38 years old Malay lady presented with a month's history of bilateral neck swelling. The swelling was painless, gradually increasing in size and did not reduce any neck movement. She also experienced intermittent fever but was not associated with any other constitutional symptoms such as chills, weight loss, anorexia and night sweats. There was no history of epistaxis, rhinorrhea, nasal blockage, chronic cough, sore throat, hoarseness, ear fullness, tinnitus, or hearing impairment. 
She sought treatment at the health clinic and was prescribed with a course of oral augmentin. However, the neck swelling persisted. She had no history of contact with pulmonary tuberculosis-infected individuals and no history of malignancy in her family.
Neck examination revealed two lymph nodes over the left posterior triangle at level 5a, each measuring 1.5cm x 1.5cm and 3cm x 3cm, firm in consistency and non-tender.
On the right side of the neck, there was one lymph node at level 2 measuring 3cm x 3cm with similar characteristics. Oropharynx and ear examinations were unremarkable. Nasoendoscopy examination revealed a centrally located mass predominantly at the left posterior nasopharyngeal wall with an irregular surface but an otherwise normal fossa of Rosenmuller (FOR) and Eustachian tube (Figure 1). 
Blood parameters were within normal limits with the erythrocyte sedimentation rate (ESR) value of 14 mm/hour and a negative sputum acid-fast bacilli (AFB) staining. Chest radiography showed normal lung findings. 
Fine needle aspiration (FNAC) was performed over the left posterior triangle lymph node and showed features consistent with the necrotic lymph node. However, tuberculous lymphadenitis or tumour necrosis cannot be excluded from the cytological findings. Therefore, a contrasted enhanced computed tomography (CECT) scan was done and revealed a well-defined enhancing hypodense lesion, predominantly at the left posterior nasopharyngeal wall, measuring 8.2mm x 6.2mm, without any extension towards bilateral FOR (Figure 2a, 2b). 
There were also enlarged rim-enhancing hypodense lesions over bilateral level 2 and left level 5a of the neck (Figure 2c). 
An excision biopsy of the left posterior triangle lymph node and a biopsy of the nasopharyngeal mass was performed under general anaesthesia. Histopathological examination (HPE) revealed epithelioid cell granulomas with central areas of necrosis surrounded by epithelioid cells mixed with lymphoplasmacytic cell infiltrates and occasional Langhans type multinucleated giant cells (Figure 3). 
No fungal elements, atypical or malignancy cells present. Surprisingly, the Ziehl-Neelsen (ZN) stain for acid-fast bacilli was negative. A further study performed on the paraffin-embedded tissue for mycobacterium (MTB) polymerase chain reaction (PCR) was also negative for acid-fast bacilli. Given the histopathological findings showing typical features of necrotizing granulomatous lymphadenitis together with the clinical presentation, a diagnosis of nasopharyngeal tuberculosis was made. She was referred to the chest clinic at Hospital Sultan Abdul Halim, Sungai Petani, for the commencement of directly observed treatment short-course (DOTS) for nasopharyngeal tuberculosis.
She was treated with an anti-tuberculous therapy regime consisting of Isoniazid, Rifampicin, Ethambutol, Pyrazinamide and Pyridoxine for 2 months during the intensive phase followed by 4 months of Isoniazid and Rifampicin during the maintenance phase. Upon completion of her intensive phase of treatment, her neck swelling had completely resolved, and the nasopharyngeal mass was no longer visualized.