Primary Tubercular Sialadenitis - A Diagnostic Dilemma

Abstract

Introduction: Involvement of the salivary glands in tuberculosis is rare, even in countries where tuberculosis is endemic. It can occur by systemic dissemination from a distant focus or, less commonly, as primary involvement. This article focuses on its myriad clinical presentations that pose a diagnostic challenge to the clinician. We discuss the schema of investigations required to confirm the diagnosis and the limitations faced in the low-cost setting of a developing country.

Materials and methods: Medical records, including history, physical examination and imaging findings, and the results of cytological, microbiological and histopathological studies of patients diagnosed with primary tubercular sialadenitis were retrieved and analyzed.

Results: Seven patients were treated over a 2-year period. The most common mode of presentation was a painless mass of the involved gland in four patients. One patient each presented with chronic non-obstructive sialadenitis, sialolithiasis, and acute suppurative sialadenitis. Fine needle aspiration cytology was diagnostic in five out of seven cases (71.4%), while mycobacterial culture was positive in two patients (28.6%). In one patient, a diagnosis could only be reached on histopathological examination of the resected gland.

Conclusion: We recommend cytology studies, acid-fast bacilli staining, and mycobacterial culture as the initial investigation on the aspirate in suspected patients, while polymerase chain reaction should be reserved for negative cases. A high index of suspicion, early diagnosis, and timely institution of anti-tuberculosis treatment is essential for establishing cure. The role of surgery in diagnosed cases of tuberculosis is limited.

Keywords: Parotid gland; Salivary fistula; Salivary gland calculi; Sialadenitis; Submandibular gland; Tuberculosis.

Fig 1

Right submandibular swelling, which increases with food intake. Associated with palpable calculus in submandibular duct

Fig 2

Right submandibular swelling associated with pain. Arrow marks the site of FNAC

Fig 3

Submandibular swelling (arrow) associated with lymph node enlargement at level 2 (star)

Fig 4

Bilateral diffuse parotid swelling with right sided grade 3 facial palsy

Fig 5

Parotid swelling with multiple fistulas over it

Fig 6

Contrast-enhanced CT scan of previous patient showing a bulky left parotid gland with multiple necrotic intra-parotid lymph nodes

Fig 7

Healed scar post-excision of submandibular gland and fistula