : 199-201  

Tuberculosis of parotid gland masquerading parotid neoplasm


1 Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
3 Department of Cytology, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication4-May-2013

Correspondence Address:
Sameer Vyas
Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-5950.111381

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   Abstract 

Parotid gland involvement in tuberculosis is rare. We present a case of middle aged male presenting with parotid swelling for 1 year and diagnosed to have parotid tuberculosis on fine needle aspiration cytology. A brief review of radiological findings in tuberculous parotitis is discussed which can help in correct interpretation and timely diagnosis, and thus avoiding unnecessary parotidectomies.

Keywords: Cytology, parotid, tuberculosis


How to cite this article:
Vyas S, Kaur N, Yadav TD, Gupta N, Khandelwal N. Tuberculosis of parotid gland masquerading parotid neoplasm. Natl J Maxillofac Surg 2012;3:199-201

How to cite this URL:
Vyas S, Kaur N, Yadav TD, Gupta N, Khandelwal N. Tuberculosis of parotid gland masquerading parotid neoplasm. Natl J Maxillofac Surg [serial online] 2012 [cited 2019 Nov 20];3:199-201. Available from: http://www.njms.in/text.asp?2012/3/2/199/111381


   Introduction Top


Tuberculous involvement of parotid gland is extremely rare. [1],[2],[3],[4] It is generally overlooked by clinicians and otolaryngologists (even in countries where tuberculosis is endemic) with most of cases undergoing unnecessary surgeries. [4],[5],[6],[7],[8],[9] Correct radiological interpretation can help in differentiating tuberculous involvement from benign neoplasms (pleomorphic adenoma) with which it is commonly confused.


   Case Report Top


A 45-years-male presented with mass in right parotid region, progressively increasing for last 1 year. No abnormality was found on physical examination. Local examination revealed a palpable 5 × 4 × 4.5 cm firm to hard lobulated mass in the right parotid region with no obvious systemic complaints. Ultrasound examination­ [Figure 1] using a linear array transducer showed diffusely­ enlarged right parotid gland with heterogeneously­ hypoechoic echotexture with no calcification­ or cystic degeneration. Contrast-enhanced computed tomography of neck [Figure 2] showed right parotid enlargement with illdefined hypodense lesions. A provisional diagnosis of neoplasm was made. Fine needle aspiration cytology (FNAC) done from the lesion proved to be tuberculosis [Figure 3] with positive stain for acid fast bacilli (AFB). Retrospective analysis of radiological images provided clue to the lesion being infective (tuberculous) rather than neoplastic. The patient was successfully treated with standard anti-tubercular regimen for 6 months and showed complete resolution of the disease.
Figure 1: USG of right parotid region showed diffusely enlarged parotid gland with heterogeneously hypoechoic echotexture of parotid parenchyma and multiple focal anechoic areas with thick walls (arrows)

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Figure 2: Contrast enhanced CT neck showed enlarged right parotid gland with multiple central hypodense areas showing peripheral enhancement (arrows)

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Figure 3: Fine needle aspiration cytology showing an epithelioid cell granuloma, necrotic fragment and a tiny cluster of salivary ductal epithelial cells (arrow) in a background comprising of lymphocytes and histiocytes (Hematoxylin and Eosin 20×)

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   Discussion Top


Extrathoracic involvement in tuberculosis occurs in approximately 20% of cases with tuberculous lymphadenitis being most common form involving cervical lymph nodes. [1],[2] Isolated involvement of parotid gland by mycobacterium is rare. [10],[11],[12],[13] Salivary gland infection is believed to be direct extension of the bacilli from the oral cavity via the gland ductal system (due to preceding tooth or tonsil infection). Hematogenous or lymphatic spread of infection is also known. 25% of patients with isolated tubercular parotitis have pulmonary infection. [4] Clinical presentation can be acute in form of parotitis or chronic as progressively increasing mass of months to years duration. [4] Chronic cases are difficult to distinguish from benign parotid neoplasms (pleomorphic adenoma). Preoperative diagnosis can be suggested by imaging methods with confirmation of diagnosis by FNAC/biopsy.

