A 45-year-old male patient presented with a swelling in the right submandibular region (just inferior to the angle and adjoining part of the body of the mandible) associated with pain for one month. The onset of symptoms was sub acute in nature. There was no history of fever, cough, weight loss or other systemic symptoms ("B" symptoms). There were no symptoms suggestive of pulmonary tuberculosis. The patient was immunocompetent and there was no family history of tuberculosis. The patient consulted a dentist, who diagnosed it as lower jaw tooth abscess. He was treated with antibiotics and lower 2nd molar tooth extraction was done. Even after 2 weeks of treatment the swelling increased in size, hence the patient was referred to the surgical outpatient department. His general physical examination was unremarkable. Local examination detected a diffuse, non-tender, hard, bi-digitally palpable swelling of 6 cm Chi 5cm in the submandibular region just inferior to the angle and adjacent part of the body of the mandible on the right side. The skin overlying the swelling was normal. The swelling was indistinguishable from the mandible. There was no purulent discharge from the Wharton's duct and its opening was normal. The rest of the oral cavity and oropharyngeal examination was unremarkable. The deep cervical lymph nodes were palpable on right side (level 2); the biggest being 3 cm x 2cm in size, fixed and hard in consistency [Figure 1]. The rest of the systemic examination revealed no abnormality.
The complete blood count was normal except for a raised ESR of 45 mm. Liver function tests (LFT) including the liver enzymes and serum proteins were within normal limits. Chest X-ray did not reveal any pulmonary lesion. Enzyme linked immuno sorbent assay (ELISA) for human immunodeficiency virus (HIV) and hepatitis B surface antigen (HBs Ag) were non-reactive. Fine needle aspiration cytology (FNAC) from the swelling showed benign ductal cells, stromal fragments with fibrosis, myxoid ground substance with few neutrophilic and lymphocytic inflammatory cells suggestive of chronic sialadinitis. FNAC from the lymph node showed reactive population of lymphoid cells, suggestive of reactive hyperplasia; few histiocytes, and vague epithelioid granulomas. The pathologist suggested incisional biopsy to rule out tuberculosis. The radiograph did not show any abnormality in the mandible. CT scan of head and neck showed enlarged right submandibular salivary gland with diffuse fat stranding. Inflammatory hypo dense mass was noted surrounding the gland with thickening of overlying subcutaneous tissue and skin. Enlarged right submandibular lymph node and a necrotic right deep cervical lymph node (level 2), 1.2 cm size were noted. Fat planes of mylohyoid muscles were lost. Bony structures of neck showed no abnormality. These findings suggested the possibility of inflammatory etiology-right submandibular sialadinitis [Figure 2]. Incisional biopsy from the swelling showed chronic inflammatory process with a few vague granulomas comprising epithelioid cells, Langhan's giant cells, and lymphocytes. Special stains for acid fast bacillus (AFB) were negative. These features were suggestive of chronic granulomatous disease, most likely tuberculosis [Figure 3a and b]. Serology for toxoplasmosis proved negative. Polymerase chain reaction (PCR) for mycobacterium tuberculosis was positive. Based on these findings, tuberculous sialadenitis was diagnosed and antitubercular treatment (ATT) was started, i.e., Isoniacid (INH) 300 mg, Rifampicin 450 mg, Pyrazinamide 1500 mg, and Ethambutol 800 mg for 2 months; INH 300 mg and Rifampicin 450 mg for 7months. Patient responded well to seven months' ATT and the swelling completely disappeared [Figure 4]. At 6 months post-ATT follow-up, the patient was asymptomatic without any swelling.