Tubercu los i s The pharynx is not a common site for clinically manifest TB; however, it is the site of primary

infection almost always in children and results in an asymptomatic primary focus in the pharynx ( usually tonsil or adenoid) with cervical lymphadenopathy. Secondary TB affects the pharynx, but only in patients with massive positive and usually cavitating pulmonary TB. This is in contrast to laryngeal TB in which lesions do occur with low grade or inactive pulmonary disease. The pharyngeal lesions are secondary to coughing up heavily infected sputum and consist of multiple, painful shallow ulcers in the pharynx or oral cavity. !ccasionally, the pharynx is involved in patients with widespread military TB and here the lesions may be from blood borne as well as sputum borne dissemination of disease. "upus vulgaris is a low grade cutaneous form of TB and has been described in the nasal cavities and in the pharynx. Tuberculous otitis media is probably a blood borne dissemination of the disease but, on occasion, can result from pharyngeal disease by spread from the #ustachian tube. The resurgence of TB has closely paralled the epidemic caused by $%&. %n both the 'S( and (frica, the areas with the highest rates of $%& infection and high ris) groups, such as intravenous drug abusers, are those that have sustained the highest increase in TB. *overty, overcrowding and homelessness are the socioeconomic factors common to co infection with both. $%& infected individuals are at ris) of reactivation of previous TB and to rapid progression of ac+uired infection. The presentation is often atypical and an increase in extrapulmonary TB has been demonstrated. The diagnosis is usually clear because of the association with pulmonary disease, both clinically and radiologically, although pharyngeal S,, with pulmonary metastases is the obvious differential. -icroscopic examination of stained smears for acid fast bacilli is still one of the most useful tests for the initial diagnosis of TB. (lthough less sensitive and specific than culture the sensitivity can be greatly improved by using phenol auramine stain as compared with the older .iehl/ielsen techni+ue. Semi automated and continuous monitoring systems developed specifically for the isolation of mycobacteria include en0yme lin)ed immunosorbent assay (#"%S() tests to detect antigens and polymerase chain reactions (*,1) to detect genetic elements.

*haryngeal TB re+uires no special treatment. %t will, in principle, be treated at the same time as the pulmonary disease with triple therapy, usually isonia0id, rifampicin and pyri0inamide as first line drugs. (ll cases should be treated in association with an interested specialist. 2rug resistance (21) worsens outcomes and may have significant cost implications. -ultiple drug resistance (-21) is found globally. -anagement relies upon treatment with at least three drugs to which the isolate is susceptible. 2irectly observed treatment strategy should be used in adults and children where there is a significant ris) of 3 noncompliance and is vital to cut down transmission of disease in the community. %n TB cases with -21, stand ard regimens result in unacceptably high failure rates (45. 6 p ercent ) . 7or all other drug resistant fonns of TB, rifampicin based short course chemo therapy p rovides satisfactory results. To prevent development of drug resistance, the proportion of defaulters must be decreased, prevention and control st rategies endorsed by the 8orld $ealth !rgani0atio n (8$!), a nd the %nternational 'nion (gainst Tuberculosis and "ung 2isease must be implemented nationwide. The errors that lead to the development of 21 are inappropriate regimens, nonadherence to therapy by patients, the sale and availability of over the co unter drugs, an interruption in the drug supply and the unavailability of free diagnosis and treatment. (s a result, d rug resistant organisms are spread in the community, generating secondary cases with primary 21, which in turn can spread and generate further cases. The uninterrupted cycle of creation and circulation is responsible fo r the increases in 21. (ccording to global data on anti TB 21 appearing in the 8$! monographs, 21 is so ubi+uitous as to be encountered in every country. (nti TB 21 among previously treated cases was found to be very h igh in some countries but remained relatively low in others. $epatotoxicity o ccurred in a high proportion of patients prescribed pyri0inamide. Tuberculosis can be controlled if appropriate policies are followed, effective clinical and p ublic health management is ensured, and there are committed and coordinated efforts from within and outside the health sector. $owever, in the context of an epidemic of (%2S, the incidence o f TB will inevitably rise. By 499 6 , less than :9 percent of global TB cases were reported to have received effective diagnosis, treatment and monitoring. 1apid expansion of effective TB contro l services is urgently re+uired to avert the continued high burden of morbidity and mortality from TB and its effects

on the $%& pandemic.