Mandibular Tuberculosis

Topic Name Introduction Clinical Manifestations Diagnosis Differential Diagnosis Management Complications Special Considerations

Introduction

Mandibular tuberculosis is a rare form of extrapulmonary tuberculosis affecting the mandibular bone, accounting for less than 3% of skeletal tuberculosis cases in children. It presents unique diagnostic challenges due to its nonspecific presentation and potential confusion with other mandibular pathologies.

Key Points

• Age predilection: Usually affects children aged 4-12 years
• Gender distribution: Slight male predominance
• Primary site: Most commonly affects the mandibular angle and ramus
• Association: May coexist with pulmonary TB in 50% cases

Pathophysiology

• Routes of Infection:
  • Hematogenous spread from primary focus
  • Lymphatic spread from cervical nodes
  • Direct extension from adjacent structures
  • Through extracted tooth socket or dental infection
• Tissue Response:
  • Granulomatous inflammation
  • Caseous necrosis
  • Bone resorption
  • Periosteal reaction

Clinical Manifestations

Early Symptoms

• Constitutional Symptoms:
  • Low-grade fever
  • Weight loss
  • Fatigue
  • Night sweats
• Local Symptoms:
  • Gradually increasing swelling
  • Dull, aching pain
  • Difficulty in mouth opening
  • Dental malocclusion

Advanced Manifestations

• Mandibular Involvement:
  • Pathological fractures
  • Multiple sinus formations
  • Sequestration
  • Loosening of teeth
• Soft Tissue Signs:
  • Cervical lymphadenopathy
  • Abscess formation
  • Cutaneous fistula
  • Facial asymmetry
• Functional Impairment:
  • Trismus
  • Difficulty in mastication
  • Speech alterations
  • Temporomandibular joint dysfunction

Diagnosis

Laboratory Investigations

• Hematological Tests:
  • Complete blood count
  • Elevated ESR (>50 mm/hr)
  • Increased CRP levels
• Immunological Tests:
  • Tuberculin skin test (Mantoux)
  • Interferon-gamma release assays (IGRAs)
• Microbiological Studies:
  • AFB staining from tissue/discharge
  • Culture on Löwenstein-Jensen medium
  • PCR for MTB DNA
  • Gene Xpert MTB/RIF assay

Imaging Studies

• Conventional Radiography:
  • Panoramic views
  • Lateral oblique views
  • PA mandible views
• Advanced Imaging:
  • CT Scan findings:
    • Lytic lesions
    • Cortical erosion
    • Sequestration
    • Periosteal reaction
  • MRI features:
    • Bone marrow changes
    • Soft tissue involvement
    • Abscess delineation

Histopathological Examination

• Characteristic Features:
  • Epithelioid granulomas
  • Langhans giant cells
  • Caseous necrosis
  • Chronic inflammatory infiltrate

Differential Diagnosis

• Infectious Conditions:
  • Osteomyelitis
  • Actinomycosis
  • Non-tuberculous mycobacterial infection
• Neoplastic Conditions:
  • Primary bone tumors
  • Metastatic lesions
  • Langerhans cell histiocytosis
• Inflammatory Conditions:
  • Sarcoidosis
  • Chronic recurrent multifocal osteomyelitis

Management

Medical Management

• Anti-tubercular Therapy:
  • Initial Phase (2-3 months):
    • Isoniazid (10 mg/kg/day)
    • Rifampicin (15 mg/kg/day)
    • Pyrazinamide (35 mg/kg/day)
    • Ethambutol (20 mg/kg/day)
  • Continuation Phase (4-7 months):
    • Isoniazid
    • Rifampicin
• Supportive Care:
  • Nutritional supplementation
  • Pain management
  • Dental hygiene maintenance

Surgical Management

• Indications:
  • Large sequestrum
  • Pathological fracture
  • Non-healing sinuses
  • Extensive bone destruction
• Procedures:
  • Sequestrectomy
  • Curettage
  • Sinus tract excision
  • Mandibular reconstruction (if needed)

Complications

• Early Complications:
  • Abscess formation
  • Sinus tract development
  • TMJ ankylosis
  • Facial deformity
• Late Complications:
  • Pathological fracture
  • Permanent jaw deformity
  • Growth disturbances
  • Dental malocclusion

Special Considerations

Monitoring and Follow-up

• Clinical Monitoring:
  • Monthly assessment of symptoms
  • Evaluation of drug side effects
  • Growth monitoring
  • Dental assessment
• Investigations:
  • Serial ESR monitoring
  • Liver function tests
  • Follow-up imaging

Prevention

• Early detection of primary TB
• Contact screening
• Maintenance of oral hygiene
• Regular dental check-ups

Prognosis

• Favorable with early diagnosis
• Complete healing in 6-12 months
• Risk of residual deformity
• Need for long-term follow-up

Disclaimer

The notes provided on Pediatime are generated from online resources and AI sources and have been carefully checked for accuracy. However, these notes are not intended to replace standard textbooks. They are designed to serve as a quick review and revision tool for medical students and professionals, and to aid in theory exam preparation. For comprehensive learning, please refer to recommended textbooks and guidelines.