Tornwaldt's Disease

Tornwaldt's disease is the inflammation or abscess of the embryonic cyst of pharyngeal bursa. It is located in the midline of the posterior wall of the nasopharynx. It is covered anteriorly by mucosa in the adenoid mass. It is bounded posteriorly by longus muscle.

Signs and symptoms

The symptoms usually appear when there is inflammation of pharyngeal bursa causing Tornwaldt's cyst. This is caused by spontaneous drainage in the nasopharyngeal cavity or can also be caused because of involvement of nervous plexus. The symptoms are occipital headache, cough, middle ear effusion, cervical myalgia, halitosis ie bad breath. When there is an enlargement of the cyst it causes symptoms like nasal obstruction, post nasal discharge with foul smelling odour, blockage of Eustachian tube causing otalgia and secretory otitis media, retro orbital pain.

Cause

Tornwaldt's disease is caused by many different causative agents of stimulus. This includes excessive alcohol and tobacco which causes decrease in local immune resistance and so the pathogenic microbes take advantage and lead to the disease. Frequent contact with high temperature, malnutrition, chronic heart disease, kidney disease, joint disease, poor living and working conditions and contact with dust and harmful gases leads to the thornwaldt's disease.

Pathogenesis

Tornwaldt's disease is a rare benign disorder caused by persistent notochord remnants. This disease almost remains asymptomatic. At about the 10th week of embryonic development, the pharyngeal pouch forms by adhesion of the pharyngeal ectoderm to the cranial end of the notochord. This become closed at the orifice or crusts adhere to the orifice without closing. The contact between these remnants and pharyngeal ectoderm leads to the growth of respiratory epithelium. This forms Tornwaldt's bursa which drains into the nasopharyngeal cavity. This only forms cyst when the orifice partially or completely obstructed by infection. A Tornwaldt's cyst progresses in to Tornwaldt's disease only after infection or inflammation occurs.

Diagnosis

CT scan shows solid mass of Tornwaldt's cyst and MRI shows glass shaped lesion with a fluid on upper part of posterior nasopharyngeal wall. Additionally, a cystic mass in upper part of nasopharyngeal wall and mucopurulent discharge from upper part of the mass can be seen on nasal endoscopy. Among them MRI is the best for diagnosing the Tornwaldt's cyst.

Treatment

Antibiotics are given to treat the infection. If there is a large symptomatic lesion, surgery by transnasal endoscopic marsupialisation is the treatment option because it is safe, fast and provides good visualization during surgery and for small lesion Endonasal approach is recommended.

History

Tornwaldt's disease was noted by Mayer in 1840. He noted it in an autopsy specimen but founded as a pathologic entity by German physician Gustavust L. Tornwaldt in 1855. Only a few cases have been reported in Japan between 1929 and 1992. In 2008-2009, six patients were diagnosed to have nasopharyngeal bursitis.Out of which four were males and two females

See also

• Tornwaldt cyst