Nasal obstruction, rhinorrhagia, epistaxis, and headache, are common symptoms of this disease. In the physical assessment or with nasal endoscopy, nasal and nasopharyngeal granular lesions are observed, a biopsy is possible to perform under local anesthesia. The obtained material is sent for both histopathological examination, mycobacterial culture and susceptibility testing.

  Pharyngeal tuberculosis is a rare extrapulmonary manifestation. Pharyngeal tuberculosis presents as the main reason for consultation odynophagia and long-term difficulty in swallowing, where there is no response to conventional treatment. On physical examination, the posterior pharyngeal wall, tonsils, and uvula showed the presence of whitish, punched-out lesions, erythematous and swollen mucosa. There is also bilateral lymphadenopathy in the upper and middle jugular region, painless and without signs of phlogosis.

  The material obtained from the biopsies goes to the Histopathology laboratory, the Microbiology laboratory for smears, culture, and PSD of mycobacteria.

  Histopathological examination is performed by staining with hematoxylin-eosin. Diagnosis is provided by the presence of chronic granulomatous inflammatory exudates, with or without classification.

  The microbiological diagnosis through the detection of acid-fast bacilli in smears. Although it may take 6 weeks or longer for the organism to grow on solid culture media, growth generally occurs within 7 to 21 days with liquid culture media. Culture is also necessary for drug susceptibility testing. On the other hand, molecular techniques, such as the polymerase chain reaction, detect DNA or RNA from samples with results much faster than culture and can often be obtained in 24-48 hours [10].

  The definitive diagnosis is made by the histological study of the biopsy of the lesion and the isolation of the mycobacterium. Identification of the latter is important, since the finding of acid-fast bacilli may be due to an infection caused by nontuberculous mycobacteria.

  Surgery is performed to establish the diagnosis and be able to begin effective treatment, therapy starts with 4 drugs [11] initial phase with isoniazid, rifampicin, pyrazinamide, and ethambutol followed later treatment with isoniazid and rifampicin.

Discussion

  Tuberculosis (TB) is one of the most frequent granulomatous infections that affect the ENT region. With the advent of TB therapy, the incidence has dropped significantly, but there is a resurgence of extrapulmonary TB (EPTB), including primary otolaryngological TB due to the human immunodeficiency virus (HIV).

  The diagnosis of the disease in otorhinolaryngology is a challenge since the symptoms are like those of other pathologies. Differential diagnoses should be made with other chronic infections, such as fungal infection, syphilis, leprosy, with non-infectious diseases such as neoplasms, Wegener's granulomatosis [12,13]. This is possible through a histopathological examination since each of these conditions has a characteristic picture in histology.

  Laryngeal tuberculosis and tuberculosis of the middle ear, frequently associated with pulmonary tuberculosis [7], but can also present as primary tuberculosis in any of these areas.

  Patients with the immunosuppressive disease are more likely to have primary TB, especially of the extrapulmonary form [8].

Conclusion

  The suspected diagnosis of TB disease in the ENT area is important to establish adequate surgical treatment with sampling and thus be able to begin antituberculosis treatment. Tuberculosis in the primary ENT area can present without coexisting pulmonary tuberculosis. The histopathological (biopsy) and microbiological (culture) diagnosis of otorhinolaryngological TB given a positive result.