Imaging modalities for evaluating parotid and other salivary gland include ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI). They are helpful in differentiating benign from malignant neoplasms. [10],[11],[12],[13] In addition, they are very useful in showing whether a palpable lesion arises within the parotid gland or is periparotid in location. Radiologically tubercular parotitis can be differentiated as parenchymal and periparotid type. [5] Sonographically parenchymal type presents as diffusely enlarged gland showing heterogeneously hypoechoic parenchyma with focal hypoechoic or anechoic areas within the gland. On colour Doppler minimally increased colour flow has been reported around the anechoic lesions. [5] Periparotid type presents with enlarged hypoechoic nodes in periphery of gland with parenchyma showing hyperechogenicity. [5] Neoplasms appear as well defined hypoechoic nodule with necrosis or hemorrhage seen as cystic areas with significant color flow with tumour substance on colour Doppler imaging. CT findings of a solid nodule with homogeneous enhancement, multiloculated rim enhancing nodule with central lucency and contrast enhancing solid nodule with an eccentric nonenhancing microcyst have been reported. [6],[7] Specific CT findings are multiple round, smooth thick, walled rim enhancing lesion with central lucency within parotid with parenchyma showing diffuse enhancement with filling defects. [8] Two typical patterns of tuberculous lymphadenitis are multilocated nodal mass with thick smooth-walled enhancing rims and central lucency and another pattern of low-density central mass with thick corrugated enhancing rim. [8] Non-specific pattern are homogeneously enhanced masses and thin rim enhancing­ masses. On MRI lesions are hypointense on T1-weighted images, hyperintense on T2-weighted images with homogeneous postcontrast enhancement. FNAC or biopsy can be done to confirm the diagnosis with identification of bacilli by Ziehl-Neelsen (ZN) staining for AFB or culture methods. Medical therapy is treatment of choice with most of patients showing complete recovery. Index case has been treated with antitubercular therapy with near complete resolution of parotid swelling. The differential diagnosis of parotid mass lesion includes generally benign and malignant neoplasm of the parotid gland; however, tuberculosis and sarcoidosis should also be considered.

To conclude, parotid tuberculosis is an uncommon entity with atypical clinical presentations. It should be kept as differential diagnosis in solitary slowly enlarging parotid swelling with further characterization of the lesion by various imaging modalities. Correct radiological interpretation can rule out benign parotid neoplasm in most of cases and provide clue toward tubercular pathology.

 
   References Top

1.Lee IK, Liu JW. Tuberculous parotitis: Case report and literature review. Ann Otol Rhinol Laryngol 2005;114:547-51.  Back to cited text no. 1
    
2.Hamdan AL, Hadi U, Shabb N. Tuberculous parotitis: A forgotten entity. Otolaryngol Head Neck Surg 2002;126:581-2.  Back to cited text no. 2
    
3.Talmi YP, Shem-Tov Y, Gal R, Finkelstein Y, Zohar Y. Tuberculosis of a periglandular lymphnode presenting as a parotid tumor. J Otolaryngol 1990;19:73-5.  Back to cited text no. 3
    
4.Zheng JW, Zhang QH. Tuberculosis of the parotid gland: A report of 12 cases. J Oral Maxillofac Surg 1995;53:849-51.  Back to cited text no. 4
    
5.Chou YH, Tiu CM, Liu CY, Hong TM, Lin CZ, Chiou HJ, et al. Tuberculosis of the parotid gland: Sonographic manifestations and sonographically guided aspiration. J Ultrasound Med 2004;23:1275-81.  Back to cited text no. 5
    
6.Reede DL, Bergeron RT. Cervical tuberculous adenitis: CT manifestations. Radiology 1985;154:701-4.  Back to cited text no. 6
    
7.Wei Y, Xiao J, Pui MH, Gong Q. Tuberculosis of the parotid gland: Computed tomographic findings. Acta Radiol 2008;49:458-61.  Back to cited text no. 7
    
8.Bhargava S, Watmough DJ, Chisti FA, Sathar SA. Case report: Tuberculosis of the parotid gland-diagnosis by CT. Br J Radiol 1996;69:1181-3.  Back to cited text no. 8
    
9.Birkent H, Karahatay S, Akcam T, Durmaz A, Ongoru O. Primary parotid tuberculosis mimicking parotid neoplasm: A case report. JMed Case Rep 2008;2:62.  Back to cited text no. 9
    
10.Thakur JS, Thakur A, Mohindroo NK, Mohindroo S, Sharma DR. Bilateral parotid tuberculosis. J Glob Infect Dis 2011;3:296-9.  Back to cited text no. 10
    
11.Garg R, Verma SK, Mehra S, Srivastawa AN. Parotid tuberculosis. Lung India 2010;27:253-5.  Back to cited text no. 11
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12.Süoglu Y, Erdamar B, Cölhan I, Katircioglu OS, Cevikbas U. Tuberculosis­ of the parotid gland. J Laryngol Otol 1998;112:588-91.  Back to cited text no. 12
    
13.Janmeja AK, Das SK, Kochhar S, Handa U. Tuberculosis of the parotid gland. Indian J Chest Dis Allied Sci 2003;45:67-9.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]


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