INTRODUCTION
Tuberculosis of the paranasal sinus is uncommon and typically results from pulmonary tuberculosis. There have been 71 reports of paranasal sinus TB worldwide, 29 of which are primary forms.[1] Tuberculosis of the maxillary sinus does not usually present with characteristic features, which may result in failure to diagnose the condition leading to spread of the disease and life-threatening complications.[2,3]
An unusual case of primary tuberculosis affecting the maxillary sinus in a male subject, aged 54 years, is discussed in the current case report.
CASE HISTORY
Clinical history
A male subject, aged 54 years, is presented to the Department of Oral Medicine for a regular check-up.
Intra-oral examination revealed gingival recession and cervical abrasion with respect to 14, 15, and 16. Also, mesio-occlusal caries with respect to 16, mild erythema, and obliteration of the buccal vestibule with respect to 15 and 16 were noted [Figure 1].
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Figure 1: Obliterated and erythematous buccal vestibule with respect to 15,16
Diagnostic assessment
FNAC in the vestibular region of 15,16 revealed cheesy material [Figure 2], and hence, a provisional diagnosis of odontogenic keratocyst involving the right maxillary posterior region and a differential diagnosis of chronic maxillary sinusitis were considered. IOPAR with respect to 16 exhibited mesio-occlusal caries with periapical granuloma and vertical bone loss with respect to 15, 16, and 17 [Figure 3a]. As the findings on IOPAR did not support the provisional diagnosis, a CBCT was performed which revealed a mild enhancing lesion involving the anteroinferior aspect extending to the periapical region of 15 and 16 with loss of anterior and medial walls of the right maxillary sinus [Figure 3b]. Based on CBCT findings, radiographic differential diagnoses of malignancy of the maxillary sinus and fungal sinusitis were considered.
Figure 2: FNAC revealed cheesy material
Figure 3: (a) IOPAR of posterior right maxillary quadrant revealed mesio-occlusal caries with periapical granuloma with respect to 16, and angular bone loss with respect to 15,16,17, and 18. (b) Destruction of anterior and medial wall in the inferior aspect of the right maxillary sinus
The vestibular region of 15,16 was biopsied, and the histopathology was indicative of a chronic granulomatous lesion. AFB staining was negative for TB. Nevertheless, polymerase chain reaction (TB-PCR) and Gene Xpert MTB/RIF (mycobacterium tuberculosis complex resistance to rifampicin) test were conducted, confirming the diagnosis of tuberculosis. The patient was referred to a general physician for further evaluation. Chest radiograph, trans-abdominal ultrasound, and hepatic panel tests were unremarkable. An ELISA test was also performed to rule out HIV infection and was found to be negative. On the basis of clinical features, imaging, and the above-mentioned investigations, a final diagnosis of primary tuberculosis of the right maxillary sinus was made.
Therapeutic intervention
The patient was prescribed antitubercular treatment (ATT) consisting of Isoniazid-600 mg, Rifampicin-300 mg, Pyrazinamide-1500 mg, and Ethambutol-400 mg for 2 months followed by a 10-month ATT consisting of Isoniazid-300 mg, Rifampicin-300 mg, and Ethambutol-400 mg. Root canal therapy was also performed with respect to 16.
Follow-up and outcome
The patient did not experience any significant adverse effects apart from mild knee joint pain for which he was prescribed calcium supplements. A gradual reduction in vestibular obliteration was noted approximately 4 months after the initiation of therapy. The patient has been followed up for up to 2 years, and no signs of recurrence were noted.
TIMELINE OF HISTORY
DISCUSSION
TB of the maxillary sinus may resemble several pathologies such as sarcoidosis, Wegener’s granulomatosis, rhinosclerosis, fungal infections, malignancies, or odontogenic infections.
The most common initial sign of maxillary sinus TB is a fluctuant swelling noted on the midface known as pot’s puffy tumor.[4] Rhinorrhea, postnasal drip, and nasal obstruction may also appear. As the disease progresses, cervical lymphadenopathy and epistaxis may appear.[5] With the exception of vestibular obliteration with regard to 16, none of the above-mentioned signs and symptoms were noted in the present case.
The following forms of paranasal sinus tuberculosis have been delineated:
- Mucosal involvement with polyp formation.
- Bony involvement with fistula, and nasal discharge.
- Bony involvement with mucosal hyperplasia and tuberculoma.[5]
The second form of sinonasal tuberculosis was detected in the present case. However, there was no fistula formation.
Typically, TB is diagnosed on the basis of clinical symptoms and a plethora of investigations. Although histopathological findings may be diagnostic, approximately 7.8% of specimens stain positively for AFB. PCR-TB test is highly sensitive as the detection of a single bacterium in a given specimen is possible. The Gene Xpert MTB/RIF may diagnose tuberculosis in less than two hours with a sensitivity of 89% and a specificity of 67%.
Although the histological findings in the present case suggested a granulomatous lesion, the presence of acid-fast bacilli could not be established. Hence, it was decided to perform advanced diagnostic tests namely Gene Xpert and PCR-TB as TB is the most common granulomatous condition, observed in the Indian population. These tests confirmed the presence of tuberculosis.
The primary modality of treatment for paranasal sinus tuberculosis is anti tuberculosis therapy, and surgery may be required in severe forms. Prognosis is dependent on the magnitude of tissues affected and timely initiation of suitable antitubercular therapy.
CONCLUSION
In the present case, PCR/Gene Xpert confirmed the diagnosis emphasizing the importance of advanced diagnostic aids in the identification of TB. Pathologies affecting the maxillary sinus may initially present in the oral cavity due to its close contiguity with the sinus. Therefore, a dentist should possess adequate knowledge of the clinical manifestations of tuberculosis in the maxillofacial region.
Patient perspective
I am thankful for the doctors’ swift identification of my condition.
Declaration of patient consent
The patient’s consent has been obtained for the usage of his records for publication. He has been assured of total confidentiality of the data published.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
REFERENCES
1. Kar IB, Panda SN, Mishra N, Kar R, Singh AK. Resurgence of tuberculosis:A rare case of primary orbitomaxillary tuberculoma. Oral Surg Oral Med Oral Pathol Oral Radiol 2013;116:27–31.
2. Gleitsmann JW. Tuberculosis of the accessory sinuses of the nose. Laryngoscope 1907;17:445–50.
3. Jain MR, Chundawat HS, Batra V. Tuberculosis of the maxillary antrum and of the orbit. Indian J Ophthalmol 1979;27:18–20.
4. Jain P, Jain I. Oral manifestations of tuberculosis:A step towards early diagnosis. J Clin Diagn Res 2014;8:18–21.
5. Shukla GK, Dayal D, Chabra DK. Tuberculosis of maxillary sinus. J Laryngol Otol 1972;86:747–54.
