Sinonasal TB is a rare entity, even in TB endemic countries like India, and thus often flies under the radar of suspicion. Paranasal sinus involvement may rarely be primary, however, it more commonly occurs secondary to pulmonary TB, either through infected droplets or miliary or lymphatic spread.
1 The risk factors identified include immunosuppression, as in our patient, human immunodeficiency virus infection, and diabetes. The nasal cavity and paranasal sinuses are protected from developing TB by bactericidal secretions, ciliary functions, and mechanical filtering by the nasal vibrissae.
1,2 The most common paranasal sinus involved is the maxillary sinus, as in our patient, and the disease is commonly unilateral.
1 Paranasal sinus TB without the involvement of the nasal cavity, as in our patient, has been rarely reported in literature.
2
Females are more commonly affected and the clinical spectrum commonly includes non-specific symptoms such as nasal obstruction, recurrent epistaxis, rhinorrhoea, nasal crusting, hyposmia, and headache.
1,2 Patients may rarely present with facial swelling mimicking an odontogenic infection, with ear discharge, hearing loss, and tinnitus due to middle ear involvement, with cheek pain and numbness resembling trigeminal neuralgia, and proptosis and trismus resembling malignancy.
3,4,5
Confirmation of the diagnosis of sinonasal TB is often difficult. Nasal swabs and nasal secretions cannot be used due to their paucibacillary yield. Tissue specimens may show acid-fast bacilli but are not always confirmatory of the diagnosis. Histopathological examination may be required showing caseating granulomas with necrosis.
2 Molecular methods, as in our patient, can be used to diagnose TB on the tissue specimen with a high specificity. However, in many cases, neither a histological nor a microbiological confirmation is possible, resulting in the diagnosis being made on the basis of the absence of a clinical improvement to antibiotics, and the presence of a clinical response to ATT. Findings on CT or MRI are non-specific for the diagnosis of paranasal sinus TB, however, these modalities are primarily used to determine the size and extent to the disease.
2
LMN facial palsy has been reported in association with several forms of head and neck TB, however, it has not been previously reported with paranasal sinus TB. In our case, we ruled out intracranial and temporal bone tuberculomas as potential causes of LMN facial palsy on CT and MRI imaging. Additionally, imaging showed a tubercular lesion restricted to the maxillary sinus, thus direct facial nerve compression from the paranasal sinus lesion was ruled out. For Bell’s palsy, steroids should be administered within 72 hours of paralysis onset at a dose of 1 mg/kg/day of prednisone for 5-7 days.
6 Other treatment options include antiviral medications and surgical decompression of the facial nerve. However, there is no current consensus on the benefit of antivirals in cases of Bell’s palsy, and surgical options are not preferred in the acute stage and have similar outcomes with medical management.
6 Overall, Bell’s palsy has an excellent prognosis with recovery within a few weeks to months. About 80% patients recover without treatment and the addition of steroids alone increases the recovery rate to around 90-97%.
6 The facial palsy in our patient was idiopathic, and thus we treated his Bell’s palsy with steroids while concomitantly treating with ATT for his paranasal sinus TB.
| References : |
- Sharma S, Kalyan S. Primary bilateral maxillary sinus tuberculosis: a rare and an underdiagnosed entity. Int J Fam Commun Med. 2020;4(2):48-50.
- Kim KY, Bae JH, Park JS et al. Primary sinonasal tuberculosis confined to the unilateral maxillary sinus. Int J Clin Exp Pathol. 2014 Jan 15;7(2):815-8.
- Gupta A, Mehendirratta M, Sareen C et al. Primary Paranasal Tuberculosis in a Diabetic Mimicking Odontogenic Infection: A Rare Case; A Unique Presentation. J Clin Diagn Res. 2016 Mar;10(3):ZD19-21.
- Singh A, Kumar N, Kwatra K. Coexisting tuberculosis of middle ear and maxillary sinus: a rare presentation. Int J Res Med Sci. 2016 Jan 1;3052-4.
- Penjor D, Chong AW. Tuberculous granuloma of maxillary antrum and ethmoid sinus mimicking malignancy and trigeminal neuralgia: A case report and review of the literature. SAGE Open Med Case Rep. 2021 Aug 11;9:2050313X211039733.
- Hohman MH, Warner MJ, Varacallo MA. Bell Palsy. [Updated 2024 Oct 6]. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482290/
|