A 62-year-old man presented with history of a left-sided neck swelling for 20 days which was progressive in nature associated with odynophagia and hoarseness. He gave history of chronic nonproductive cough for three months with loss of appetite. There was no history of fever or hemoptysis. His past history was insignificant except for a residual left hemiparesis due to a cerebrovascular accident 7 years ago.
Examination revealed an ill-defined swelling on the left anterior aspect of the neck, approximately 4 x 3 cms which was cystic, fluctuant, and nontender. There were no palpable neck nodes, and oral cavity was normal.
Flexible nasal endoscopy (Olympus flexible endoscope) revealed a normal laryngopharynx except for a mucosal swelling on the left side of vallecula.
A provisional diagnosis of neck abscess was made. We aspirated the abscess with an 18G needle and drained 20 mL of pus. The pus was sent for routine culture, fungal smears, and AFB (acid fast bacilli) smears which did not yield any positive result.
Three samples of sputum for AFB were sent in view of a cavity seen in the left upper zone on the chest X-ray (Figure 1), which were negative. Blood investigations done showed no immunocompromised status or other sources of infection.
A contrast enhanced computed tomography of the neck and thorax revealed an enhancing ill-defined osteolytic lesion of the body of hyoid with peripherally enhancing collection. The collection extended anteroinferiorly beneath the strap muscles along the anterior aspect of the thyroid cartilage (Figure 2).
Posteriorly the collection was found to protrude into the preepiglottic space (Figure 3). An incision and drainage of the abscess were planned. However as the patient suddenly developed a muffled voice, an elective tracheostomy was performed in anticipation of an impending airway compromise.
Intraoperatively there was a necrotic tissue with sero-sanguineous collection in the preepiglottic space. About 20 mL of fluid was drained. The body and the greater and lesser cornu of hyoid bone on the left side were found to be necrotic.
Histopathology of the hyoid revealed fibrocollagenous tissue with many discrete and confluent granulomas composed of epitheloid histiocytes and Langhans-type multinucleate giant cells rimmed by lymphocytes. Special stains done for fungal organisms were negative. A polymerase chain reaction study confirmed the diagnosis of tuberculosis.