Grand Rounds

Maxillary Sinus Tuberculosis with Lower Motor Neuron Facial Palsy: A Rare Presentation

Dhruv Gandhi, Ira Shah
Department of Pediatric Infectious Diseases, BJ Wadia Hospital for Children, Mumbai, India

Address for Correspondence: Dhruv Gandhi, 5B/13 Shyam Niwas, Breach Candy, Mumbai-400026, Maharashtra, India. Email: dhruvgandhi2610@gmail.com

Keywords: Paranasal sinus tuberculosis, Bells palsy, steroids, Antitubercular therapy, Tuberculosis management, Maxillary TB

Clinical Problem:
A 5-year-old male was diagnosed to have Rosai-Dorfman disease in 2006 for which he received chemotherapy with vincristine, methotrexate, 6-mercaptopurine, cyclophosphamide, prednisolone and celecoxib. After treatment completion at 6 years of age, he had multiple recurrences of Rosai-Dorfman disease. In September 2024, at 23 years of age, he had fever, breathlessness and productive cough for 3 days for which he was put on mechanical ventilation and underwent pleural effusion drainage at another centre. He was investigated and non-contrast computerized tomography (NCCT) chest showed multiple small nodules in the lungs and a right-sided pleural effusion. Blood cultures were negative. Bronchoalveolar lavage (BAL) Xpert MTB/Rif was positive for rifampicin-sensitive Mycobacterium tuberculosis (MTB). BAL Mycobacterium growth indicator tube culture was positive and phenotypic drug-susceptibility testing revealed sensitivity to isoniazid, rifampicin, pyrazinamide and ethambutol. Other investigations are shown in Table 1. He was started on steroids and first-line antitubercular therapy (ATT) with isoniazid, rifampicin, pyrazinamide and ethambutol. He was subsequently weaned off the ventilator and discharged in October 2024. However, he developed drug induced liver injury and was shifted to ethambutol, amikacin and moxifloxacin. In November 2024, he developed a recurrence of Rosai-Dorfman disease for which he received weekly vinblastine (10 mg/m²/dose) and also developed a right-sided maxillary swelling. NCCT paranasal sinuses showed a 4.6x5.2x5.5 cm swelling in the right maxillary sinus, eroding into the side of the maxilla and extending into the right ethmoid sinus, sphenopalatine foramen and pterygopalatine fossa. There was no intracranial extension. Tissue biopsy Xpert MTB/Rif was positive for rifampicin-sensitive MTB complex. Bacterial and fungal cultures of the biopsied tissue were negative. The same ATT was continued. In December 2024, he developed right-sided lower motor neuron (LMN) type of facial palsy. He was subsequently referred to us for further management. Magnetic resonance imaging (MRI) brain in December 2024 showed a stable size of the maxillary sinus lesion (5x4.9 cm) and no brain parenchymal lesions. He started on prednisolone (1 mg/kg/day) and ATT was changed to linezolid, amikacin, ethambutol and moxifloxacin. In January 2025, at the 1-month follow-up, his facial weakness had recovered and he was advised to taper and stop prednisolone.

Table 1. Investigations of the patient.

Parameters	November 2024	December 2024	January 2025	Reference Ranges
Hemoglobin (gm/dL)	-	9.5	-	11.5-15.5
White blood cell count (cells/cumm)	-	3420	-	5000-13,000
Platelets (105 cells/cumm)	-	5.10	-	1.50-4.50
ALT (IU/L)	141	711	143	<41
AST (IU/L)	224	450	138	<41
Total bilirubin (mg/dL)	0.42	0.73	-	0.0-1.10
Direct bilirubin (mg/dL)	0.21	0.15	-	0.0-0.60
Serum total protein (gm/dL)	-	8.38	7.96	6.00-8.30
Serum albumin (gm/dL)	-	4.13	4.46	3.80-5.40

Note : ALT- Alanine aminotransferase, AST- Aspartate aminotransferase.

How common is paranasal sinus tuberculosis (TB) and how to treat LMN facial palsy with paranasal sinus TB?